Prophylaxis of Surgical Site Infection in Adult Spine Surgery

Journal of Clinical Neuroscience xxx (2018) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience

journal homepage: www.elsevier.com/locate/jocn
Review article
Prophylaxis of surgical site infection in adult spine surgery: A systematic

review q
Reina Yao a, Terence Tan b,c, Jin Wee Tee b,c, John Street a,⇑
a
Division of Spine Surgery, Dept. of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
b
Dept. of Neurosurgery, The Alfred, Melbourne, Victoria, Australia
c
National Trauma Research Institute Melbourne, Victoria, Australia
a r t i c l e i n f o a b s t r a c t
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),
2 R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx
identify all strategies studied to date for prophylaxis of SSI in Table 1

adult spine surgery but also to systematically review and evaluate Levels of evidence for therapeutic studies (adapted from Wright et al. 2003 [156]).
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.
We included studies which reported prophylactic measures to

3.2. Overview of included studies
prevent SSIs following adult spinal surgery. Excluded studies
included those which reported treatment of pre-existing SSIs, eval-
11 randomized controlled trials (RCTs), 51 case-controlled stud-
uation of pediatric patient populations, and those articles pub-
ies (CCS), and 7 case series were identified (Table 3). 7 studies were
lished in languages other than English or articles without an
characterized as level I evidence, 16 as level II, 38 as level III, and
abstract.
the remaining 8 as level IV. We noted wide variation in surgical
indications, approaches, procedures, and even definitions of SSI.
2.4. Determining level of evidence and grading recommendations Intra-wound vancomycin powder was the most widely studied
intervention, with 21 studies (one RCT, 18 CCS, 2 case series). 13
Two authors, one each in Canada and Australia, independently studies looked at perioperative antibiotic protocols (4 RCTs, 7
extracted data and rated quality of the included studies. Extracted CCS, 2 case series), of which 5 looked at the efficacy of single-
data included prophylactic measures, comparative measures, dose preoperative antibiotics compared to multiple-dose perioper-
spinal level, surgical indication, approach, and procedure, whether ative antibiotics (1 RCT, 4 CCS) while the remainder compared
instrumentation was placed, and outcome. Study quality was different durations or selection guidelines of perioperative antibi-
assessed based on study design, method of data collection, sample otics. 8 studies looked at closed- suction wound drainage alone
size, reporting of bias- prone issues, and definition of SSI, in similar (2 RCTs, 5 CCS, 1 case series). 2 studies looked at povidone-
fashion to the review by van Middendorp et al. Levels of evidence iodine solution irrigation alone (2 RCTs). 3 studies looked at
were assigned per an existing guideline (Table 1) [156], and con- use of 2-octyl-cyanoacrylate for skin closure (2 CCS, 1 case series).
sensus reached between all four authors if there were any dis- 7 studies looked at the efficacy of a combination of multiple inter-
agreements. Grade of recommendation, again based on an ventions (7 CCS) (see Table 4).
existing guideline (Table 2) [157], was then made for each prophy- 15 standalone interventions were examined by only a single
lactic measure based on existing guidelines. study each (2 RCTs, 11 CCS, 2 case series).
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
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
colonized pts stenosis,

with intranasal spondylolisthesis
mupirocin
Cheng et al. 2005 RCT Pro I Povidone-iodine 208 64 (NR) Saline wound 206 61 (NR) Povidone-iodine C,T,L NR Y Trauma, Fusion,
[25]
solution wound (0) irrigation (7) solution wound deformity, instrumentation
irrigation irrigation degenerative
decreased SSI stenosis, tumor
Chin et al. 2007 Case Retro IV N/A N/A N/A No iodophor- 616 52 (17- No SSI C A Y NR ACDF
[26]
series impregnated (0) 83)
drapes over
incision site
Choi et al. 2016 CCS Retro III Closed-suction wound 42 (0) 49.93 (NR) No closed- suction 39 (2) 43.86 ND L P N Disc disease Discectomy
[27] drainage wound drainage (NR)
Christdolou 2006 HCCS Retro and II After 26 (1) 53.0 Before 42 (7) 51.0 Implementation NR NR NR Trauma, NR
et al.
[28]
(continued on next page)
3
4
Table 3 (continued)
Pro implementation (NR) implementation (NR) of Nine P’s deformity,

of protocol of protocol protocol degenerative
(Nine P’s decreased SSI stenosis,
protocol) spondylolisthesis
Demura 2009 HCCS Pro II PGE1 administration 22 (1) NR No PGE1 22 (7) NR PGE1 administration C,T,L NR Y Trauma, deformity, Fusion, instrumentation
et al. administration
[31]
postoperatively postoperatively postoperative degenerative
in in decreased SSI in stenosis, tumor
preoperatively preoperatively preoperatively
irradiated irradiated irradiated
patients patients patients
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,
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
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
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
postoperatively and antibiotics

postoperatively
at discretion of
surgeon or
antibiotics
intraoperatively
q3h, single-dose
antibiotic
postoperatively
Kanayama 2007 HCCS Pro II Single-dose 464 55.4 Multiple-dose 1133 55.4 ND L P N Degenerative Fusion,
et al.
[70]
antibiotics on (2) (NR) antibiotics (9) (NR) stenosis, discectomy
day of surgery postoperatively spondylolisthesis
Kanayama 2010 HCCS Retro III Closed-suction 298 44 (NR) No closed- 262 48 (NR) ND L P Some Trauma, Decompression,
et al.
[71]
wound drainage (0) suction wound (0) deformity, laminectomy,
drainage degenerative instrumentation,
stenosis, disc discectomy,
disease tumor resection
Khan et al. 2009 CCS Retro II Single-dose antibiotics 21 (0) NR (18–70) 2 doses antibiotics 59 (5) NR ND L P N Degenerative stenosis, Decompression, laminectomy
[73] preoperatively postoperatively (18– disc disease
5

6
Table 3 (continued)
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,
[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)
[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)
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
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
Antibiotics preoperatively 83 (0) NR

and for 2 days postoperatively
Takemoto 2015 RCT Pro I Perioperative 170 57.4 Perioperative 144 58.1 ND T,L NR Some Deformity, Decompression,
et al.
[136]
antibiotics for (21) (18–86) antibiotics for (19) (19– degenerative laminectomy,
88)
24 h drain duration stenosis, fusion,
spondylolisthesis, instrumentation
disc disease
Theologis 2014 HCCS Retro III Intrawound 151 62.4 No powder 64 (7) 60 (21- Vancomycin NR NR Y Deformity Fusion,
et al
[139]
vancomycin (4) (18–88) 85) decreased SSI instrumentation
powder (2g)
Tofuku et al 2012 HCCS Pro II Vancomycin 196 57.9 No vancomycin 188 52 (7- Vancomycin C,T,L A, Y Trauma, Fusion,
[140] P,combo
powder (0) (12–89) powder or fibrin (11) 89) powder deformity, instrumentation
impregnated sealant impregnated degenerative
7
8
Table 3 (continued)
fibrin sealant fibrin sealant stenosis,

decreased SSI spondylolisthesis,
tumor, infection
Tomov et al 2015 HCCS Retro III Betadine (0.3%) 1173 NR Saline irrigation, 1252 NR Betadine C,T,L A, Some NR NR
[141] P,combo
irrigation and (15) no powder (30) irrigation and
intrawound vancomycin
vancomycin decreased SSI
powder (1g)
Tubaki et al 2013 RCT Pro I Intrawound 433 43.7 No powder 474 46.7 ND C,T,L,S A, Some NR NR
[143] P,combo
vancomycin (7) (NR) (NR)
powder (1g)
Ueno et al 2015 HCCS Retro III Triclosan coated Vicryl (Vicryl 200 56.8 (NR) Non-coated Vicryl 205 57.4 Triclosan coated Vicryl C,T,L A, Some Trauma, deformity, Decompression, laminectomy,
[144] Plus) wound closure (fascia, (1) wound closure (8) (NR) decreased SSI P,combo degenerative stenosis, fusion, instrumentation,
subcutaneous (fascia, spondylolisthesis, disc discectomy, tumor resection

subcutaneous) disease, tumor
Ulivieri et al 2011 HCCS Retro and III Povidone-iodine and 490 NR No povidone- iodine 460 NR Povidone-iodine and C,T,L A, Some Trauma, degenerative Decompression, laminectomy,
[145] Pro hydrogen peroxide mixture (0) and hydrogen (7) hydrogen peroxide mixture P,combo stenosis, fusion, instrumentation,
wound irrigation peroxide mixture wound irrigation decreased spondylolisthesis, disc discectomy, tumor resection
wound irrigation SSI disease, tumor
Wachter 2010 Case Pro IV 2-octylcyanoacrylate skin 235 60 (25–84) Suture skin closure 503 NR Low SSI rate compared to C,L A,P Some Degenerative stenosis, ACDF, decompression, fusion,
et al. series closure (1) (NR) historical comparative group disc disease discectomy
[151]
Walid et al. 2012 CCS Retro III Closed-suction wound 285 NR No closed-suction 117 NR ND L P NR Degenerative stenosis, Decompression, laminectomy,
[152] drainage (10) wound drainage (3) spondylolisthesis, disc fusion, instrumentation
disease
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.
3.4. Perioperative antibiotic prophylaxis 3.6. Povidone-iodine solution irrigation
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
Table 4
10
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

Devin et al. 2015 + + + + + + + + + NR
Dobzyniak et al. 2003 + + + + + + + 1.5/1.5/1.5
Ehlers et al. 2016 + + + + + + + NR/NR/16.5
Epstein 2007 + + NR
Featherall et al. 2016 + + + + + + + + NR
Gaviola et al. 2016 + + + + + + + + NR
Ghobrial et al. 2014 + + + + + + + + + NR
Godil et al. 2013 + + + + + + + + 1/6.25/7.5
Gruenberg et al. 2004 + + + + + + + + 6/I:35,II:28/67
Hayashi et al. 2015 + + + + NR
Hellbusch et al. 2008 + + + + + + + + + NR
Heller et al. 2015 + + + + + + 1.5/NR/NR
Hill et al. 2014 + + + + + + + 1/8.73-10.03/NR
Howard et al. 2014 + + + + + + + + NR
Hu et al. 1998 + + + + + + + NR
Kakimaru et al. 2010 + + + + + + + + NR
Kanayama et al. 2007 + + + + + + + 6/6/6
Kanayama et al. 2010 + + + + + NR
Khan et al. 2009 + + + + + + + 1/NR/>6
Kim et al. 2010 + + + + NR/NR/6
Lee et al. 2016 + + + + + + + + 8-11/NR/NR
Liu et al. 2015 + + + + + + + + + NR
Martin et al. 2014 + + + + + + + + + NR
Martin et al. 2015 + + + + + + + + + NR
Mastronardi et al. 2004 + + + + + + + + + NR
Meyer et al. 2010 + + + NR
Mikhael et al. 2009 + + + + + + 12/NR/NR
Molinari et al. 2012 + + + + + + + + + NR
Nunez-Perez et al. + + + + + + + 9/NR/NR
2011
Ohtori et al. 2008 + + + + NR
O’Neill et al. 2011 + + + + + + + + + + + NR/6-7.5/NR
Pahys et al. 2013 + + + + + + + NR
Park et al. 2006 + + + + + + NR
Payne et al. 1996 + + + + + + + NR
Petignat et al. 2008 + + + + + + + + + + 1.5/NR/6
Poorman et al. 2014 + + + + + + + NR
Rehman et al. 2015 + + + + + + + NR
Riley 1998 + + + + + + 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
of betadine irrigation and placement of intrawound vancomycin
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-
+
+
+
gen peroxide mixture irrigation followed by copious saline irriga-

tion in spinal surgery with intact dura [144]. The rate of SSI was
0% in the mixture irrigation group as compared to 1.5% in the no
mixture irrigation group.
Conclusion: There is insufficient evidence that irrigation with a
mixture of povidone-iodine and hydrogen peroxide followed by
copious saline irrigation reduces SSI rates.
+
+
+
+
+
+
+
+
+
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
+
+
+
+
+
+
+
+
+
+
+
+
+
+
exhaust gowns reduces SSI rates.
3.8.5. Protocol for identification and addressing predisposing factors

for SSI
+
+
+
+
+
+
+
+
+
+
+
One level II study demonstrated a reduced rate of SSI with

implementation of a protocol (‘‘Nine Ps”) to identify and address
all predisposing factors for SSI that were amenable to risk-
reducing interventions [27].
+
Conclusion: There is insufficient evidence that implementation

of a protocol (‘‘Nine Ps”) to identify and address predisposing
factors for SSI reduces SSI rates.
3.8.6. Implementation of infection prevention bundles

+
+
+
+
+
+
+
+
+
+
+
+
+
+
One level II study demonstrated a reduced rate of SSI with

implementation of a nine-point infection prevention bundle con-
sisting of MRSA screening and nasal decolonization with mupiro-
cin, self- preparation bath with chlorhexidine gluconate, self-
preparation with chlorhexidine wipes, storage optimization of
operative supplies, preoperative antibiotic administration algo-
+
+
+
+
+
+
+
+
+
+
+
+
+
+
SSI = surgical site infection, F/U = follow-up, NR = not reported.
rithm, staff training on betadine scrub and paint, intrawound van-

comycin in instrumented cases, postoperative early mobilization,
and wound checks at 2 and 6 weeks postoperatively [42]. One level
+
+
+
+
+
+
+
+
+
+
+
+
+
+
III study demonstrated a reduced rate of SSI with implementation

of a nine-point perioperative care bundle consisting of limiting in-
hospital stay to a maximum of 2 days, preoperative hair removal (if
needed) with a clipper or depilatory cream and immediately prior
to surgery, use of cefazolin for antibiotic prophylaxis with individ-
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
ual adjusted dosing and readministration q3-4h, use of iodophor

impregnated drapes, double gloving, expedient and atraumatic
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
surgical technique combined with saline wound irrigation, anes-

Strom et al. (cervical)
Schroeder et al. 2016
Takemoto et al. 2015

Strom et al. (lumbar)
Theologis et al. 2014

Takahashi et al 2009
thesiology cooperation to avoid hypothermia and hyperglycemia

Wachter et al. 2010
Scuderi et al. 2005
Ulivieri et al. 2011

Tofuku et al. 2012
Tomov et al. 2015
Tubaki et al. 2013
Sweet et al. 2011
Saulle et al. 2013
Walid et al. 2012

Ueno et al. 2015
and ensure optimal oxygenation and hemostasis while providing

Sohn et al. 2013
intraoperative muscle relaxation, avoiding drains when possible

and using them for as short a duration as possible if needed, and
2013
2013
application of a watertight drape as dressing with the dressing to

remain unchanged for at least 48 h and only changed if bleeding,
contaminated, or signs of infection [87].
Conclusion: As no two studies describe the same infection 3.9.7. Microscope

prevention bundle, there is insufficient evidence that the imple- One level III study demonstrated no difference in the rate of SSIs
mentation of any one infection prevention bundle reduces SSI with use of a microscope in spinal surgery at any level for a variety
rates. of pathologies [10].
Conclusion: There is insufficient evidence that use of a micro-
3.9. Standalone study interventions scope during surgery affects SSI rates.
3.9.1. Presurgical shaving 3.9.8. Silver-impregnated dressing

One level I study demonstrated an increased rate of SSI with One level III study demonstrated a reduction in the rate of SSIs
shaving of the surgical site with a razor in patients undergoing pos- with use of a silver-impregnated dressing in posterior lumbar
terior lumbar surgery for a variety of pathologies [19]. laminectomy with posterolateral instrumented fusions [39]. There
Conclusion: There is Grade B evidence that shaving the surgical were no SSIs in the silver-impregnated dressing group as compared
site in posterior lumbar surgery increases SSI rates. to 9.1% in the regular dry gauze dressing group.
Conclusion: There is insufficient evidence that the use of a
silver-impregnated dressing reduces SSI.
3.9.2. Postoperative total parenteral nutrition (TPN)
One level II study demonstrated no difference in SSI rate with 3.9.9. Iodine-impregnated implants
administration of TPN in place of standard crystalloid fluids follow- One level III study demonstrated a reduction in the rate of SSIs
ing each stage of a two-stage anterior and posterior thoracolumbar with use of iodine-impregnated spinal instruments in combined
spinal surgery, despite improvements in nutritional parameters anterior and posterior approach total en bloc spondylectomy for
[64]. tumor [56]. There was a SSI rate of 1.4% with iodine-impregnated
Conclusion: There is insufficient evidence that postoperative spinal instruments as compared to 12.5% without iodine-
TPN has any effect on SSI rates in two- stage anterior and posterior impregnated spinal instruments.
thoracolumbar spinal surgery. Conclusion: There is insufficient evidence that the use of iodine-
impregnated spinal instruments reduces SSI in combined anterior
3.9.3. Postoperative PGE1 administration and posterior approach total en bloc spondylectomy for tumor.
One level II study demonstrated a reduction in SSI rate with
postoperative PGE1 administration in preoperatively irradiated 3.9.10. Irradiated bone allograft
patients with spinal metastases [30]. The rate of SSI was 4.5% with One level III study demonstrated no difference in the rate of SSIs
postoperative PGE1 as compared to 31.8% without postoperative with use of irradiated allograft in spinal fusions (anterior, poste-
PGE1. rior, or combined approach) as compared to use of nonirradiated
Conclusion: There is insufficient evidence that postoperative allograft or autograft [88].
PGE1 administration in preoperatively irradiated patients with Conclusion: There is insufficient evidence that the use of a irra-
spinal metastases reduces SSI rates. diated allograft reduces SSI as compared to nonirradiated allograft
or to autograft in spinal fusions.
3.9.4. Vancomycin powder-impregnated fibrin sealant coating
One level II demonstrated a reduction in deep SSI rate with 3.9.11. Triclosan-coated vicryl suture
application of a vancomycin powder- impregnated fibrin sealant One level III study demonstrated a reduction in the rate of SSIs
onto spinal instrumentation in situ [139]. There were no deep SSIs with use of triclosan-coated polyglactin 910 (Vicryl Plus) suture for
in the vancomycin impregnated fibrin sealant group as compared wound closure (fascia and subcutaneous layers) as compared to
to 5.8% deep SSI rate in the control group. non-coated polyglactin 910 (Vicryl) suture [143]. The SSI rate
Conclusion: There is insufficient evidence that application of a was 0.5% in the Vicryl Plus group as compared to 3.9% in the Vicryl
vancomycin powder-impregnated fibrin sealant onto spinal instru- group.
mentation in situ reduces SSI rates. Conclusion: There is insufficient evidence that the use of
triclosan-coated polyglactin 910 suture for wound closure reduces
SSI.
3.9.5. MRSA screening and treatment of colonization
One level III study demonstrated no difference in the rate of 3.9.12. Autologous blood transfusion
early wound infections with use of MRSA screening and treatment One level III study demonstrated no difference in the rate of SSIs
in posterior midline spinal surgery at any spinal level for a variety with autologous transfusion (preoperative blood deposit and
of pathologies [22]. retransfusion) compared to homologous transfusion in posterior
Conclusion: There is insufficient evidence that MRSA screening instrumented spinal fusion for stenosis or spondylolisthesis
and treatment has no effect on rate of SSI in posterior midline [102]. The SSI rate was 3.3% (1/30) in the autologous group as com-
spinal surgery. pared to 0% (0/32) in the homologous group.
Conclusion: There is insufficient evidence that autologous blood
3.9.6. Incisional negative pressure wound therapy (NPWT) transfusion reduces SSI.
One level III study demonstrated a reduction in SSI with
application of incisional NPWT in long-segment posterior 3.9.13. Outer glove removal prior to implant insertion
thoracolumbar instrumented fusions [3]. The incisional NPWT One level III study demonstrated a reduction in the rate of SSIs
was set on a continuous setting at -80 mmHg and continued with removal of outer gloves after initial double gloving prior to
for 3 days postoperatively. The SSI rate was 10.63% in the handling and inserting instrumentation reduced the rate of SSIs
incisional NPWT group as compared to 14.91% in the regular as compared to single gloving with no glove change in lumbar pos-
dressing group. terior spinal instrumented fusion [111]. The SSI rate was 0.48% in
Conclusion: There is insufficient evidence that incisional NPWT the outer glove removal group vs. 3.35% in the single glove group.
reduces SSI rates in long-segment posterior thoracolumbar instru- Conclusion: There is insufficient evidence that outer glove
mented fusions. removal reduces SSI.
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.
4.4. Povidone-Iodine solution irrigation 4.7. Standalone study interventions
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
Table 5
Reported features for diagnosis of spinal surgical site infection.
Authors SSI Distinction Distinction Types of Criterion/Features for Diagnosis of SSI

definition between defined? SSI
reported superficial/ observed
deep
CDC Erythema Edema Pus Wound Fluctuance Fever Signs of Positive Positive Pain Blood Required Intraoperative Surgeon MRI
Criteria Dehiscence Meningitis Blood Wound (Increasing) Testing Surgery Findings Impression
Culture Culture
Adogawa et al. Y Y Y D + + + + + + + + +
2014
Ando et al. 2014 Y Y Y D,S + +
Basques et al. 2014 Y Y N D,S +
Brown et al. 2004 N N
Caroom et al. 2013 N N
Celik et al. 2007 Y Y N S + + + + + +
Chang et al. 2006 Y Y Y D + +
Chen et al. 2012 Y N + + +
Cheng et al. 2005 Y Y Y D,S + + + + + + + +

Chin et al. 2007 Y N N + + + + +
Choi et al. 2016 N N + + +
Christdolou et al. N N
2006
Demura et al. 2009 N Y N D +
Dennis et al. 2016 Y Y Y D,S + + + + + + +
Devin et al. 2015 Y Y N D,S + +
Dobzyniak et al. Y N + + + + +
2003
Ehlers et al. 2016 N N
Epstein 2007 Y Y N D,S + +
Featherall et al. N N
2016
Gaviola et al. 2016 Y Y Y D,S + + + + + + + + + +
Ghobrial et al. 2014 Y N N D + +
Godil et al. 2013 Y Y N D,S + +
Gruenberg et al. Y N + + +
2004
Hayashi et al. 2015 N Y N D +
Hellbusch et al. Y Y Y S + + +
2008
Heller et al. 2015 Y Y Y D,S + + +
Hill et al. 2014 Y Y Y D,S + + +
Howard et al. 2014 N Y N D,S
Hu et al. 1998 Y N + +
Kakimaru et al. Y Y Y D,S +
2010
Kanayama et al. Y Y N D,S + + + + + +
2007
Kanayama et al. N N
2010
Khan et al. 2009 Y Y Y S + +
Kim et al. 2010 N Y N D,S
Lee et al. 2016 Y Y Y D,S + + + +
Liu et al. 2015 Y N +
Martin et al. 2014 Y Y Y D + + + + + + + + + + +
Martin et al. 2015 Y N + + + + + + + +
Mastronardi et al. Y N N D,S + + + + +
2004
15
16
Table 5 (continued)
Authors SSI Distinction Distinction Types of Criterion/Features for Diagnosis of SSI

definition between defined? SSI
reported superficial/ observed
deep
CDC Erythema Edema Pus Wound Fluctuance Fever Signs of Positive Positive Pain Blood Required Intraoperative Surgeon MRI
Criteria Dehiscence Meningitis Blood Wound (Increasing) Testing Surgery Findings Impression
Culture Culture
Meyer et al. 2010 N Y N D
Mikhael et al. 2009 Y Y N D + +
Molinari et al. 2012 Y Y Y D +
Nunez-Perez et al. Y Y Y D,S + +
2011
Ohtori et al. 2008 N N
O’Neill et al. 2011 Y Y Y D,S + +
Pahys et al. 2013 Y Y Y D + + +
Park et al. 2006 Y N + +
Payne et al. 1996 N N N S
Petignat et al. 2008 Y Y Y D,S +

Poorman et al. N N
2014
Rehman et al. 2015 Y N + +
Riley 1998 N N
Saulle et al. 2013 N N N
Schroeder et al. N N +
2016
Scuderi et al. 2005 N Y N D,S
Sohn et al. 2013 N N + + + + + + + +
Strom et al. N N
(cervical) 2013
Strom et al. Y N N D,S +
(lumbar) 2013
Sweet et al. 2011 Y Y Y D,S + + + + + + + + + +
Takahashi et al. Y Y Y D,S +
2009
Takemoto et al. Y Y N D,S + + + + + +
2015
Theologis et al. Y N N +
2014
Tofuku et al. 2012 Y Y Y D +
Tomov et al. 2015 Y N N D +
Tubaki et al. 2013 N Y N D,S
Ueno et al. 2015 Y Y N D,S + + + + + +
Ulivieri et al. 2011 Y Y N D + +
Wachter et al. 2010 N N N D
Walid et al. 2012 N N
SSI = surgical site infection, S = superficial, D = deep.

Table 6
Prophylactic strategies for spinal surgical site infection with Grade A and B recommendations.
Grade of Recommended Intervention

Evidence
Grade A Use of a closed-suction wound drain does not affect SSI rates
Use of 0.35% povidone-iodine solution wound irrigation reduces SSI rates
Grade B Administration of single dose preoperative antibiotics reduces SSI rates as compared to no administration of antibiotics
Multiple dose perioperative antibiotics does not affect SSI rates as compared to single dose preoperative antibiotics in noninstrumented lumbar
spine surgery
Multiple dose perioperative antibiotics does not affect SSI rates as compared to single dose preoperative antibiotics in instrumented lumbar fusion
Three or more days of postoperative antibiotics does not affect SSI rates as compared to two days of postoperative antibiotics when single dose
preoperative antibiotics are given
Extending postoperative antibiotics past 24 h for the duration of drain usage does not affect SSI rates in thoracolumbar spine surgery
Shaving the surgical site in posterior lumbar surgery increases SSI rates
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].
5. Conclusions [11] Bejko J, Tarzia V, Carrozzini M, Gallo M, Bortolussi G, Comisso M, et al.

Comparison of efficacy and cost of iodine impregnated drape vs. standard
drape in cardiac surgery: study in 5100 patients. J Cardiovasc Transl Res
An expanding number of prophylactic measures have been 2015;8(7):431–7.
studied for SSI in adult spine surgery. However, most measures [12] Bhende S, Rothenburger S, Spangler DJ, Dito M. In vitro assessment of
microbial barrier properties of Dermabond topical skin adhesive. Surg Infect
have only one study behind them and need further investigation
(Larchmt) 2002;3(3):251–7.
to determine their efficacy. For this reason, there is insufficient evi- [13] Blood AG, Sandoval MF, Burger E, Halverson-Carpenter K. Risk and protective
dence to make any recommendation on most interventions. In the factors associated with surgical infections among spine patients. Surg Infect
(Larchmt) 2017;18(3):234–49.
case of intrawound vancomycin, numerous studies have been
[14] Bode LG, Kluytmans JA, Wertheim HF, Bogaers D, Vandenbroucke-Grauls CM,
done, but these have almost all been level III studies and the con- Roosendaal R, et al. Preventing surgical-site infections in nasal carriers of
flicting results between these and the one RCT done results in only Staphylococcus aureus. N Engl J Med. 2010;362(1):9–17.
level C evidence for its efficacy in reducing SSI. To delineate [15] Bratzler DW, Houck PM. Surgical Infection Prevention Guideline Writers
Workgroup. Antimicrobial prophylaxis for surgery: an advisory statement
whether it is truly efficacious in reducing SSI in adult spine surgery, from the National Surgical Infection Prevention Project. Am J Surg 2005;189
another RCT is in order as has been recommended by the authors of (4):395–404.
previous meta-analyses on intrawound vancomycin. [16] Brown MD, Brookfield KF. A randomized study of closed wound suction
drainage for extensive lumbar spine surgery.. Spine (Phila Pa 1976) 2004;29
Most of the prophylactic measures evaluated to date in adult (10):1066–8.
spine surgery have been studied in other disciplines for prevention [17] Caroom C, Tullar JM, Benton Jr EG, Jones JR, Chaput CD. Intrawound
of SSI, and often pioneered there. While future investigation into vancomycin powder reduces surgical site infections in posterior cervical
fusion. Spine (Phila Pa 1976) 2013;38(14):1183–7.
measures already studied in spine surgery should continue, pro- [18] Casey AL, Karpanen TJ, Nightingale P, Conway BR, Elliott TS. Antimicrobial
phylactic measures currently being assessed in other surgical spe- activity and skin permeation of iodine present in an iodine-impregnated
cialties such as gentamicin-collagen sponges or antimicrobial skin surgical incise drape. J Antimicrob Chemother 2015;70(8):2255–60.
[19] Celik SE, Kara A. Does shaving the incision site increase the infection rate after
sealants represent opportune targets for study in adult spine. Hav-
spinal surgery? Spine (Phila Pa 1976) 2007;32(15):1575–7.
ing been evaluated in other areas of surgery, the efficacy of these [20] Chang FY, Chang MC, Wang ST, Yu WK, Liu CL, Chen TH. Can povidone-iodine
interventions has been verified to a degree, and has at least some solution be used safely in a spinal surgery? Eur Spine J 2006;15(6):
1005–14.
safety data in the clinical scenario.
[21] Chang WK, Srinivasa S, Morton R, Hill AG. Triclosan-impregnated sutures to
While a small body of evidence underscores a select few inter- decrease surgical site infections: systematic review and meta-analysis of
ventions for SSI prophylaxis in adult spine surgery, most proposed randomized trials. Ann Surg 2012;255(50):854–9.
measures have not been investigated beyond a single study. Fur- [22] Chen AF, Chivukula S, Jacobs LJ, Tetreault MW, Lee JY. What is the prevalence
of MRSA colonization in elective spine cases? Clin Orthop Relat Res. 2012;470
ther high level evidence is required to justify and implement SSI (10):2684–9.
preventative treatments. [23] Chen AF, Wessel CB, Rao N. Staphylococcus aureus screening and
decolonization in orthopaedic surgery and reduction of surgical site
infections. Clin Orthop Relat Res 2013;471(7):2383–99.
Declarations of interest [24] Cheng MT, Chang MC, Wang ST, Yu WK, Liu CL, Chen TH. Efficacy of dilute
betadine solution irrigation in the prevention of postoperative infection of
spinal surgery. Spine (Phila Pa 1976) 2005;30(15):1689–93.
None. [25] Chin KR, London N, Gee AO, Bohlman HH. Risk for infection after anterior
cervical fusion: Prevention with iodophor-impregnated incision drapes. Am J
Orthop (Belle Mead NJ) 2007;36(8):433–5.
Sources of support [26] Choi HS, Lee SG, Kim WK, Son S, Jeong TS. Is surgical drain useful for lumbar
disc surgery? Korean J Spine. 2016;13(1):20–3.
[27] Christodoulou AG, Givissis P, Symeonidis PD, Karataglis D, Pournaras J.
This research did not receive any specific grant from funding Reduction of postoperative spinal infections based on an etiologic protocol.
agencies in the public, commercial, or not-for-profit sectors. Clin Orthop Relat Res 2006;444:107–13.
[28] Dai Y, Zhang C, Ma X, Chang W, Hu S, Jia H, et al. Outbreak of carbapenemase-
producing Klebsiella pneuomoniae neurosurgical site infections associated
References with a contaminated shaving razor used for preoperative scalp shaving. Am J
Infect Control 2014;42(7):805–6.
[29] Daoud FC, Edmiston Jr CE, Leaper D. Meta-analysis of prevention of surgical
[1] Abdullah KG, Attiah MA, Olsen AS, Richardson A, Lucas TH. Reducing surgical
site infections following incision closure with triclosan-coated sutures:
site infections following craniotomy: examination of the use of topical
robustness of new evidence. Surg Infect (Larchmt) 2014;15(3):165–81.
vancomycin. J Neurosurg 2015;123(6):1600–4.
[30] Demura S, Kawahara N, Murakami H, Nambu K, Kato S, Yoshioka K, et al.
[2] Akcay E, Ersahin Y, Ozer F, Duransoy YK, Camlar M, Atci I, et al. Neurotoxic
Surgical site infection in spinal metastasis: Risk factors and countermeasures.
effect of povidone-iodine on the rat spine using a laminectomy-durotomy
Spine (Phila Pa 1976) 2009;34(6):635–9.
model. Childs Nerv Syst 2012;28(12):2071–5.
[31] Dennis HH, Wei DT, Darren KZ, Shantakumar JT, Kumar N, Lau LL, et al. Is
[3] Adogwa O, Fatemi P, Perez E, Moreno J, Gazcon GC, Gokaslan ZL, et al.
intraoperative local vancomycin powder the answer to surgical site infections
Negative pressure wound therapy reduces incidence of postoperative wound
in spine surgery? Spine (Phila Pa 1976) 2016 [Epub ahead of print].
infection and dehiscence after long- segment thoracolumbar spinal fusion: A
[32] Devin CJ, Chotai S, McGirt MJ, Vaccaro AR, Youssef JA, Orndorff DG, et al.
single institutional experience. Spine J 2014;14(12):2911–7.
Intrawound vancomycin decreases the risk of surgical site infection after
[4] Al-Maiyah M, Bajwa A, Finn P, Mackenney P, Hill D, Port A, et al. Glove
posterior spine surgery – a multicenter analysis. Spine (Phila Pa 1976) 2015
perforation and contamination in primary total hip arthroplasty. J Bone J Surg
[Epub ahead of print].
(Br) 2005;87-B(4):556–9.
[33] De Vries FE, Wallert ED, Solomkin JS, Allegranzi B, Egger M, Dellinger EP, et al.
[5] Anderson DJ, Podgorny K, Berrios-Torres SI, Bratzler DW, Dellinger EP, Greene
A systematic review and meta-analysis including GRADE qualification of the
L, et al. Strategies to prevent surgical site infections in acute care hospitals:
risk of surgical site infections after prophylactic negative pressure wound
2014 update. Infect Control Hosp Epidemiol 2014;35(6):605–27.
therapy compared with conventional dressings in clean and contaminated
[6] Ando M, Tamaki T, Yoshida M, Sasaki S, Toge Y, Matsumoto T, et al. Surgical
surgery. Medicine (Baltimore) 2016;95(36):e4673.
site infection in spinal surgery: A comparative study between 2-octyl-
[34] Dobzyniak MA, Fischgrund JS, Hankins S, Herkowitz HN. Single versus
cyanoacrylate and staples for wound closure. Eur Spine J 2014;23(4):854–62.
multiple dose antibiotic prophylaxis in lumbar disc surgery. Spine (Phila Pa
[7] Apisarnthanarak A, Singh N, Bandong AN, Madriaga G. Triclosan-coated
1976) 2003;28(21):E453–5.
sutures reduce the risk of surgical site infections: a systematic review and
[35] Dumville JC, Gray TA, Walter CJ, Sharp CA, Page T, Macefield R, et al. J.
meta-analysis. Infect Control Hosp Epidemiol 2015;36(2):169–79.
Dressings for the prevention of surgical site infection. Cochrane Database Syst
[8] Armaghani SJ, Menge TJ, Lovejoy SA, Mencio GA, Martus JE. Safety of topical
Rev. 2016;12:CD003091.
vancomycin for pediatric spinal deformity: nontoxic serum levels with
[36] Edmiston Jr CE, Daoud FC, Leaper D. Is there an evidence-based argument for
supratherapeutic drain levels. Spine (Phila Pa 1976) 2014;39(20):1683–7.
embracing an antimicrobial (triclosan)-coated suture technology to reduce
[9] Barker FG. Efficacy of prophylactic antibiotic therapy in spinal surgery: a
the risk for surgical-site infections?: A meta-analysis. Surgery 2013;154
meta-analysis. Neurosurgery 2002;51(2):391–400.
(1):89–100.
[10] Basques BA, Golinvaux NS, Bohl DD, Yacob A, Toy JO, Varthi AG, et al. Use of an
[37] Edwards BL, Stukenborg GJ, Brenin DR, Schroen AT. Use of prophylactic
operating microscope during spine surgery is associated with minor increases
postoperative antibiotics during surgical drain presence following
in operating room times and no increased risk of infection. Spine (Phila Pa
mastectomy. Ann Surg Oncol 2014;21(10):3249–55.
1976) 2014;39(22):1910–6.
[38] Ehlers AP, Khor S, Shonnard N, Oskouian Jr RJ, Sethi RK, Cizik AM, et al. Intra- [63] Howard BM, Eshraghi SR, Holland CM, Refai D. Octyl-cyanoacrylate skin
wound antibiotics and infection in spine fusion surgery: a report from adhesive is effective for wound closure in posterior spinal surgery without
Washington State’s SCOAP- CERTAIN collaborative. Surg Infect (Larchmt) increased risk of wound complications. Clin Neurol Neurosurg
2016;17(2):179–86. 2014;125:137–42.
[39] Epstein NE. Do silver-impregnated dressings limit infections after lumbar [64] Hu SS, Fontaine F, Kelly B, Bradford DS. Nutritional depletion in staged spinal
laminectomy with instrumented fusion? Surg Neurol 2007;68(5):483–5. reconstructive surgery. the effect of total parenteral nutrition. Spine (Phila Pa
discussion 485. 1976) 1998;23(12):1401–5.
[40] Evans RP. Current concepts for clean air and total joint arthroplasty: laminar [65] Humphreys H, Becker K, Dohmen PM, Petrosillo N, Spencer M, van Rijen M,
airflow and ultraviolet radiation: a systematic review. Clin Orthop Relat Res et al. Staphylococcus aureus and surgical site infections: benefits of
2011;469(4):945–53. screening and decolonization before surgery. J Hosp Infect 2016;94
[41] Fairclough JA, Johnson D, Mackie I. The prevention of wound contamination (3):295–304.
by skin organisms by the pre-operative application of an iodophor [66] Jacobson C, Osmon DR, Hanssen A, Trousdale RT, Pagnano MW, Pyrek J, et al.
impregnated plastic adhesive drape. J Int Med Res 1986;14(2):105–9. Prevention of wound contamination using DuraPrep solution plus Ioban 2
[42] Featherall J, Miller JA, Bennett EE, Lubelski D, Wang H, Khalaf T, et al. drapes. Clin Orthop Relat Res 2005;439:32–7.
Implementation of an infection prevention bundle to reduce surgical site [67] Kadar A, Eisenberg G, Yahav E, Drexler M, Salai M, Steinberg EL. Surgical site
infections and cost following spine surgery. JAMA Surg 2016;151 infection in elderly patients with hip fractures, silver-coated versus regular
(10):988–90. dressings: a randomised prospective trial. J Wound Care. 2015;24(10):441–2.
[43] Fournel I, Tiv M, Soulias M, Hua C, Astruc K, Aho Glelel LS. Meta-analysis of 444-445.
intraoperative povidone-iodine application to prevent surgical-site infection. [68] Kakimaru H, Kono M, Matsusaki M, Iwata A, Uchio Y. Postoperative
Br J Surg 2010;97(11):1603–13. antimicrobial prophylaxis following spinal decompression surgery: Is it
[44] Fraeman KH, Reynolds MW, Vaughn BB, Hart JC. Patient outcomes associated necessary? J Orthop Sci 2010;15(3):305–9.
with 2-octyl cyanoacrylate topical skin adhesive in coronary artery bypass [69] Kanayama M, Hashimoto T, Shigenobu K, Oha F, Togawa D. Effective
graft surgery. Surg Infect (Larchmt) 2011;12(4):307–16. prevention of surgical site infection using a Centers for Disease Control and
[45] Friedman R, Homering M, Holberg G, Berkowitz SD. Allogenic blood Prevention guideline-based antimicrobial prophylaxis in lumbar spine
transfusions and postoperative infections after total hip or knee surgery. J Neurosurg Spine (Phila Pa 1976) 2007;6(4):327–9.
arthroplasty. J Bone Joint Surg Am 2014;96(4):272–8. [70] Kanayama M, Oha F, Togawa D, Shigenobu K, Hashimoto T. Is closed-suction
[46] Gans I, Dormans JP, Spiegel DA, Flynn JM, Sankar WN, Campbell RM, et al. drainage necessary for single-level lumbar decompression?: Review of 560
Adjunctive vancomycin powder in pediatric spine surgery is safe. Spine (Phila cases. Clin Orthop Relat Res 2010;468(10):2690–4.
Pa 1976) 2013;38(19):1703–7. [71] Karthikesalingam A, Walsh SR, Sadat U, Tang TY, Koraen L, Varty K.
[47] Gastmeier P, Breier A-C, Brandt C. Influence of laminar airflow on prosthetic Efficacy of closed suction drainage in lower limb arterial surgery: a
joint infections: a systematic review. J Hosp Infect 2012;81:73–8. meta-analysis of published clinical trials. Vasc Endovascular Surg 2001;42
[48] Gaviola ML, McMillian WD, Ames SE, Endicott JA, Alston WK. A retrospective (3):243–8.
study on the protective effects of topical vancomycin in patients undergoing [72] Khan IU, Janjua MB, Hasan S, Shah S. Surgical site infection in lumbar
multilevel spinal fusion. Pharmacotherapy 2016;36(1):19–25. surgeries, pre and postoperative antibiotics and length of stay: a case study. J
[49] Ghobrial GM, Thakkar V, Andrews E, Lang M, Chitale A, Oppenlander ME, et al. Ayub Med Coll Abbottabad 2009;21(3):135–8.
Intraoperative vancomycin use in spinal surgery: Single institution [73] Kim B, Moon SH, Moon ES, Kim HS, Park JO, Cho IJ. Antibiotic microbial
experience and microbial trends. Spine (Phila Pa 1976) 2014;39(7):550–5. prophylaxis for spinal surgery: Comparison between 48 and 72-hour AMP
[50] Ghobrial GM, Thakkar V, Singhal S, Oppenlander E, Maulucci CM, Harrop JS, protocols. Asian Spine J 2010;4(2):71–6.
et al. Efficacy of intraoperative vancomycin powder use in intratechal [74] Kock R, Becker K, Cookson B, van Gemert-Pijnen JE, Harbarth S, Kluytmans J,
baclofen pump implantation procedures: single institutional series in a et al. Systematic literature analysis and review of targeted preventive
high risk population. J Clin Neurosci 2014;21(10):1786–9. measures to limit healthcare- associated infections by methicillin-resistant
[51] Ghobrial GM, Cadotte DW, Williams Jr K, Fehlings MG, Harrop JS. Staphylococcus aureus. Euro Surveill 2014;19(29):23–49.
Complications from the use of intrawound vancomycin in lumbar spinal [75] Koretz RL, Lipman TO, Klein S. American Gastroenterological Association. AGA
surgery: a systematic review. Neurosurg Focus 2015;39(4):E11. technical review on parenteral nutrition. Gastroenterology 2001;121
[52] Godil SS, Parker SL, O’Neill KR, Devin CJ, McGirt MJ. Comparative effectiveness (4):970–1001.
and cost- benefit analysis of local application of vancomycin powder in [76] Lee GI, Bak KH, Chung HJ, Choi KS. Effect of using local intrawound
posterior spinal fusion for spine trauma: clinical article. J Neurosurg Spine vancomycin powder in addition to intravenous antibiotics in posterior
2013;19(3):331–5. lumbar surgery: midterm result in a single-center study. Korean J Spine
[53] Gruenberg MF, Campaner GL, Sola CA, Ortolan EG. Ultraclean air for 2016;13(2):47–52.
prevention of postoperative infection after posterior spinal fusion with [77] Lefebvre A, Saliou P, Lucet JC, Mimoz O, Keita-Perse O, Grandbastien B, et al.
instrumentation: A comparison between surgeries performed with and French Study Group for the Preoperative Prevention of Surgical Site
without a vertical exponential filtered air-flow system. Spine (Phila Pa Infections. Preoperative hair removal and surgical site infections: network
1976) 2004;29(20):2330–4. meta-analysis of randomized controlled trials. J Hosp Infect 2015;91
[54] Guo J, Pan LH, Li YX, Yang XD, Li LQ, Zhang CY, et al. Efficacy of triclosan- (2):100–8.
coated sutures for reducing risk of surgical site infection in adults: a meta- [78] Lietman SA, Tomford WW, Gebhardt MC, Springfield DS, Mankin HJ.
analysis of randomized clinical trials. J Surg Res 2016;201(1):105–17. Complications of irradiated allografts in orthopaedic tumor surgery. Clin
[55] Hanna KR, Tilt A, Holland M, Colen D, Bowen B, Stovall M, et al. Reducing Orthop Relat Res 2000;375:214–7.
infectious complications in implant based breast reconstruction: impact of [79] Lovati AB, Romano CL, Monti L, Vassena C, Previdi S, Drago L. Does PGE1
early expansion and prolonged drain use. Ann Plast Surg 2016;76(Suppl. 4): vasodilator prevent orthopaedic implant-related infection in diabetes?
S312–5. Preliminary results in a mouse model. PLoS One 2014;9(4):e94758.
[56] Hayashi H, Murakami H, Demura S, Kato S, Yoshioka K, Shinmura K, et al. [80] Liu N, Wood KB, Schwab JH, Cha TD, Puhkan RD, Osler PM, et al. Comparison
Surgical site infection after total en bloc spondylectomy: risk factors and the of intrawound utility in posterior instrumented spine surgeries between
preventive new technology. Spine J 2015;15(1):132–7. patients with tumor and nontumor patients. Spine (Phila Pa 1976) 2015;40
[57] Heiss MM, Mempel W, Jauch KW, Delanoff C, Mayer G, Mempel M, et al. (20):1586–92.
Beneficial effect of autologous blood transfusion on infectious complications [81] Ma N, Cameron A, Tivey D, Grae N, Roberts S, Morris A. Systematic review of a
after colorectal cancer surgery. Lancet 1993;342(8883):1328–33. patient care bundle in reducing staphylococcal infections in cardiac and
[58] Hellbusch LC, Helzer-Julin M, Doran SE, Leibrock LG, Long DJ, Puccioni MJ, orthopaedic surgery. ANZ J Surg 2017;87(4):239–46.
et al. Single-dose vs multiple-dose antibiotic prophylaxis in instrumented [82] Martin JR, Adogwa O, Brown CR, Bagley CA, Richardson WJ, Lad SP, et al.
lumbar fusion–a prospective study. Surg Neurol. 2008;70(6):622–7. Experience with intrawound vancomycin powder for spinal deformity
discussion 627. surgery. Spine (Phila Pa 1976) 2014;39(2):177–84.
[59] Heller A, McIff TE, Lai SM, Burton DC. Intrawound vancomycin powder [83] Martin JR, Adogwa O, Brown CR, Kuchibhatla M, Bagley CA, Lad SP, et al.
decreases staphylococcal surgical site infections after posterior instrumented Experience with intrawound vancomycin powder for posterior cervical fusion
spinal arthrodesis. J Spinal Disord Tech 2015;28(10):E584–589. surgery. J Neurosurg Spine 2015;22(1):26–33.
[60] Hetem DJ, Bootsma MC, Bonten MJ. Prevention of surgical site infections: [84] Martinez-Velez D, Gonzalez-Fernandez E, Esteban J, Cordero-Ampuero J.
decontamination with mupirocin based on preoperative screening for Prevalence of asymptomatic bacteriuria in knee arthroplasty patients and
Staphylococcus carriers or universal decontamination? Clin Infect Dis subsequent risk of prosthesis infection. Eur J Orthop Surg Traumatol 2016;26
2016;62(5):631–6. (2):209–14.
[61] Hill BW, Emohare O, Song B, Davis R, Kang MM. The use of vancomycin [85] Mastronardi L, Tatta C. Intraoperative antibiotic prophylaxis in clean spinal
powder reduces surgical reoperation in posterior instrumented and surgery: A retrospective analysis in a consecutive series of 973 cases. Surg
noninstrumented spinal surgery. Acta Neurochir (Wien) 2014;156 Neurol 2004;61(2):129–35.
(4):749–54. [86] McHugh SM, Hill AD, Humphreys H. Laminar airflow and the prevention of
[62] Hooper GJ, Rothwell AG, Frampton C, Wyatt MC. Does the use of laminar flow surgical site infection. More harm than good? Surgeon 2015;13(1):52–8.
and space suits reduce early deep infection after total hip and knee [87] Meyer D, Klarenbeek R, Meyer F. Current concepts in perioperative care for
replacement?: the ten-year results of the New Zealand Joint Registry. J the prevention of deep surgical site infection in elective spine surgery. Cent
Bone Joint Surg Br 2011;93(1):85–90. Eur Neurosurg 2004;71(3):117–20.
[88] Mikhael MM, Huddleston PM, Nassr A. Postoperative culture positive surgical [114] Samraj K, Gurusamy KS. Wound drains following thyroid surgery. Cochrane
site infections after the use of irradiated allograft, nonirradiated allograft, or Database Syst Rev 2007;17(4). CD006099.
autograft for spinal fusion. Spine (Phila Pa 1976) 2009;34(22):2466–8. [115] Sano T, Masuda M, Morita S, Yasui H. Prostaglandin E1 attenuates
[89] Miller AG, Swank ML. Dermabond efficacy in total joint arthroplasty wounds. impairment of cellular immunity after cardiopulmonary bypass. Jpn J
Am J Orthop (Belle Mead NJ) 2010;39(10):476–8. Thorac Cardiovasc Surg 2006;54(4):149–54.
[90] Misteli H, Weber WP, Reck S, Rosenthal R, Zwahlen M, Fueglstaler P, et al. [116] Saulle D, Fu KM, Shaffrey CI, Smith JS. Multiple-day drainage when using
Surgical glove perforation and the risk of surgical site infection. Arch Surg bone morphogenic protein for long-segment thoracolumbar fusions is
2009;144(6):553–8. associated with low rates of wound complications. World Neurosurg
[91] Molinari RW, Khera OA, Molinari 3rd WJ. Prophylactic intraoperative 2013;80(1–2):204–7.
powdered vancomycin and postoperative deep spinal wound infection: [117] Scalise A, Calamita R, Tartaglione C, Pierangeli M, Bolletta E, Gioacchini M,
1,512 consecutive surgical cases over a 6-year period. Eur Spine J 2012;21 et al. Improving wound healing and preventing surgical site complications of
(Suppl 4):S476–82. closed surgical incisions: a possible role of incisional negative pressure
[92] Mueller TC, Loos M, Haller B, Mihalijevic AL, Nitsche U, Wilhelm D, et al. wound therapy. A systematic review of the literature. Int Wound J 2016;13
Intra-operative wound irrigation to reduce surgical site infections after (6):1260–81.
abdominal surgery: a systemic review and meta-analysis. Langenbecks Arch [118] Schroeder JE, Girardi FP, Sandhu H, Weinstein J, Cammisa FP, Sama A. The use
Surg 2015;400(2):167–81. of local vancomycin powder in degenerative spine surgery. Eur Spine J
[93] Newman ET, Watters TS, Lewis JS, Jennings JM, Wellman SS, Attarian DE, et al. 2016;25(4):1029–33.
Impact of perioperative allogenic and autologous blood transfusion on acute [119] Scuderi GJ, Brusovanik GV, Fitzhenry LN, Vaccaro AR. Is wound drainage
wound care infection following total knee and total hip arthroplasty. J Bone necessary after lumbar spinal fusion surgery? Med Sci Monit 2005;11(2):
Joint Surg Am 2014;96(4):279–84. CR64-6.
[94] Newton Ede MP, Philp AM, Philp A, Richardson SM, Mohammad S, Jones SW. [120] Schuster JM, Rechtine G, Norvell DC, Dettori JR. The influence of perioperative
Povidone- iodine has a profound effect on in vitro osteoblast proliferation and risk factors and therapeutic interventions on infection rates after spine
metabolic function and inhibits their ability to mineralize and form bone. surgery: a systematic review. Spine (Phila Pa 1976) 2010;35(9 Suppl). S125-37.
Spine (Phila Pa 1976) 2016;41(9):729–34. [121] Semsarzadeh NN, Tadisina KK, Maddox J, Chopra K, Singh DP. Closed incisions
[95] Nota SPFT, Braun Y, Ring D, Schwab JH. Incidence of surgical site infection negative-pressure therapy is associated with decreased surgical-site
after spine surgery what is the impact of the definition of infection? Clin infections: a meta-analysis. Plast Reconstr Surg 2015;136(3):592–602.
Orthop Relat Res 2015;473(5):1612–9. [122] Shaffer WO, Baisden JL, Fernand R, Matz PG. North American Spine Society.
[96] Nunez-Pereira S, Pellise F, Rodriguez-Pardo D, Pigrau C, Sanchez JM, Bago J, An evidence-based clinical guideline for antibiotic prophylaxis in spine
et al. Individualized antibiotic prophylaxis reduces surgical site infections by surgery. Spine J 2013;13(10):1387–92.
gram-negative bacteria in instrumented spinal surgery. Eur Spine J 2011;20 [123] Shiga K, Tateda M, Saijo S. Complication-free laryngeal surgery after
(Suppl. 3):397–402. irradiation failure with prostaglandin E1 administration. Ann Otol Rhinol
[97] Ohtori S, Inoue G, Koshi T, Yamashita M, Yamauchi K, Suzuki M, et al. Long- Laryngol 2002;111(9):783–8.
term intravenous administration of antibiotics for lumbar spinal surgery [124] Shirai T, Shimizu T, Ohtani K, Zen Y, Takaya M, Tsuchiya H. Antibacterial
prolongs the duration of hospital stay and time to normalize body iodine- supported titanium implants. Acta Biomater 2011;7(4):1928–33.
temperature after surgery. Spine (Phila Pa 1976) 2008;33(26):2935–7. [125] Shirai T, Tsuchiya H, Nishida H, Yamamoto N, Watanabe K, Nakase J, et al.
[98] O’Neill KR, Smith JG, Abtahi AM, Archer KR, Spengler DM, McGirt MJ, et al. Antimicrobial megaprostheses supported with iodine. J Biomater Appl
Reduced surgical site infections in patients undergoing posterior spinal 2014;29(4):617–23.
stabilization of traumatic injuries using vancomycin powder. Spine J 2011;11 [126] Shirai T, Watanabe K, Matsubara H, Nomura I, Fujiwara H, Arai Y, et al.
(7):641–6. Prevention of pin tract infection with iodine-supported titanium pins. J
[99] Ong J, Ho KS, Chew MH, Eu KW. Prospective randomised study to evaluate the Orthop Sci 2014;19(4):598–602.
use of DERMABOND ProPen (2-octylcyanoacrylate) in the closure of [127] Sitges-Serra A, Hernandez R, Maestro S, Fernandez N, Girvent M, Sancho JJ.
abdominal wounds versus closure with skin staples in patients undergoing Influence of parenteral nutrition on postoperative recovery in an
elective colectomy. Int J Colorectal Dis 2010;25(7):899–905. experimental model of peritonitis. Clin Nutr 2001;20(5):439–43.
[100] Pada S, Perl TM. Operating room myths: what is the evidence of common [128] Sohn S, Chung CK, Kim CH. Is closed-suction drainage necessary after
practices. Curr Opin Infect Dis 2015;28(4):369–74. intradural primary spinal cord tumor surgery? Eur Spine J 2013;22
[101] Pahys JM, Pahys JR, Cho SK, Kang MM, Zebala LP, Hawasli AH, et al. Methods (3):577–83.
to decrease postoperative infections following posterior cervical spine [129] Souza EC, Fitaroni RB, Januzelli DM, Macruz HM, Camacho JC, Souza MR. Use
surgery. J Bone Joint Surg Am 2013;95(6):549–54. of 2- octyl cyanoacrylate for skin closure of sternal incisions in cardiac
[102] Park MS, Moon SH, Kim HS, Hahn SB, Park HW, Park SY, et al. A comparison of surgery: observations of microbial barrier effects. Curr Med Res Opin 2008;24
autologous and homologous transfusions in spinal fusion. Yonsei Med J (1):151–5.
2006;47(6):840–6. [130] Strom RG, Pacione D, Kalhorn SP, Frempong-Boadu AK. Decreased risk of
[103] Parker MJ, Livingstone V, Clifton R, McKee A. Closed suction surgical wound wound infection after posterior cervical fusion with routine local application
drainage after orthopaedic surgery. Cochrane Database Syst Rev 2007;18(3): of vancomycin powder. Spine (Phila Pa 1976) 2013;38(12):991–4.
CD001825. [131] Strom RG, Pacione D, Kalhorn SP, Frempong-Boadu AK. Lumbar laminectomy
[104] Payne DH, Fischgrund JS, Herkowitz HN, Barry RL, Kurz LT, Montgomery DM. and fusion with routine local application of vancomycin powder: Decreased
Efficacy of closed wound suction drainage after single-level lumbar infection rate in instrumented and non-instrumented cases. Clin Neuro
laminectomy. J Spinal Disord 1996;9(5):401–3. Neurosurg 2013;115(9):1766–9.
[105] Petignat C, Francioli P, Harbarth S, Regli L, Porchet F, Reverdin A, et al. [132] Swanson EW, Cheng HT, Susarla SM, Lough DM, Kumar AR. Does negative
Cefuroxime prophylaxis is effective in noninstrumented spine surgery: A pressure wound therapy applied to closed incisions following ventral hernia
double-blind, placebo-controlled study. Spine (Phila Pa 1976) 2008;33 repair prevent wound complications and hernia recurrence? A systematic
(18):1919–24. review and meta-analysis. Plast Surg (Oakv) 2016;24(2):113–8.
[106] Pinder EM, Bottle A, Aylin P, Loeffler MD. Does laminar flow ventilation [133] Sweet FA, Roh M, Sliva C. Intrawound application of vancomycin for
reduce the rate of infection? An observational study of trauma in England. prophylaxis in instrumented thoracolumbar fusions: Efficacy, drug levels,
Bone Joint J 2016;98-B(9):1262–9. and patient outcomes. Spine (Phila Pa 1976) 2011;36(24):2084–8.
[107] Plymale MA, Harris JW, Davenport DL, Smith N, Levy S, Scott Roth J. [134] Takahashi H, Wada A, Iida Y, Yokoyama Y, Katori S, Hasegawa K, et al.
Abdominal wall reconstruction: the uncertainty of the impact of drain Antimicrobial prophylaxis for spinal surgery. J Orthop Sci 2009;14(1):40–4.
duration upon outcomes. Am Surg 2016;82(3):207–11. [135] Takemoto RC, Lonner B, Andres T, Park J, Ricart-Hoffiz P, Bendo J, et al.
[108] Poorman CE, Passias PG, Bianco KM, Boniello A, Yang S, Gerling MC. Appropriateness of twenty-four-hour antibiotic prophylaxis after spinal
Effectiveness of postoperative wound drains in one- and two- level cervical surgery in which a drain is utilized: A prospective randomized study. J
spine fusions. Int J Spine Surg 2014;8. https://doi.org/10.14444/1034. Bone Joint Surg Am 2015;97(12):979–86.
eCollection 2014. [136] Tanner J, Padley W, Assadian O, Leaper D, Kiernan M, Edmiston C. Do surgical
[109] Radcliff KE, Neusner AD, Millhouse PW, Harrop JD, Kepler CK, Rasouli MR, care bundles reduce the risk of surgical site infections in patients undergoing
et al. What is new in the diagnosis and prevention of spine surgical site colorectal surgery? A systematic review and cohort meta-analysis of 8,515
infections. Spine J 2015;15(2):336–47. patients. Surgery 2015;158(1):66–77.
[110] Rasouli JJ, Kopell BH. The adjunctive use of vancomycin powder appears safe [137] Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site
and may reduce the incidence of surgical-site infections after deep brain infection. Cochrane Database Syst Rev 2011;9(11):CD004122.
stimulation surgery. World Neurosurg 2016;95:9–13. [138] Theologis AA, Demirkiran G, Callahan M, Pekmezci M, Ames C, Deviren V.
[111] Rehman A, Rehman AU, Rehman TU, Freeman C. Removing outer gloves as a Local intrawound vancomycin powder decreases the risk of surgical site
method to reduce spinal surgery infection. J Spinal Disord Tech 2015;28(6): infections in complex adult deformity reconstruction: A cost analysis. Spine
E343–346. (Phila Pa 1976) 2014;39(22):1875–80.
[112] Riley 3rd LH. Prophylactic antibiotics for spine surgery: Description of a [139] Tofuku K, Koga H, Yanase M, Komiya S. The use of antibiotic-impregnated
regimen and its rationale. J Southern Orthop Assoc 1998;7(3):212–7. fibrin sealant for the prevention of surgical site infection associated with
[113] Roth B, Birkhauser FD, Zehnder P, Thalmann GN, Huwyler M, Burkhard FC, spinal instrumentation. Eur Spine J 2012;21(10):2027–33.
et al. Parenteral nutrition does not improve postoperative recovery from [140] Tomov M, Mitsunaga L, Durbin-Johnson B, Nallur D, Roberto R. Reducing
radical cystectomy: results of a prospective randomised trial. Eur Urol surgical site infection in spinal surgery with betadine irrigation and
2013;63(3):475–82. intrawound vancomycin powder. Spine (Phila Pa 1976) 2015;40(7):491–9.
[141] Tsuchiya H, Shirai T, Nishida H, Murakami H, Kabata T, Yamamoto N, et al. [149] Von Keudell A, Canseco JA, Gomoll AH. Deleterious effects of diluted
Innovative antimicrobial coating of titanium implants with iodine. J Orthop povidone-iodine on articular cartilage. J Arthroplasty 2013;28(6):918–21.
Sci 2012;17(5):595–604. [150] Wachter D, Bruckel A, Stein M, Oertel MF, Christophis P, Boker DK. 2-octyl-
[142] Tubaki VR, Rajasekaran S, Shetty AP. Effects of using intravenous antibiotic cyanoacrylate for wound closure in cervical and lumbar spinal surgery.
only versus local intrawound vancomycin antibiotic powder application in Neurosurg Rev 2010;33(4):483–9.
addition to intravenous antibiotics on postoperative infection in spine [151] Walid MS, Abbara M, Tolaymat A, Davis JR, Waits KD, Robinson 3rd JS, et al.
surgery in 907 patients. Spine (Phila Pa) 2013;38(25):2149–55. The role of drains in lumbar spine fusion. World Neurosurg 2012;77(3-
[143] Ueno M, Saito W, Yamagata M, Imura T, Inoue G, Nakazawa T, et al. Triclosan- 4):564–8.
coated sutures reduce wound infections after spinal surgery: A retrospective, [152] Wang ZX, Jiang CP, Cao Y, Ding YT. Systematic review and meta-analysis of
nonrandomized, clinical study. Spine J 2015;15(5):933–8. triclosan- coated sutures for the prevention of surgical-site infection. Br J
[144] Ulivieri S, Toninelli S, Petrini C, Giorgio A, Olivieri G. Prevention of post- Surg 2013;100(4):465–73.
operative infections in spine surgery by wound irrigation with a solution of [153] Webster J, Scuffham P, Stankiewicz M, Chaboyer WP. Negative pressure
povidone-iodine and hydrogen peroxide. Arch Orthop Trauma Surg 2011;131 wound therapy for skin grafts and surgical wounds healing by primary
(9):1203–6. intention. Cochrane Database Syst Rev 2014;7(10):CD009261.
[145] Van Herwijnen B, Evans NR, Dare CJ, Davies EM. An intraoperative [154] Webster J, Alghamdi A. Use of plastic adhesive drapes during surgery for
irrigation regiment to reduce the surgical site infection rate following preventing surgical site infection. Cochrane Database Sst Rev 2015;22(4):
adolescent idiopathic scoliosis surgery. Ann R Coll Surg Engl 2016;98 CD006353.
(5):320–3. [155] Wong A, Lee S, Nathan NS, Wang F, Hansen SL, Harris HW, et al. Postoperative
[146] Van Meurs SJ, Gawlitta D, Heemstra KA, Poolman RW, Vogely HC, Kruyt MC. prophylactic antibiotic use following ventral hernia repair with placement of
Selection of an optimal antiseptic solution for intraoperative irrigation: an surgical drains reduces the postoperative surgical-site infection rate. Plast
in vitro study. J Bone Joint Surg Am 2014;96(4):285–91. Reconstr Surg 2016;137(1):285–94.
[147] Van Middendorp JJ, Pull ter Gunne AF, Schuetz M, Habil D, Cohen DB, Hosman [156] Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to
AJF, et al. A methodological systematic review on surgical site infections The Journal. J Bone Joint Surg Am 2003;85-A(1):1–3.
following spinal surgery. Part 2: prophylactic treatments. Spine (Phila Pa [157] Wright JG, Einhorn TA, Heckman JD. Grades of recommendation. J Bone Joint
1976) 2012;37(24):2034–45. Surg Am 2005;87-A(9):1909–10.
[148] Vignali A, Braga M, Dionigi P, Radaelli G, Gentilini O, Bellini A, et al. Impact of [158] Yan H, He J, Chen S, Yu S, Fan C. Intrawound application of vancomycin
a programme of autologous blood donation on the incidence of infection in reduces wound infection after open release of post-traumatic stiff elbows: a
patients with colorectal cancer. Eur J Surg 1995;161(7):487–92. retrospective comparative study. J Shoulder Elbow Surg 2014;23(3):686–92.

Prophylaxis of Surgical Site Infection in Adult Spine Surgery

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Prophylaxis of Surgical Site Infection in Adult Spine Surgery

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Journal of Clinical Neuroscience xxx (2018) xxx–xxx

Contents lists available at ScienceDirect

Journal of Clinical Neuroscience

Prophylaxis of surgical site infection in adult spine surgery: A systematic

identify all strategies studied to date for prophylaxis of SSI in Table 1

We included studies which reported prophylactic measures to

colonized pts stenosis,

(continued on next page)

Pro implementation (NR) implementation (NR) of Nine P’s deformity,

postoperatively and antibiotics

(continued on next page)

Antibiotics preoperatively 83 (0) NR

(continued on next page)

fibrin sealant fibrin sealant stenosis,

R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx

3.4. Perioperative antibiotic prophylaxis 3.6. Povidone-iodine solution irrigation

R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx

of betadine irrigation and placement of intrawound vancomycin

gen peroxide mixture irrigation followed by copious saline irriga-

exhaust gowns reduces SSI rates.

3.8.5. Protocol for identification and addressing predisposing factors

One level II study demonstrated a reduced rate of SSI with

Conclusion: There is insufficient evidence that implementation

3.8.6. Implementation of infection prevention bundles

One level II study demonstrated a reduced rate of SSI with

SSI = surgical site infection, F/U = follow-up, NR = not reported.

rithm, staff training on betadine scrub and paint, intrawound van-

III study demonstrated a reduced rate of SSI with implementation

ual adjusted dosing and readministration q3-4h, use of iodophor

surgical technique combined with saline wound irrigation, anes-

Takemoto et al. 2015

Theologis et al. 2014

thesiology cooperation to avoid hypothermia and hyperglycemia

Ulivieri et al. 2011

Walid et al. 2012

and ensure optimal oxygenation and hemostasis while providing

intraoperative muscle relaxation, avoiding drains when possible

application of a watertight drape as dressing with the dressing to

Conclusion: As no two studies describe the same infection 3.9.7. Microscope

3.9.1. Presurgical shaving 3.9.8. Silver-impregnated dressing

4.4. Povidone-Iodine solution irrigation 4.7. Standalone study interventions

Reported features for diagnosis of spinal surgical site infection.

Authors SSI Distinction Distinction Types of Criterion/Features for Diagnosis of SSI

R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx

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Authors SSI Distinction Distinction Types of Criterion/Features for Diagnosis of SSI

R. Yao et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx

SSI = surgical site infection, S = superficial, D = deep.

Grade of Recommended Intervention

5. Conclusions [11] Bejko J, Tarzia V, Carrozzini M, Gallo M, Bortolussi G, Comisso M, et al.

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