European Society of Clinical Microbiology and Infectious Diseases/European Committee on infection control clinical guidelines on pre-operative decolonization and targeted prophylaxis in patients colonized by multidrug-resistant Gram-positive bacteria befo

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Abstract

[Indexed for MEDLINE] 6. Spine J. 2020 Mar;20(3):435-447. doi: 10.1016/j.spinee.2019.09.013. Epub 2019 Sep 23. Prophylactic postoperative measures to minimize surgical site infections in spine surgery: systematic review and evidence summary. Tan T(1), Lee H(1), Huang MS(2), Rutges J(3), Marion TE(4), Mathew J(5), Fitzgerald M(5), Gonzalvo A(6), Hunn MK(2), Kwon BK(7), Dvorak MF(7), Tee J(8). Author information: (1)Department of Neurosurgery, The Alfred Hospital, Level 1, Old Baker Building, 55 Commercial Rd, Melbourne, Victoria 3004, Australia; National Trauma Research Institute, Melbourne, Victoria, Australia. (2)Department of Neurosurgery, The Alfred Hospital, Level 1, Old Baker Building, 55 Commercial Rd, Melbourne, Victoria 3004, Australia. (3)Department of Orthopedics, Erasmus MC, Rotterdam Area, Netherlands. (4)Department of Orthopedic Surgery, Northern Ontario School of Medicine, Ontario, Canada. (5)National Trauma Research Institute, Melbourne, Victoria, Australia. (6)Department of Neurosurgery, Austin Hospital, Heidelberg, Victoria, Australia. (7)Department of Orthopedics, Vancouver Spine Surgery Institute, University of British Columbia, Vancouver, BC, Canada; ICORD (International Collaboration on Repair Discoveries), University of British Columbia, Vancouver, BC, Canada. (8)Department of Neurosurgery, The Alfred Hospital, Level 1, Old Baker Building, 55 Commercial Rd, Melbourne, Victoria 3004, Australia; National Trauma Research Institute, Melbourne, Victoria, Australia. Electronic address: jin.tee@ntrispine.com. BACKGROUND CONTEXT: There are three phases in prophylaxis of surgical site infections (SSI): preoperative, intraoperative and postoperative. There is lack of consensus and paucity of evidence with SSI prophylaxis in the postoperative period. PURPOSE: To systematically evaluate the literature, and provide evidence-based summaries on postoperative measures for SSI prophylaxis in spine surgery. STUDY DESIGN: Systematic review, meta-analysis, evidence synthesis. METHODS: A systematic review conforming to PRIMSA guidelines was performed utilizing PubMed (MEDLINE), EMBASE, and the Cochrane Database from inception to January 2019. The GRADE approach was used for quality appraisal and synthesis of evidence. Six postoperative care domains with associated key questions were identified. Included studies were extracted into evidence tables, data synthesized quantitatively and qualitatively, and evidence appraised per GRADE approach. RESULTS: Forty-one studies (nine RCT, 32 cohort studies) were included. In the setting of preincisional antimicrobial prophylaxis (AMP) administration, use of postoperative AMP for SSI reduction has not been found to reduce rate of SSI in lumbosacral spine surgery. Prolonged administration of AMP for more than 48 hours postoperatively does not seem to reduce the rate of SSI in decompression-only or lumbar spine fusion surgery. Utilization of wound drainage systems in lumbosacral spine and adolescent idiopathic scoliosis corrective surgery does not seem to alter the overall rate of SSI in spine surgery. Concomitant administration of AMP in the presence of a wound drain does not seem to reduce the overall rate of SSI, deep SSI, or superficial SSI in thoracolumbar fusion performed for degenerative and deformity spine pathologies, and in adolescent idiopathic scoliosis corrective surgery. Enhanced-recovery after surgery clinical pathways and infection-specific protocols do not seem to reduce rate of SSI in spine surgery. Insufficient evidence exists for other types of spine surgery not mentioned above, and also for non-AMP pharmacological measures, dressing type and duration, suture and staple management, and postoperative nutrition for SSI prophylaxis in spine surgery. CONCLUSIONS: Despite the postoperative period being key in SSI prophylaxis, the literature is sparse and without consensus on optimum postoperative care for SSI prevention in spine surgery. The current best evidence is presented with its limitations. High quality studies addressing high risk cohorts such as the elderly, obese, and diabetic populations, and for traumatic and oncological indications are urgently required. Copyright © 2019 Elsevier Inc. All rights reserved. DOI: 10.1016/j.spinee.2019.09.013