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Article history: Introduction: Surgical site infection (SSI) remains a significant source of morbidity in spine surgery, with
Received 6 January 2018 reported rates varying from 0.7 to 16%.
Accepted 12 March 2018 Objective: To systematically review and evaluate the evidence for strategies for prophylaxis of SSI in adult
Available online xxxx
spine surgery in the last twenty years.
Methods: Two independent systematic searches were conducted, at two international spine centers,
Keywords: encompassing PubMed, ClinicalTrials.gov, Cochrane Database, EBSCO Medline, ScienceDirect, Ovid
Surgical site infection
Medline, EMBASE (Ovid), and MEDLINE. References were combined and screened, then distilled to 69
Infection prophylaxis
Adult spine surgery
independent studies for final review.
Systematic review Results: 11 randomized controlled trials (RCTs), 51 case-controlled studies (CCS), and 7 case series were
identified. Wide variation exists in surgical indications, approaches, procedures, and even definitions of
SSI. Intra-wound vancomycin powder was the most widely studied intervention (19 studies, 1 RCT).
Multiple studies examined perioperative antibiotic protocols, closed-suction drainage, povidone-iodine
solution irrigation, and 2-octyl-cyanoacrylate skin closure. 18 interventions were examined by a single
study only. There is limited evidence for the efficacy of intra-wound vancomycin. There is strong evi-
dence that closed-suction drainage does not affect SSI rates, while there is moderate evidence for the effi-
cacy of povidone-iodine irrigation and that single-dose preoperative antibiotics is as effective as multiple
doses. Few conclusions can be drawn about other interventions given the paucity and poor quality of
studies.
Conclusions: While a small body of evidence underscores a select few interventions for SSI prophylaxis in
adult spine surgery, most proposed measures have not been investigated beyond a single study. Further
high level evidence is required to justify SSI preventative treatments.
Ó 2018 Published by Elsevier Ltd.
1. Introduction the incidence of spinal SSI has been reported from 0.7 to 16%. Risk
factors for SSI have been well studied and reported in a number of
Despite efforts to reduce its incidence, surgical site infection systematic reviews [147,109], and mitigation against these is one
(SSI) remains a common and costly complication of adult spine area for focus of prevention of SSI. Prophylactic measures – preop-
surgery. SSI is associated with greater length of stay, morbidity, erative, intraoperative, or postoperative – are another focus to
and mortality. It has been estimated by the Society for Healthcare reduce SSI rates.
Epidemiology of America (SHEA) that up to 60% of SSIs are pre- Since the first systematic review on prophylactic strategies
ventable if evidence based guidelines are followed [5]. However, against SSI in spine surgery by Brown et al. in 2004 [16], there
has been an expansion of the number of preventative measures
introduced and studied in the spine literature, most notably intra-
q
Portions of this work were presented in abstract form at the 17th Canadian wound application of vancomycin powder. However, as noted by
Spine Society Meeting, Montreal, Canada, February 25, 2017 and in poster form at van Middendorp et al. [147], many studies are of lower method-
the AOSpine Fellows Forum, Banff, Canada, March 24, 2017.
⇑ Corresponding author at: Division of Spine Surgery, Department of Orthopae- ologic quality and there is significant heterogeneity in the use of
dics, University of British Columbia, 818 W 10th Ave, Vancouver, BC V5Z 1M9, prophylactic strategies that are not part of the intervention stud-
Canada. ied in these papers [147]. As such, our objectives were to not only
E-mail address: john.street@vch.ca (J. Street).
https://doi.org/10.1016/j.jocn.2018.03.023
0967-5868/Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Yao R et al. Prophylaxis of surgical site infection in adult spine surgery: A systematic review. J Clin Neurosci (2018),
https://doi.org/10.1016/j.jocn.2018.03.023
2 R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx
the evidence, serving as an update of similar such reviews. Given Level I Randomized controlled trial with significant difference or no sig-
the changes to spine surgery in terms of technique and nificant difference but with narrow confidence intervals
instrumentation, as well as to the perioperative routines such as Systematic review of homogenous Level I randomized controlled
trials
administration of preoperative antibiotics that may affect SSI Level Prospective cohort study
rates, we limited our review to studies published in the last II Poor quality randomized controlled trial
twenty years. Systematic review of Level II studies or non-homogenous Level I
studies
Level Case-control study
2. Methods III Retrospective cohort study
Systematic review of Level III studies
Level Case series
2.1. Study design IV
Level Expert opinion
We conducted a formal systematic review of any published lit- V
erature from the last twenty years assessing prophylactic measures
against surgical site infection in adult spine surgery. Two concur-
rent independent searches, one each in Canada and in Australia,
were performed to optimize capture of all relevant studies. The
Table 2
level of evidence was assessed for each study included. The
Grade of recommendation for reviews of surgical studies (adapted from Wright et al.
strength of evidence was then graded for each prophylactic 2005 [157]).
measure.
Grade A Good evidence (Level I studies with consistent findings) for or
against recommending intervention
2.2. Search strategy Grade B Fair evidence (Level II or III studies with consistent findings)
for or against recommending intervention
Grade C Conflicting or poor-quality evidence (Level IV or V studies) not
The Canadian search was run from inception on August 8, 2016, allowing a recommendation for or against intervention
with a second search on October 12, 2016, encompassing PubMed, Grade I There is insufficient evidence to make a recommendation
ClinicalTrials.gov, Cochrane Database of Systematic Reviews,
EBSCO Medline, ScienceDirect, Ovid Medline, EMBASE (Ovid), and
MEDLINE with limits of English language, Clinical Trial, Humans,
and Adults age 19+. Search terms used were (spine OR spinal) 3. Results
AND (infection) AND (prophylaxis OR prevention OR antibiotics
OR surgery OR surgical). 3.1. Search results
The Australian search encompassed MEDLINE with the MeSH
Heading search terms (exp = (surgical wound infection) AND exp The Canadian search returned 13,418 unique titles, of which 98
= (spinal)) NOT (exp = (surgical wound infection) AND (exp = (lami articles were deemed potentially relevant. The Australian search
nectomy) OR exp = (laminoplasty) OR exp = (spinal fusion)) refined returned 47 unique titles, with an additional 49 potentially rele-
by MeSH qualifier (prevention control). The references from this vant titles found from screening of those references, resulting in
search were then screened for additional potentially relevant a total of 96 articles deemed potentially relevant. The final pool
studies. of articles from both searches were then combined and screened
by all authors, then distilled down to 69 independent studies
2.3. Study selection included for our review.
Please cite this article in press as: Yao R et al. Prophylaxis of surgical site infection in adult spine surgery: A systematic review. J Clin Neurosci (2018),
https://doi.org/10.1016/j.jocn.2018.03.023
Table 3
Characteristics of all included studies.
Authors Year Study Data Level of Intervention Comparative Group Result Spinal Approach Instrumentation Indication for Surgery Surgical Procedure
Design Collection Evidence Levels
SSI Prophylaxis # of Mean SSI Prophylaxis # of Mean
pts Age in pts Age in
(SSI Years (SSI Years
cases) (Range) cases) (Range)
Adogawa 2014 HCCS Retro III Negative 46 (5) 65.31 No NPWT 114 63.28 NPWT T,L P Y Deformity Fusion,
et al [2]
pressure wound (NR) (17) (NR) decreased SSI instrumentation
therapy (NPWT)
Ando et al. 2014 HCCS Pro II 2-octyl- 315 66.4 Staples skin 294 65.3 2-octyl- C,T,L A,P Some Trauma, Decompression,
[6]
cyanoacrylate skin closure (0) (13–94) closure (8) (15– cyanoacrylate degenerative laminectomy,
91)
skin closure stenosis, fusion,
decreased SSI spondylolisthesis, instrumentation,
disc disease, discectomy
https://doi.org/10.1016/j.jocn.2018.03.023
tumor
Basques 2014 CCS Pro III Microscope 2226 NR No microscope 21,444 NR ND C,T,L A,P Some NR Decompression,
et al.
[10]
(16) (NR) (2 2 5) (NR) laminectomy,
fusion,
instrumentation,
discectomy
Brown et al. 2004 RCT Pro II Closed-suction 42 (0) 67.4 No closed- 41 (0) 67.4 ND L NR Y Deformity, Fusion,
[17]
wound drainage (NR) suction wound (NR) degenerative instrumentation
drainage stenosis,
spondylolisthesis
Caroom et al. 2013 HCCS Pro II Intrawound 40 (0) NR No powder 72 NR Vancomycin C P Y Cervical Decompression,
[18]
vancomycin (11) decreased SSI degenerative laminectomy,
powder (1g) myelopathy fusion,
instrumentation
Celik et al. 2007 RCT Pro I Shaving surgical site 371 41 (NR) No shaving surgical 418 44 (NR) Shaving increased SSI L P Some Degenerative stenosis, Decompression, laminectomy,
[20] (4) site (1) spondylolisthesis, disc fusion, instrumentation
disease
Chang et al. 2006 RCT Pro I Povidone-iodine 120 67.1 Saline wound 124 65.4 Povidone-iodine L,S P Y Degenerative Decompression,
[21]
irrigation irrigation disease fusion,
solution wound (0) (48–82) irrigation (6) (22– solution wound stenosis, disc laminectomy,
89)
decreased SSI instrumentation
Chen et al. 2012 CCS Pro II MRSA screening 503 57.3 No MRSA 487 56.9 ND C,T,L P Some Deformity, NR
[24]
& treatment of (17) (NR) screening (17) (NR) degenerative
R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx
Please cite this article in press as: Yao R et al. Prophylaxis of surgical site infection in adult spine surgery: A systematic review. J Clin Neurosci (2018),
3
4
Table 3 (continued)
Authors Year Study Data Level of Intervention Comparative Group Result Spinal Approach Instrumentation Indication for Surgery Surgical Procedure
Design Collection Evidence Levels
SSI Prophylaxis # of Mean SSI Prophylaxis # of Mean
pts Age in pts Age in
(SSI Years (SSI Years
cases) (Range) cases) (Range)
https://doi.org/10.1016/j.jocn.2018.03.023
Dennis et al 2016 CCS Retro III Intrawound 117 45 (11- No powder 272 48 (11- Vancomycin C,T,L A,P, Y Trauma, Instrumentation
[32] lateral
vancomycin (1) 84) (17) 85) decreased SSI deformity, +/ fusion
powder (1g) degenerative
stenosis, disc
disease,
spondylolisthesis,
tumor
Devin et al. 2015 CCS Pro II Intrawound 966 60.5 No powder 1090 59.5 Vancomycin C,T,L P Some Trauma, Decompression,
[33]
vancomycin (21) (NR) (56) (NR) decreased SSI degenerative instrumentation,
powder stenosis, fusion
(1g/10 cm) spondylolisthesis,
tumor
Dobzyniak 2003 HCCS Retro III Single-dose 192 43 (NR) Mutliple-doses 418 43 (NR) ND L P N NR Decompression,
et al.
[35]
antibiotics (3) antibiotics (5) laminectomy,
preoperatively perioperatively discectomy
Ehlers e al 2016 CCS Pro II Intrawound 5359 58 (NR) No powder 4464 58 (NR) ND C,T,L A,P Y NR NR
[39]t
vancomycin (43) (67)
powder
Epstein [40] 2007 CCS Retro III Silver- 106 49.1 Iodine or 128 49.6 Trend towards L P Y Degenerative NR
impregnated (0) (29–75) alcohol-based (14) (23– silver- stenosis, disc
77)
dressing swab and dry impregnated disease
dressing dressing
decreasing SSI
Featherall 2016 HCCS Pro II Implementation 799 58 (NR) Before 971 58 (NR) Implementation C,T,L A,P Some Deformity, Decompression,
R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx
et al [43]
of infection (16) implementation (40) of infection degenerative fusion,
prevention of infection prevention stenosis, disc instrumentation,
bundle prevention bundle reduced disease, tumor discectomy
bundle SSI
Gaviola et al 2016 CCS Retro III Intrawound 116 62 No powder 210 55 Trend towards C,T,L A,P Some NR Instrumentation,
[49]
vancomycin (6) (49–71) (23) (40– vancomycin fusion
67)
powder (2g) decreasing SSI (multilevel)
Ghobrial 2014 Case Retro IV Intrawound 981 59.4 N/A N/A N/A No conclusion NR NR NR NR NR
et al [52]
series vancomycin (66) (16–95) re: overall SSI
powder (0.5–6 g) rate but noted
higher rate of
Gram negative
bacilli or
polymicrobial
SSIs
Please cite this article in press as: Yao R et al. Prophylaxis of surgical site infection in adult spine surgery: A systematic review. J Clin Neurosci (2018),
Godil et al. 2013 CCS Retro III Intrawound vancomycin 56 (0) 43 (NR) No powder 54 (0) 45 (NR) Vancomycin decreased SSI C,T,L P Y Trauma Fusion, instrumentation
[53] powder (1g)
Gruenberg 2004 CCS Retro III Vertical laminar 40 (0) 40.9 Conventional 139 47.3 Vertical laminar NR NR N NR Decompression,
et al.
[54]
flow operating (19–75) operating room (18) (18– flow operating laminectomy,
89)
room and total room and total discectomy
body exhaust body exhaust
gown gown decreased
SSI
Hayashi et al 2015 CCS Retro III Iodine- 69 (1) 55.1 Regular 56 (7) 52.1 Iodine- NR A,P Y Tumor Decompression,
[57]
impregnated (16–73) implants (19– impregnated laminectomy,
77)
implants implants fusion,
decreased SSI instrumentation
Hellbusch 2008 RCT Pro I Single-dose 117 NR (21- Multiple-doses 116 NR (21- ND L P N Degenerative Fusion,
et al [59]
antibiotics (5) 82) antibiotics (2) 82) stenosis, disc discectomy
https://doi.org/10.1016/j.jocn.2018.03.023
preoperatively perioperatively disease
Heller et al. 2015 HCCS Retro III Intrawound 342 55.3 No powder 341 49.1 Vancomycin C,T,L P Y Trauma, Decompression,
[60]
vancomycin (9) (NR) (18) (NR) decreased SSI deformity, laminectomy,
powder (0.5–2 g) degenerative fusion,
stenosis, instrumentation
spondylolisthesis,
disc disease,
tumor
Hill et al. 2014 CCS Retro III Intrawound vancomycin 150 54.14 (20–86) No powder 150 58.33 Vancomycin decreased SSI C,T,L P Some NR Decompression, laminectomy,
[62] powder (1g) (5) (11) (24– fusion, instrumentation
87)
Howard et al 2014 CCS Pro III 2-octyl- 353 NR Staples skin 27 (1) NR ND, but authors C,T,L P Some Trauma, Decompression,
[64]
cyanoacrylate (8) closure suggest no degenerative laminectomy,
skin closure conclusion stenosis, fusion,
because of few spondylolisthesis, instrumentation,
patients in disc disease, discectomy
comparative tumor
group
Hu et al [65] 1998 RCT Pro II Total parenteral nutrition 17 (3) 54 (23–75) No total parenteral 18 (1) 47 (20– ND NR Combo Y Deformity, NR
postoperatively nutrition 73) spondylolisthesis,
postoperatively pseudarthrosis
Kakimaru 2010 HCCS Pro II Single-dose 143 64 (NR) Single-dose 141 62 (NR) ND C,T,L P N Degenerative Decompression,
et al [69]
antibiotics (2) antibiotics (4) stenosis, disc discectomy
preoperatively, preoperatively, disease
intraoperatively either no
q3h, no antibiotics
antibiotics intraoperatively
R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx
Please cite this article in press as: Yao R et al. Prophylaxis of surgical site infection in adult spine surgery: A systematic review. J Clin Neurosci (2018),
5
70)
3 doses antibiotics 20 (1) NR
postoperatively (18–
70)
Kim et al. 2010 RCT Pro II Single-dose 221 60.4 Single-dose 280 58.8 ND C,T,L NR Some NR NR
[74]
antibiotics (3) (NR) antibiotics (1) (NR)
preoperatively preoperatively
and 48 h and 72 h
antibiotics antibiotics
postoperatively postoperatively
Lee et al. 2016 HCCS Retro III Intrawound vancomycin 275 50.2 (NR) No powder 296 52.1 Vancomycin decreased SSI L P Some NR Decompression, fusion,
https://doi.org/10.1016/j.jocn.2018.03.023
[77] powder (1g) (15) (29) (NR) instrumentation
Liu et al. [80] 2015 HCCS Retro III Intrawound 180 67 (56- No powder 154 63 Vancomycin C,T,L P Y Deformity, Decompression,
vancomycin (5) 74 (11) (53.5- decreased SSI degenerative fusion,
powder (1g) 71) stenosis, instrumentation
spondylolisthesis,
tumor
Martin et al 2014 HCCS Retro III Intrawound 156 63.4 No powder 150 62.7 ND T,L,S P Y Deformity, Fusion,
[83]
vancomycin (8) (NR) (8) (NR) spondylolisthesis instrumentation
powder (2g)
Martin et al 2015 HCCS Retro III Intrawound 115 62.3 No powder 174 57.6 ND C P Y Trauma, Fusion,
[84]
vancomycin (6) (NR) (11) (NR) deformity, instrumentation
powder (2g) degenerative
stenosis, tumor
Mastronardi 2004 Case Retro IV Intraoperative antibiotic 973 NR N/A N/A N/A Low SSI rate compared to C,T,L A, Some Trauma, degenerative Decompression, laminectomy,
et al. series protocol where IV teicoplanin (9) literature P,?combo stenosis, fusion, instrumentation, discectomy
[86] given at induction if surgery spondylolisthesis, disc
anticipated to be > 120 min or disease, tumor
if implants to be inserted,
repeat dose q4h
intraoperatively, in addition
to standard preoperative
antibiotics (IV ampicillin and
sulbactam
Meyer et al. 2010 HCCS Retro III Implementation of new 887 NR Prior to 1048 NR Implementation of new C,T,L,S NR Y NR Instrumentation, otherwise NR
[88] perioperative care protocol (0) implementation of (6) perioperative care protocol
protocol decreased SSI
Mikhael 2009 CCS Retro III Irradiated allograft 114 NR Nonirradiated 441 NR ND NR A,P NR NR Fusion, otherwise NR
et al. (3) allograft (15)
R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx
[89]
Autograft 580 NR
(33)
Molinari 2012 Case Retro IV Intrawound vancomycin 1512 NR N/A N/A N/A Low SSI rate compared to C,T,L A, Some Trauma, degenerative Decompression, laminectomy,
et al. series powder (1g) (15) literature P,combo stenosis, fusion, instrumentation, discectomy
[92] spondylolisthesis, disc
disease, tumor
Nunez- 2011 HCCS Retro III Individualized antibiotic 223 NR Standard 236 NR Individualized antibiotic T,L P Y Trauma, deformity, Fusion, instrumentation
Perez prophylaxis based on urine (15) preoperative (22) prophylaxis decreased Gram degenerative stenosis,
et al. culture antibiotic prophylaxis negative bacilli SSI spondylolisthesis, disc
[97] disease, tumor
Ohtori et al. 2008 CCS Pro III Antibiotics for 2 days 70 (1) NR Antibiotics for 9 days 65 (0) NR ND L P Y Deformity, degenerative Fusion, instrumentation
[98] postoperatively postoperatively stenosis,
spondylolisthesis
O’Neill et al. 2011 CCS Retro III Intrawound vancomycin 56 (0) 43 (NR) No powder 54 (7) 45 (NR) Vancomycin decreased SSI C,T,L P Y Trauma Fusion, instrumentation
[99] powder (1g)
Pahys et al. 2013 HCCS Retro III Alcohol foam and drain, 195 57.1 (NR) Standard 483 53.6 Both alcohol-drain- C P Some Trauma, deformity, Decompression, laminectomy,
[102] intrawound vancomycin (0) perioperative (9) (NR) vancomycin and alcohol-drain degenerative stenosis, fusion, instrumentation, discectomy
powder (0.5 g) antibiotic prophylaxis reduced SSI compared to spondylolisthesis, disc
standard disease, tumor
Alcohol foam and drain 323 56.9 (NR)
(1)
Please cite this article in press as: Yao R et al. Prophylaxis of surgical site infection in adult spine surgery: A systematic review. J Clin Neurosci (2018),
Park et al. 2006 CCS Retro III Autologous blood transfusion 30 (0) 53.6 (NR) Homologous 32 (1) 56.9 ND NR NR Y? NR Decompression, laminectomy,
[103] transfusion (NR) fusion, instrumentation
Payne et al. 1996 RCT Pro II Closed-suction wound 103 NR No closed- suction 97 (1) NR ND L P N Degenerative stenosis Decompression, laminectomy
[105] drainage (2) wound drainage
Petignat 2008 RCT Pro I Single-dose antibiotics 613 45 (19–85) Placebo 624 NR Single-dose antibiotic NR P N Disc disease Decompression, laminectomy,
et al. preoperatively (8) (18) preoperatively decreased SSI discectomy
[106]
Poorman 2014 HCCS Retro III Closed-suction wound 39 (0) 46.4 (NR) No closed- suction 42 (1) 45.1 ND C A Y Degenerative stenosis, Decompression, fusion,
et al. drainage wound drainage (NR) disc disease instrumentation
[109]
Rehman 2015 HCCS Retro III Outer glove removal prior to 210 NR No outer glove 179 NR Outer glove removal L P Y Deformity, degenerative Decompression, fusion,
et al. implant handling (1) removal prior to (6) decreased SSI stenosis, instrumentation
[112] implant handling spondylolisthesis
Riley [113] 1998 Case Retro IV Gentamicin and cefuroxime 40 (0) 52 (22–84) N/A N/A N/A No SSI with use of cefuroxime C,T,L A, Some NR Decompression, laminectomy,
series preoperatively and gentamicin P,combo fusion, instrumentation,
preoperatively discectomy, hardware removal,
foreign body removal
Saulle et al. 2013 Case Retro IV Timing of drain removal 87 (2) 58.5 (20–81) N/A N/A N/A Acceptable SSI rate despite T,L P Y Deformity, Fusion, instrumentation
[117] series based on drainage <30 cc 2 lengthy duration of drain spondylolisthesis
shifts when BMP used, retention
https://doi.org/10.1016/j.jocn.2018.03.023
prophylactic antibiotics
(cefazolin or vancomycin)
over drain duration
Schroeder 2016 HCCS Retro III Intrawound vancomycin 1224 NR No powder 2253 NR Vancomycin decreased SSI C,T,L A, Some NR Decompression, fusion,
et al. powder (1–1.5 g) (5) (30) P,combo instrumentation, irrigation and
[119] debridement
Scuderi et al 2005 Case Retro IV N/A N/A N/A No closed-suction 85 (2) 45.3 Comparable SSI rate to L P Y Degenerative stenosis, Decompression and fusion
[121] series wound drainage (24– literature spondylolisthesis
61)
Sohn et al. 2013 HCCS Retro III Closed-suction wound 94 (0) 51.05 (NR) No closed- suction 75 (2) 46.0 ND NR P N Intradural tumor Decompression, tumor excision,
[129] drainage wound drainage (NR) durotomy with dural repair
Strom et al 2013 HCCS Retro III Intrawound vancomycin 79 (2) 60 (NR) No powder 92 60 (NR) Vancomycin decreased SSI C P Y Trauma, degenerative Decompression, laminectomy,
[131] powder (1g) (10) stenosis, infection, fusion, instrumentation
(cervi- tumor
cal)
Strom et al 2013 HCCS Retro III Intrawound vancomycin 156 64 (NR) No powder 97 64 (NR) Vancomycin decreased SSI T,L,S P Some Trauma, deformity, Decompression, laminectomy,
[132] powder (1g) (0) (11) degenerative stenosis, fusion, instrumentation
(lumbar) spondylolisthesis, disc
disease, tumor
Sweet et al 2011 HCCS Retro III Intrawound vancomycin 911 56 (12–86) No powder 821 53 (14– Vancomycin decreased SSI T,L P Y Trauma, deformity, Decompression, laminectomy,
[134] powder (2g) (2) (21) 83) degenerative stenosis, fusion, instrumentation, discectomy
spondylolisthesis, tumor
Takahashi 2009 HCCS Retro III Antibiotics preoperatively 536 NR Antibiotics for 7 days 539 47.4 Antibiotics preoperatively NR NR Some? NR Decompression, laminectomy,
et al. and for 5 days postoperatively (5) postoperatively (14) (NR) regardless of duration fusion, instrumentation
[135] postoperatively as short as 2
days decreased SSI
Antibiotics 257 NR
preoperatively (0)
and for 3 days
postoperatively
R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx
Please cite this article in press as: Yao R et al. Prophylaxis of surgical site infection in adult spine surgery: A systematic review. J Clin Neurosci (2018),
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8
Table 3 (continued)
https://doi.org/10.1016/j.jocn.2018.03.023
Please cite this article in press as: Yao R et al. Prophylaxis of surgical site infection in adult spine surgery: A systematic review. J Clin Neurosci (2018),
Authors Year Study Data Level of Intervention Comparative Group Result Spinal Approach Instrumentation Indication for Surgery Surgical Procedure
Design Collection Evidence Levels
SSI Prophylaxis # of Mean SSI Prophylaxis # of Mean
pts Age in pts Age in
(SSI Years (SSI Years
cases) (Range) cases) (Range)
SSI = surgical site infection, HCCS = historical case control study, CCS = case control study, RCT = randomized control trial, Retro = retrospective, Pro = prospective, NR = not recorded, ND = no difference, N/A = not applicable, C =
cervical, T = thoracic, L = lumbar, S = sacral, A = anterior, P = posterior, combo = combined anterior-posterior, ACDF = anterior cervical discectomy and fusion, BMP = bone morphogenetic protein.
R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx 9
3.3. Intrawound vancomycin powder compared to single dose preoperative antibiotics in instrumented
lumbar fusion. There is Grade B evidence that three or more days
Two level II studies and thirteen level III studies demonstrated a of postoperative antibiotics does not affect SSI rates as compared
reduction in SSI rate with use of intrawound vancomycin powder to two days of postoperative antibiotics when single dose preoper-
[17,31,32,48,52,59,61,76,80,98,118,130,131,133,138], while one ative antibiotics are given. There is insufficient evidence that addi-
level IV study found that there was a lower rate of SSI compared tional intraoperative dosing of teicoplanin for spine cases of
to the literature [91]. Eleven of these studies used 1 g of van- duration longer than 120 min or in instrumented cases affects SSI
comycin, three used 2 g, one used anywhere from 0.5 g to 2 g, rates. There is insufficient evidence that individualized antibiotic
and one used anywhere from 1 g to 1.5 g. However, one level I prophylaxis based on urine culture affects SSI rates, whether over-
study, one level II study, and two level III studies showed no differ- all or gram negative bacilli. There is Grade B evidence that extend-
ence in SSI with use of intrawound vancomycin powder ing postoperative antibiotics past 24 h for the duration of drain
[38,82,83,142], while one level IV study had no conclusion with usage does not affect SSI rates in thoracolumbar spine surgery.
regards to overall SSI rate but found a higher rate of gram negative
bacilli or polymicrobial SSIs compared to the literature [50]. Two of 3.5. Closed suction wound drainage
these studies used 2 g of vancomycin, one used 1 g, one used any-
where from 0.5 g to 6 g, and the remaining study did not specify as Two level II studies, five level III studies, and one level IV study
it used a state-wide database that only recorded if intrawound have all demonstrated no difference in SSI with use of a closed-
antibiotics were placed. suction wound drain. [16,26,70,104,108,119,128,151].
Conclusion: There is Grade C evidence that use of intrawound Conclusion: There is Grade A evidence that use of a closed-
vancomycin powder reduces SSI rates. suction wound drain does not affect SSI rates.
One level I study demonstrated a reduction in the SSI rate with Two level I studies have demonstrated a reduction in the SSI
administration of a single dose of preoperative intravenous (IV) rate with 0.35% povidone-iodine solution wound irrigation as com-
antibiotics as compared to placebo in non-instrumented spine sur- pared to regular saline irrigation [20,24]. The rate of SSI was 0% in
gery [105]. The rate of SSI was 1.3% in the 1.5 g IV cefuroxime the povidone-iodine group in both studies, as compared to 4.8%
group as compared to 2.9% in the placebo group. [20] and 3.4% [24] in the saline irrigation group.
Two level II studies, and two level III studies have all demon- Conclusion: There is Grade A evidence that use of 0.35%
strated no difference in SSI with single dose preoperative IV antibi- povidone-iodine solution wound irrigation reduces SSI rates.
otics as compared to multiple dose perioperative antibiotics in
non-instrumented lumbar spine surgery [34,68,69,72], while one 3.7. 2-Octyl-cyanoacrylate skin closure
level I study has demonstrated no difference in instrumented lum-
bar fusion [58]. In all five studies, a first- or third-generation One level II study demonstrated a reduced rate of SSI with use
cephalosporin was given except in the case of penicillin-allergy, of 2-octylcyanoacrylate for skin closure as compared to staples
in which case either vancomycin or clindamycin were given. The [6] while one level IV case series demonstrated a low SSI with
multiple dose perioperative regimen ranged from a single dose of use of 2-octylcyanoacrylate that was reduced in comparison with
postoperative IV antibiotics to seven days of postoperative IV historical controls using sutures [150]. In contrast, one level III
antibiotics or three days of postoperative IV antibiotics followed study demonstrated no difference in rate of SSI between 2- octyl-
by seven days of oral antibiotics, in addition to a single dose of pre- cyanoacrylate and either nylon sutures or staples for skin closure,
operative IV antibiotics. although this was limited by the small number in the suture/staple
One level II study and two level III studies demonstrated no dif- group [63].
ference between two days of postoperative antibiotics as compared Conclusion: There is Grade C evidence that use of 2-
to longer durations – ranging from three to nine days – of postop- octylcyanoacrylate for skin closure reduces SSI rates as compared
erative antibiotics in spine surgery [73,97,134]. In all three studies, to suture or staple skin closure.
single dose preoperative antibiotics were given.
One level IV study showed a low rate of SSI with intraoperative 3.8. Combination of prophylactic measures
dosing of teicoplanin at induction and repeated every 3 h in addi-
tion to standard single dose IV antibiotics (ampicillin and sulfabac- 3.8.1. Alcohol foam, closed-suction wound drainage, and intrawound
tam) in spine cases expected to be longer than 120 min in duration vancomycin powder
or where instrumentation was placed [85]. One level III study demonstrated a reduced rate of SSI with use
One level III study showed a reduction in gram negative bacilli of alcohol foam skin preparation and placement of closed-suction
but not overall SSI rates with use of individualized antibiotic pro- wound drainage with or without intrawound vancomycin powder
phylaxis based on urine culture in posterior thoracolumbar instru- as compared to a control group with no alcohol foam skin prepara-
mented fusion [96]. tion and no drain, but no difference in SSI rate between the combi-
One level I study showed no difference in SSI rates with extend- nation of alcohol foam skin preparation, drain, and intrawound
ing use of postoperative antibiotics for the entire drain duration as vancomycin powder and the combination of only alcohol foam
compared to postoperative antibiotics for 24 h regardless of drain and drain [101].
duration in thoracolumbar spine surgery [135]. Conclusion: There is insufficient evidence that a combination of
Conclusion: There is Grade B evidence that administration of alcohol foam skin preparation and closed-suction with or without
single dose preoperative antibiotics reduces SSI rates as compared intrawound vancomycin reduces SSI rates.
to no administration of antibiotics. There is Grade B evidence that
multiple dose perioperative antibiotics do not affect SSI rates as 3.8.2. Betadine irrigation and intrawound vancomycin
compared to single dose preoperative antibiotics in non- One level III study demonstrated a reduced rate of SSI with use
instrumented lumbar spine surgery. There is Grade B evidence that of 0.3% betadine irrigation and 1 g of intrawound vancomycin pow-
multiple dose perioperative antibiotics do not affect SSI rates as der as compared to saline irrigation with no intrawound antibiotics
Please cite this article in press as: Yao R et al. Prophylaxis of surgical site infection in adult spine surgery: A systematic review. J Clin Neurosci (2018),
https://doi.org/10.1016/j.jocn.2018.03.023
Table 4
10
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Reporting of bias-prone issues for evaluation of risk factors for surgical site infections after spinal surgery.
Authors Study Time Period of Eligibility Method of Patient/ Method of Sample Size Indications Surgical Prophylactic Strategies SSI SSI Outcome Details on F/ F/U in Months
Setting Investigation Criteria Case Identification Data Calculation for Surgery Procedures Other Than Intervention Definition Assessors U Reported (Min/Mean/Max)
Retrieval Blinded
Adogawa et al. 2014 + + + + + + + + + NR
Ando et al. 2014 + + + + + + + + >1yr/NR/NR
Basques et al. 2014 + + + + + + + NR
Brown et al. 2004 + + + + + + 12/NR/NR
Caroom et al. 2013 + + + + + + + + NR
Celik et al. 2007 + + + + + + + NR
Chang et al. 2006 + + + + + + + + NR/19/NR
Chen et al. 2012 + + + + + + + + 12/12/12
Cheng et al. 2005 + + + + + + + + + 6/16/24
Chin et al. 2007 + + + + + + + + NR
Choi et al. 2016 + + + + + + + NR
Christdolou et al. 2006 + + + + + NR
Demura et al. 2009 + + + + NR
Dennis et al. 2016 + + + + + + + + + + NR
[140]. The rate of SSI was 1.3% with the betadine irrigation and
13/26.4-54/68.4 intrawound vancomycin group as compared to 2.4% with the saline
13/23.8/54/69.6
irrigation and no intrawound antibiotic group.
12/NR/NR
Conclusion: There is insufficient evidence that the combination
18/39/66
3/NR/NR
3/3/3
reduces SSI rates.
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
3.8.3. Povidone-iodine and hydrogen peroxide mixture irrigation
One level III study demonstrated a reduced rate of SSI with use
of 10 cc of 10% povidone-iodine, 5 ml of water, and 1 ml of hydro-
+
+
+
+
+
+
+
+
+
+
+
3.8.4. Vertical laminar flow operating room and total body exhaust
gown
One level III study demonstrated a reduced rate of SSI with use
of a vertical laminar flow operating room in combination with total
body exhaust gowns as compared to a use of a conventional oper-
ating room with regular gowns [53]. The rate of SSI was 0% in the
vertical laminar flow and total body exhaust gown group as com-
pared to 12.9% in the conventional operating room with regular
+
+
+
+
+
+
+
gown group.
Conclusion: There is insufficient evidence that use of a vertical
laminar flow operating room in combination with total body
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
2013
Please cite this article in press as: Yao R et al. Prophylaxis of surgical site infection in adult spine surgery: A systematic review. J Clin Neurosci (2018),
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12 R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx
Please cite this article in press as: Yao R et al. Prophylaxis of surgical site infection in adult spine surgery: A systematic review. J Clin Neurosci (2018),
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R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx 13
3.9.14. Extended closed wound drain duration based on drainage erature has similarly found it to be safe with nontoxic serum levels
amount [8] and no signs of nephrotoxicity [46]. An trend towards an
One level IV case series demonstrated a low SSI rate with increased incidence of gram-negative or polymicrobial infections
extended duration of drain use (drain removed only when <30 ml has been noted in a case series by Ghobrial [49], although this
of output for 2 consecutive 8-h shifts) in posterior long segment has not been shown to be significant in studies since. Further
thoracolumbar fusion utilizing bone morphogenetic protein study, particularly in the form of another randomized controlled
(BMP) [116]. The SSI rate was 2.3%, which was deemed comparable trial, will be needed.
to or lower than rates previously reported in the literature.
Conclusion: There is insufficient evidence that extended dura-
4.2. Perioperative antibiotic prophylaxis
tion of closed wound drainage reduces SSI in posterior long seg-
ment thoracolumbar fusion utilizing BMP.
Although only one study in spine surgery has been conducted
with regards to the efficacy of prophylactic antibiotics in SSI in
3.9.15. Iodophor-Impregnated drapes the last twenty years, its results showing a reduction in SSI rates
One level IV case series demonstrated no SSIs without with preoperative antibiotics is consistent with those from a
iodophor-impregnated drape use over the incision site in anterior meta-analysis from Barker looking at spinal surgery, general
cervical fusions [25]. neurosurgery, and orthopaedic surgery [9]. Preoperative
Conclusion: There is insufficient evidence that iodophor- antibiotic prophylaxis was one of the Surgical Care Improvement
impregnated drape use over the incision affects SSI in anterior cer- Project (SCIP) measures to reduce surgical mortality and morbid-
vical fusion. ity, coming out of the National Surgical Infection Prevention
Project [15], and is also part of the recommendations from
4. Discussion the North American Spine Society (NASS) Clinical Guidelines
[122].
While several systematic reviews have been published on SSI There seems to be consistent evidence showing that a single
prophylactic measures in spine surgery [16,120,147,109,13], our dose of preoperative IV antibiotics is sufficient in non-
review serves not only as an update to previous reviews but also instrumented lumbar spine surgery [34,68 69,72], and that this
captures the largest number of studies to date on the subject, with has been reflected in the NASS Clinical Guidelines [122]. Aside
69 studies included. Despite a greater number of studies, however, from one level I study [58], however, this has not been tested in
most proposed measures have still not been investigated beyond a instrumented spine surgery. One of the SCIP measures was
single study. Only five prophylactic measures had two or more recommendation to discontinue postoperative antibiotics within
studies behind them. Additionally, as had been identified by van 24 h after surgical end time [15]. No spine studies have compared
Middendorp as problematic in studies up to and inclusive to 24 h of postoperative IV antibiotics with longer durations,
2010, reporting of bias-prone issues (Table 4) and reporting on although there have been a number showing no difference
SSI definitions (Table 5) remains poor in more recent studies. The between two days of postoperative antibiotics as compared to
impact of this can be substantial, as different criteria for SSI can longer durations when single dose preoperative antibiotics were
result in a change in the incidence reported [95]. Several Grade A given [73,97,134].
and B recommendations for prophylactic strategies were reached, In regards to individualized antibiotics based on preoperative
however (Table 6). urine culture, the single spine study [96] showed no difference in
overall SSI rate. One study on the topic in knee arthroplasty
patients similarly found no clear effect of asymptomatic bacteri-
4.1. Intrawound vancomycin powder
uria and treatment with specific antibiotics on periprosthetic infec-
tion [84].
Despite having the largest number of studies investigating its
While the one study in spine showed no difference in SSI
efficacy, there remains no definitive evidence that intrawound van-
rate with extending postoperative antibiotics past 24 h until the
comycin powder reduces SSI rates in adult spine surgery. Only one
discontinuation of drain usage [135], prolonged use of postopera-
level I study [142], has been done, which showed no difference in
tive antibiotics during the presence of a drain has been found to
SSI rate between the intrawound antibiotic and control groups. In
reduce SSI in mastectomy [37] and ventral hernia repair [155].
contrast, numerous level II and III studies have showed a reduction
However, mean drain duration in these studies was on the order
in SSI rate with use of intrawound vancomycin. A few studies have
eleven to nineteen days, as compared to three days in the spine
now been done in non-spine surgery, with mixed results in the
study by Takemoto, and such durations far exceed those seen in
effect on SSI with intrawound vancomycin. Abdullah et al. found
most spine cases with perhaps the exception of complex
a reduction in SSI rate in a retrospective matched cohort study
reconstructions.
with intrawound vancomycin in craniotomies [1] and Yan et al.
similarly found a reduction in SSI in a retrospective comparative
study on open release of post-traumatic stiff elbows [158], while 4.3. Closed suction wound drainage
Rasouli et al. found a low rate of SSI with its use in deep brain stim-
ulation surgery [110]. However, van Herwijnen et al. found that it The adult spine literature has consistently shown no effect on
did not affect SSI rates in a low risk adolescent idiopathic scoliosis SSI rates with use of closed suction wound drainage [16,26,70,10
cohort [145] and Ghobrial et al. found an elevated rate of SSI as 4,108,119,128,151]. This is in line with a 2007 Cochrane review
compared to institutional controls in intrathecal baclofen pump on closed suction wound drainage after orthopaedic surgery which
placement patients [50]. also found no statistically significant difference in SSI [103]. Liter-
While the efficacy of intrawound vancomycin remains in ature from other disciplines have also largely found no difference
debate, it does appear to have an excellent safety profile with in SSI with wound drains, including a 2007 Cochrane review in thy-
low rate of morbidity. A systematic review on complications from roid surgery [114] and a meta-analysis in lower limb arterial sur-
use of intrawound vancomycin in lumbar spine surgery found an gery [71]. Closed suction wound drainage may still be
adverse event rate of only 0.3%, with formation of a seroma being appropriate for other indications, however, such as prevention of
the most common complication [51], while the pediatric spine lit- hematoma formation.
Please cite this article in press as: Yao R et al. Prophylaxis of surgical site infection in adult spine surgery: A systematic review. J Clin Neurosci (2018),
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14 R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx
Although two level I studies in adult spine surgery demonstrate 4.7.1. Presurgical shaving
a reduction in SSI rates with povidone- iodine solution irrigation as Preoperative hair removal by shaving appears to increase SSI in
compared to regular saline irrigation [20,24], it should be noted literature across disciplines, with a meta-analysis of RCTs in 2015
that both studies come from the same institution. A recent study demonstrating that clipping, chemical depilation, or no hair
in pediatric scoliosis surgery by van Herwijinen et al., however, removal had significantly lower SSI rates when compared to shav-
also found a reduction in SSI rate with povidone-iodine irrigation ing [77]. Similarly, a Cochrane review found that clippers were
[145]. Across surgical disciplines, a meta-analysis by Fournel associated with less SSI than use of a razor, although they found
et al., found a statistically significant decrease in SSI rates with no significant difference between depilatory creams and shaving
povidone-iodine irrigation [43], although some of the included [137]. It is thought that the higher SSI with use of a razor is due
studies did not use regular saline irrigation in their comparison to higher risk of injury to the natural skin barrier as compared to
group. other forms of depilation, thereby increasing the risk for coloniza-
More recently, a systematic review and meta-analysis on intra- tion by bacteria. If razors are reused, the risk for cross-
operative wound irrigation in abdominal surgery found a trend contamination also exists if sterilization is improperly carried out
towards a reduction in SSI rate with povidone-iodine irrigation [28].
when compared with saline irrigation [92]. There has been con-
cerns raised about potential neurotoxic effects of povidone- 4.7.2. Postoperative TPN
iodine in cases of dural injury based on basic science studies [2] Although TPN has been suggested as a means of providing addi-
and so it has been suggested that povidone-iodine irrigation not tional nutritional support for recovery from surgery, and thereby
be used in cases with intradural work or where a dural tear has improving surgical outcomes, literature to date has not shown an
occurred. Additionally, other cytotoxic effects have been shown improvement in SSI rates with addition of TPN. An in vivo study
across various cell lineages in the lab including osteoblasts [94], of peritonitis in rabbits found that TPN did not significantly reduce
chondrocytes [149], and fibroblasts and mesenchymal stromal persistent infection rates post-appendectomy and in fact had a
cells [146]. As such, some consideration should be made especially trend towards an increased rate of persistent infection [127]. Sim-
in cases of revision for non-union before using povidone-iodine ilarly, a prospective randomized study on radical cystectomy
solution irrigation. patients found that the group receiving TPN in addition to their
normal enteric intake had a higher rate of SSI as well as other infec-
tious complications as compared to the group with enteric intake
4.5. 2-Octyl-Cyanoacrylate skin closure alone, even though nutritional parameters were restored earlier
in the TPN group [113]. An increased infectious complication rate
Studies on the effect of 2-octyl-cyanoacrylate skin closure on is a known concern with the use of parenteral nutrition [75], which
SSI rates in adult spine surgery are conflicting in their results and is thought to be multifactorial in nature, and may counteract any
are further complicated by comparison groups which are not uni- benefits from accelerated recovery of nutritional parameters.
form between studies in the makeup of sutures and/or staples for
closure [6,150,63]. 2-Octyl-cyanoacrylate does appear to have 4.7.3. Postoperative PGE1 administration
microbial barrier properties in vitro [12]; however, clinical There is a small body of evidence looking at the effects of PGE1
studies in other specialities have been mixed. The addition of administration in surgery. The only other study on PGE1 adminis-
2-octyl-cyanoacrylate to suture skin closure has been found to tration on SSI, done in post-laryngectomy patients with previous
reduce SSI rates in cardiac surgery when compared to suture alone radiation, showed a reduced rate of SSI in the PGE1 group com-
[129,44], but showed no difference in SSI rates when compared to pared to control [123]. However, other studies have suggested an
staples in studies on open colectomy [99] or total joint arthroplasty improvement in immune response [115,79] and increased blood
[89]. flow [79] with administration of PGE1 as potential mechanisms
for its effects on infection rates. In the context of previously irradi-
4.6. Combination of prophylactic measures ated tissue, the vasodilatory effects of PGE1 may be particularly of
benefit with respect to wound healing. However, further research
4.6.1. Vertical laminar flow operating room and total body exhaust is needed in order to come to any recommendations with respect
gown to its use.
Most of the literature on laminar airflow systems in the operat-
ing room, which has been combined with total body exhaust 4.7.4. MRSA screening and treatment of colonization
gowns in the past, come from orthopaedic surgery and primarily While there was no difference in the rate of early wound infec-
total joint arthroplasty. Currently, the evidence is mixed in tions with use of MRSA screening and treatment in the one adult
terms of whether it reduces periprosthetic joint infections spine study [22], MRSA screening and treatment has been found
[40,47,86,100], with one study showing a significant increase in to be of benefit in the surgical literature. A systematic review of
SSI rate with laminar airflow [62]. An observational study in ortho- orthopaedic studies found that MRSA screening and decolonization
paedic trauma found no significant difference in SSI rate with use reduced SSI across all 19 studies reviewed [23]. In a multicenter
of laminar flow room [106]. RCT involving screening of surgical patients across specialties,
MRSA screening followed by treatment with nasal mupirocin and
chlorhexidine soap found that the rate of S. aureus infection was
4.6.2. Implementation of infection prevention bundles 3.4% as compared to 7.7% in the control group [14]. Another sys-
While infection prevention bundles have been shown to reduce tematic review which included studies from not only orthopaedic
SSI in adult spine surgery in a few studies [42,87], as well as in but also cardiothoracic and mixed-surgical settings also found that
other surgical disciplines such as colorectal [136] or cardiac and most, though not all, studies found a reduction in SSI with screen-
orthopaedic surgery [81], the variability in these bundles between ing and decolonization [74]. There is current discussion in the
studies and institutions makes broad conclusions about any given infection control literature in regards to moving towards universal
bundle on SSI difficult. decolonization before surgery, although there is some concern
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Table 5
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15
16
Table 5 (continued)
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Table 6
Prophylactic strategies for spinal surgical site infection with Grade A and B recommendations.
about the possibility of development of mupirocin resistant strains 4.7.9. Triclosan-coated vicryl suture
of S. aureus [65,60]. Triclosan is an antimicrobial agent which affects both gram-
positive and gram-negative bacteria, used in a wide variety of
4.7.5. Incisional negative pressure wound therapy (NPWT) health care products. There is a great deal of interest in coating
While NPWT is a well-established treatment of acute or sutures with such antimicrobial agents, reflected in the large num-
chronic open wounds to promote healing, prophylactic NPWT ber of studies and meta-analyses in the last decade evaluating the
for closed incisions to prevent SSI or other wound complications efficacy of triclosan-coated sutures on SSI. Most meta-analyses
has been a more recent development. Several systematic reviews have shown a reduction in SSI with use of triclosan-coated sutures
and meta-analyses have suggested that incisional NPWT reduces [152,29,36,7,54], with one meta-analysis finding no difference
SSI across surgical disciplines [121,33,117,132]. However, the between triclosan-coated and non-coated sutures [21]. These
last update of the Cochrane review on the subject found the results were most significant in abdominal surgery, but also held
evidence for incisional NPWT to remain unclear with respect for clean, clean-contaminated, and contaminated surgery.
to SSI [153]. One systematic review and meta-analysis found
no significant reduction in SSI with stratified analysis of studies 4.7.10. Autologous blood transfusion
in orthopaedic/trauma surgery despite an overall reduction Two studies in colorectal cancer found that there was a reduced
in SSI across studies from all specialities, and qualified the SSI rate in those patients who preoperative deposited autologous
level of evidence as low [33]. Further high-quality studies are blood for transfusion as compared to those who were assigned to
required before recommending incisional NPWT for prophylaxis receive homologous blood [57,148]. On the other hand, there is
of SSI. some conflicting evidence on autologous versus allogenic blood
transfusion and their effect on SSI in hip and knee arthroplasty lit-
erature [45,93], with one finding a lower rate of SSI with no trans-
4.7.6. Silver-impregnated dressing
fusion or autologous transfusion compared to allogenic transfusion
Silver is known to have antimicrobial properties, and so silver-
[45] and the other finding no difference [93]. Both studies, how-
impregnated dressings have long been used for treatment of acute
ever, did not distinguish between autologous blood collected pre-
or chronic open wounds to prevent or treat infection. There is
operatively versus intraoperatively.
interest in using silver-impregnated dressings for preventing SSI
in closed incisions; however, evidence to date has been mixed. A
4.7.11. Outer glove removal prior to implant insertion
Cochrane review on dressings for prevention of SSI concluded that
While only represented by a single study [111] in the spine lit-
it was uncertain whether use of a silver-containing dressing
erature, regular replacement of gloves has been shown previously
affected the risk of SSI when compared to a basic wound contact
in the hip arthroplasty literature to reduce glove perforation and
dressing for either clean or clean-contaminated surgery [35]. In
contamination [4]. A prospective study on surgical glove perfora-
fact, both studies in the clean surgery arm had a higher rate,
tion has shown that perforation correlates with SSI, although only
though not statistically significant, of SSI in the silver dressing
if no preoperative prophylactic antibiotics are given [90].
group [35]. A recent RCT in hip fracture patients not included in
the Cochrane review also found no difference in SSI with a silver-
4.7.12. Extended closed wound drain duration based on drainage
coated dressing as compared to a regular dressing [67]. At this
amount
time, there is no clear evidence suggesting the use of silver-
Prolongation of drain use has been shown in other specialties to
impregnated dressings for prevention of SSI in closed incisions.
increase the risk of SSI [55,107]. However, the time frames for drain
duration used in these surgeries are on the order of weeks, with
4.7.7. Iodine-Impregnated implants prolonged drain duration being those longer than two or three
To date, all studies on iodine-impregnated implants have come weeks, which far exceeds drain duration typically seen spine cases.
out of a single institution, using techniques for coating titanium
implant surfaces with iodine to examine its effects on prevention 4.7.13. Iodophor-Impregnated drapes
of SSI [56,125,141], pin tract infection [126], or treatment of pre- Iodine-impregnated surgical drapes are thought to help prevent
existing infection [125,141]. In vitro and in vivo studies have SSI by reducing wound contamination by skin flora [41,66], while
shown that the iodine coating has antimicrobial activity while also providing an antimicrobial effect [18]. However, a Cochrane
being cytocompatible [124]. review on the surgical draping from 2015 found no reduction in
SSI with use of iodine-impregnated drapes, and in fact found a
4.7.8. Irradiated bone allograft higher SSI rate with adhesive drapes in general, when compared
One study in orthopaedic tumor surgery using massive struc- to no drapes [154]. If compared to non-impregnated drapes, a
tural allografts found no difference in rate of infection with use study in cardiac surgery found a significant reduction in SSIs with
of irradiated as compared to non-irradiated allografts [78]. the iodine-impregnated drapes [11].
Please cite this article in press as: Yao R et al. Prophylaxis of surgical site infection in adult spine surgery: A systematic review. J Clin Neurosci (2018),
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18 R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx
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R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx 19
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