Updates on Evidence-Based Practices to Reduce Preoperative and Intraoperative Contamination of Implants in Spine Surgery: A Narrative Review

Agarwal, Aakash; Lin, Boren; Elgafy, Hossein; Goel, Vijay K.; Karas, Chris; Schultz, Christian; Anand, Neel; Garfin, S. R.; Wang, Jeffrey; Agarwal, Anand

doi:10.22603/ssrr.2019-0038

Cited by 7 publications

(5 citation statements)

References 12 publications

(35 reference statements)

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“…The proposed biological path includes the presence of occult infection in the form of bacterial growth around the implant with no known clinical symptoms of SSI [7][8][9][10][11] . This is consistent with other studies that demonstrated a positive bacterial biodose impregnation at the screw-bone interface during spine sugery [12][13][14][15] . In addition to screw loosening, studies have shown a high rate of delayed or late-onset infection only in cases with instrumentation [16][17][18][19] .…”

Section: Introductionsupporting

confidence: 93%

“…The results of the current study highlight the importance of keeping the implantable devices free from any bacterial biodose to the best of our capability. Recent studies have shown that repeated reprocessing and intraoperative exposure is a main source of such a biodose and other foreign bodies 12,14,15) . Literature shows that delayed-onset infection can occur from 90 days to a year from the date of surgery and constitutes between 15% to 35% of all reported infections 19) .…”

Section: Discussionmentioning

confidence: 99%

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High Prevalence of Biofilms on Retrieved Implants from Aseptic Pseudarthrosis Cases

Agarwal

Mooney

Agarwal

et al. 2021

Spine Surg Relat Res

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Introduction Recent literature has associated pseudarthrosis and pedicle screw loosening with subchronic infection at the pedicle of the vertebra. The positive culture results of a previous retrieval analysis show that such patients have a high frequency of bacterial contamination. The objective of this study is to visually capture the architecture of these undiagnosed infections, which have been described in other studies as biofilms on supposedly “aseptic” screw loosening. Methods Explants from 10 consecutive patients undergoing revision spine surgery for pseudarthrosis were collected and fixed in glutaraldehyde solution. Each of these implants was imaged thoroughly by using scanning electron microscopy and x-ray spectroscopy to evaluate the architecture of the biofilm. Additionally, eight patient swabs from tissues around the implants were sent for cultures to assess bacterial infiltration in tissues beyond the biofilm. The implants were also analyzed using energy dispersive x-ray spectroscopy. The exclusion criteria included clinically diagnosed infection (current or previous) and/or mechanical failure of the implant due to falls/accidents. Results The study was successful in capturing the visual architecture of the biofilm on retrieved implants. A total of 77% of pseudarthrosis cases presented with loose pedicle screws, which were diagnosed by a preoperative computed tomography scan showing radiolucency along the screw track and were confirmed intraoperatively, and 72% of the cases showed biofilm on explants. Conclusions In the absence of the clinical presentation of infection, impregnated bacteria could form a biofilm around an implant, and this biofilm can remain undetected via contemporary diagnostic methods, including swabbing. Implant biofilm is frequently present in “aseptic” pseudarthrosis cases.

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Section: Introductionsupporting

confidence: 93%

Section: Discussionmentioning

confidence: 99%

High Prevalence of Biofilms on Retrieved Implants from Aseptic Pseudarthrosis Cases

Agarwal

Mooney

Agarwal

et al. 2021

Spine Surg Relat Res

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“…27 Recent studies on identification of occult infection led hardware loosening, and propensity of bacterial infestation and growth on implant surfaces outside and inside the theatre provides further evidences of levels of higher uncertainty (of subsequent infection) involved in the management of SSI and its preventive measures. [62][63][64][65][66][67][68]…”

Section: Discussionmentioning

confidence: 99%

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

Agarwal

Kelkar

Agarwal

et al. 2019

Global Spine Journal

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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.

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“…We also observed contamination in 1/15 or 6.67% of our PBS-inoculated animals, which is consistent with the 0.7-20% infection rate observed in adult posterior spinal fusion procedures [9] . This contaminated animal was part of the PBS-inoculated cohort lacking vancomycin infusion within the bone graft, and open-air exposure to bacteria in the same hood may have contributed to this contamination, comparable to cases of contamination in the operating room [57] .…”

Section: Discussionmentioning

confidence: 99%

Synthesis and evaluation of a novel vancomycin-infused, biomimetic bone graft using a rat model of spinal implant-associated infection

Rajkovic,

Tracz,

DeMordaunt

et al. 2024

North American Spine Society Journal (NASSJ)

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Updates on Evidence-Based Practices to Reduce Preoperative and Intraoperative Contamination of Implants in Spine Surgery: A Narrative Review

Cited by 7 publications

References 12 publications

High Prevalence of Biofilms on Retrieved Implants from Aseptic Pseudarthrosis Cases

High Prevalence of Biofilms on Retrieved Implants from Aseptic Pseudarthrosis Cases

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

Synthesis and evaluation of a novel vancomycin-infused, biomimetic bone graft using a rat model of spinal implant-associated infection

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