Surgical debridement with retention of spinal instrumentation and long-term antimicrobial therapy for multidrug-resistant surgical site infections after spinal surgery: a case series

Kelkar

et al. 2019

Global Spine Journal

Study Design: A literature review.Objective: To summarize the implant removal rate, common bacterial organisms found, time of onset, ratio of superficial to deep infection, and regurgitating the prevalence among all the retrospective and prospective studies on management and characterization of surgical site infections (SSIs). Methods:PubMed was searched for articles published between 2000 and 2018 on the management or characterization of SSIs after spinal surgery. Only prospective and retrospective studies were included. Results: A total of 49 articles were found relevant to the objective. These studies highlighted the importance of implant removal to avoid recurrence of SSI. The common organisms detected were methicillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus epidermis, Staphylococcus epidermis, Staphylococcus aureus, and Propionibacterium acnes, with prevalence of 1% to 15%. A major proportion of all were deep SSI, with minority reporting on late-onset SSI. Conclusion: Long-term antibiotics administration, and continuous irrigation and debridement were common suggestion among the authors; however, the key measure undertaken or implied by most authors to avoid risk of recurrence was removal or replacement of implants for late-onset SSI.

Section: Resultsmentioning

confidence: 99%

Implant Retention or Removal for Management of Surgical Site Infection After Spinal Surgery

Kelkar

et al. 2019

Global Spine Journal

“…S. epidermidis is the most prevalent and persistent species found on the human skin and mucous membranes, constituting 65% to 90% of all staphylococci isolated from these environments [ 5 ], and it may act as a source of later bacteremia and surgical site infections. The majority of cases reported identified S. epidermidis as a common bacterium responsible for wound infections after surgery [ 6 , 7 , 8 ]. In one study by Martens et al [ 9 ], 64% infected wounds after cesarean delivery had positive bacterial cultures, with S. epidermidis (29%) being the most frequent isolates.…”

Section: Introductionmentioning

confidence: 99%

Molecular Characteristics of Methicillin-Resistant Staphylococcus epidermidis on the Abdominal Skin of Females before Laparotomy

Wang

Xie

Sun

et al. 2016

IJMS

Staphylococcus epidermidis, especially methicillin-resistant strains, may be the source of surgical site infections and may be a reservoir of staphylococcal cassette chromosome mec (SCCmec) for S. aureus. The aim of this study was to investigate the prevalence of methicillin-resistant S. epidermidis (MRSE) on the abdominal skin of females before laparotomy and determine the molecular characteristics and antimicrobial susceptibility patterns of these isolates. MRSE was found in 54 of 157 isolates based on mecA gene detection, and there was no difference in icaA gene carriage rate between MRSE and methicillin-susceptible S. epidermidis (MSSE) isolates. Antimicrobial susceptibility profiles were determined by broth microdilution antimicrobial susceptibility testing according to the latest CLSI manuals. All MRSE isolates had unfavorable antimicrobial susceptibility patterns. Twenty-three MRSE strains (42.6%) were multi-drug resistant. SCCmec typing and pulsed field gel electrophoresis (PFGE) typing was performed. Thirty-nine (72.2%) had a single SCCmec type, whereas 1.9% had two types. Fourteen strains (25.9%) were non-typeable (NT). The most frequent MRSE genotype was SCCmec type IVa. High diversity with PFGE patterns was obtained for MRSE, and there were no isolates exhibiting identical pulsotype. The results confirm that methicillin-resistant strains are frequently present among S. epidermidis on the abdominal skin of females before laparotomy. Moreover, resistance profiles seem to have no association with the SCCmec types or PFGE types for most common antibiotics.

“…Only one of the patients in our series required removal of instrumentation at 13 months following the index procedure, with complete resolution of his methicillin-resistant Staphylococcus aureus infection. Retention of instrumentation in the infected spine is supported by numerous studies, 2 , 21 but removal may have to be considered where there is ongoing infection in a stable spine with solid bony fusion. During wound debridement, no conscious effort was made to remove bone graft.…”

Section: Discussionmentioning

confidence: 99%

The Use of Vacuum Dressings for Dead Space Management in Deep Surgical Site Infections Allows Implant and Bone Graft Retention

Watt

Dunn

2017

Global Spine Journal

Study Design:Retrospective, descriptive study.Objectives:Managing early surgical site infection following elective lumbar spine surgery remains a challenge with controversy regarding retention of instrumentation and bone graft. Wound closure may also pose considerable challenges. We aim to report on our method of managing deep surgical site infections complicating elective spine surgery with surgeon assembled deep vacuum dressings. Identification of causative organisms with their sensitivities was a secondary objective.Methods:Patients were identified from a prospectively maintained, single-surgeon database from 2003-2015. Patients who had an infective or trauma related diagnosis, cervical procedures, and were younger than 18 years were excluded. Records were reviewed to identify bacteriology, laboratory tests performed, antibiotics administered, and type and frequency of surgical management. One thousand two hundred twenty patients qualified for inclusion, with 19 identified as having developed acute wound sepsis.Results:All patients had surgical debridement on the day of presentation and the majority of wounds were managed with a vacuum dressing. In all but 1 patient was instrumentation retained. Specimens for culture were taken at each debridement and antibiotics changed accordingly. Patients received a minimum 6 weeks of antibiotics.Conclusions:The management of deep surgical site infection is labor intensive and frustrating for both surgeon and patient due to the unexpected prolonged admission. Management goals are identification and eradication of the causative organism with subsequent healing of the surgical wound. This process is enhanced with the use of negative-suction dressings made from theatre stock replaced at regular intervals and allows retention of bone graft and instrumentation in the majority of cases.