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What's the Evidence? - Systematic Literature Review of Risk Factors and Preventive Strategies for Surgical Site Infections Following Pediatric Spine Surgery

Saturday, October 20, 2012: 1:14 PM
Melrose (Hilton Riverside)
Michael Glotzbecker, MD1, Matthew D. Riedel, BA2, Michael G. Vitale, MD, MPH, FAAP2, Hiroko Matsumoto, MA2, David P. Roye Jr., MD2, Mark A. Erickson, MD3, John Flynn, MD, FAAP4 and Lisa Saiman, MD, MPH5, (1)Department of Orthopaedics, Children's Hospital Boston, Boston, MA, (2)Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, (3)Orthopaedics, The Children's Hospital, Aurora, CO, (4)Department of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, PA, (5)Department of Infection Prevention and Control, Columbia University Medical Center, New York, NY

Purpose

Despite relatively high rates of surgical site infections (SSIs) after pediatric spine surgery, few studies have evaluated risk factors and preventive strategies. Thus, practice guidelines are absent and infection prevention strategies vary widely. Furthermore, no centralized summary of available literature to reduce SSIs following pediatric spine surgery exists. The purpose of this study is to provide a centralized summary of available literature regarding risk evaluation and prevention strategies to reduce SSIs following pediatric spine surgery.

Methods

A systematic review of the literature was performed in December 2011 utilizing the root search words of spine, scoliosis, and infection across multiple databases. The search was limited to pediatric populations and articles in the English language. After reviewing 9594 abstracts, 31 articles remained by removing duplicate articles and those irrelevant to risk factors and interventions for the prevention of SSIs in pediatric spine surgery. These 31 articles were rated for level of evidence by three authors using a validated rating tool. Grades of evidence for each intervention were then determined using these levels of evidence according to a validated method.

Results

Grade A recommendations suggest that ceramic has an equal risk of complications to autograft. Grade B recommendations suggest that the following increase risk of SSI: Underlying medical disease, particularly CP or myelodysplasia; Urinary or bowel incontinency; Non-adherence to antibiotic prophylaxis protocols; and increased implant prominence. Also, Gram negative infections are more frequent in neuromuscular populations and first generation stainless steel implants are associated with increased risk of delayed infection when compared to newer generation titanium implants. Grade C recommendations (inconsistent results) suggest the following increase risk of SSI: Malnutrition, positive urine culture pre-operatively; Elevated or Decreased WBC; Obesity; Number of levels fused; Extension of fusion to the sacrum/pelvis; Blood loss; Use of allograft; and that use of drains reduces risk of postoperative wound complications.  Grade I recommendations (0-1 studies in literature) were found for: chlorhexidine skin wash the night before surgery, pre-operative nasal swabs for MRSA, pre-operative patient education sheet, peri-operative skin preparation type (chlorhexidine vs. iodine-based), peri-operative IV vancomycin use, surgical site hair removal, limiting operating room access, hypothermia, wound irrigation technique (saline vs. betadine, pulsatile vs. continuous), vancomycin powder in surgical site, plastic surgery help in closure (in high risk patients), addition of antibiotics to graft (gentamicin or vancomycin), UV light use in the operating room, post-operative dressing choice (gauze, io-ban, tegaderm, etc), and frequency of post-operative dressing removal.

Conclusion

Very little literature evidence exists to support SSI risk factors and prevention interventions in pediatric spine surgery. While this study provides a standardized, comprehensive review of all available literature to prevent pediatric spine SSIs, pediatric spine surgeons will likely continue to rely on personal experience until better data is developed.