====== Surgical site infection prevention ====== {{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/16uwQpOeqFYK8R4yLAkdMsVH6xi8N6gcbAsv6ngfqJC-yqE10l/?limit=15&utm_campaign=pubmed-2&fc=20250307170145}} ---- ---- There are three phases in [[prophylaxis]] of [[surgical site infection]]s (SSI): [[Preoperative Surgical site infection prevention]] [[Intraoperative Surgical site infection prevention]] [[Postoperative Surgical site infection prevention]] There is lack of consensus and paucity of evidence with SSI prophylaxis in the postoperative period. ---- Use of postoperative surgical [[antimicrobial prophylaxis]] was not correlated with SSI rates at the [[hospital]] level after adjusting for differences in procedure mix and patient characteristics ((He K, Nayak RB, Allori AC, Brighton BK, Cina RA, Ellison JS, Goretsky MJ, Jatana KR, Proctor MR, Grant C, Thompson VM, Iwaniuk M, Cohen ME, Saito JM, Hall BL, Newland JG, Ko CY, Rangel SJ. Correlation Between Postoperative Antimicrobial Prophylaxis Use and Surgical Site Infection in Children Undergoing Nonemergent Surgery. JAMA Surg. 2022 Oct 19. doi: 10.1001/jamasurg.2022.4729. Epub ahead of print. PMID: 36260310.)) ---- To systematically evaluate the literature, and provide evidence-based summaries on postoperative measures for SSI prophylaxis in spine surgery Tan et al. published a systematic review, meta-analysis, evidence synthesis. A systematic review conforming to PRISMA guidelines was performed utilizing PubMed (MEDLINE), EMBASE, and the Cochrane Database from inception to January 2019. The [[GRADE]] approach was used for quality appraisal and synthesis of evidence. Six postoperative care domains with associated key questions were identified. Included studies were extracted into evidence tables, data synthesized quantitatively and qualitatively, and evidence appraised per GRADE approach. Forty-one studies (9 RCT, 32 cohort studies) were included. In the setting of pre-incisional antimicrobial prophylaxis (AMP) administration, use of postoperative AMP for SSI reduction has not been found to reduce rate of SSI in lumbosacral spine surgery. Prolonged administration of AMP for more than 48h postoperatively does not seem to reduce the rate of SSI in decompression-only or lumbar spine fusion surgery. Utilization of wound drainage systems in lumbosacral spine and adolescent idiopathic scoliosis corrective surgery does not seem to alter the overall rate of SSI in spine surgery. Concomitant administration of AMP in the presence of a wound drain does not seem to reduce the overall rate of SSI, deep SSI, or superficial SSI in thoracolumbar fusion performed for degenerative and deformity spine pathologies, and in adolescent idiopathic scoliosis corrective surgery. Enhanced-recovery after surgery (ERAS) clinical pathways and infection-specific protocols do not seem to reduce rate of SSI in spine surgery. Insufficient evidence exists for other types of spine surgery not mentioned above, and also for non-AMP pharmacological measures, dressing type & duration, suture & staple management and postoperative nutrition for SSI prophylaxis in spine surgery. Despite the postoperative period being key in SSI prophylaxis, the literature is sparse and without consensus on optimum postoperative care for SSI prevention in spine surgery. The current best evidence is presented with its limitations. High quality studies addressing high risk cohorts such as the elderly, obese and diabetic populations, and for traumatic and oncological indications are urgently required ((Tan T, Lee H, Huang MS, Rutges J, Marion TE, Matthew J, Fitzgerald M, Gonzalvo A, Hunn MK, Kwon BK, Dvorak MF, Tee J. Prophylactic Postoperative Measures to Minimize Surgical Site Infections in Spine Surgery: Systematic Review and Evidence Summary. Spine J. 2019 Sep 23. pii: S1529-9430(19)30977-5. doi: 10.1016/j.spinee.2019.09.013. [Epub ahead of print] Review. PubMed PMID: 31557586. )). ---- [[Surgical site infection]]s are a common, multifactorial problem after [[spine surgery]]. There is compelling evidence that improved risk stratification, detection, and prevention will reduce surgical site infections ((Radcliff KE, Neusner AD, Millhouse P, Harrop JD, Kepler CK, Rasouli MR, Albert TJ, Vaccaro AR. What's New in the Diagnosis and Prevention of Spine Surgical Site Infections. Spine J. 2014 Sep 25. pii: S1529-9430(14)01495-8. doi: 10.1016/j.spinee.2014.09.022. [Epub ahead of print] Review. PubMed PMID: 25264181.)). ---- Today’s [[health care]] environment demands more than ever of surgeons and the hospitals they work in. Payors, including [[Medicare]], increasingly refuse to pay for treating [[complication]]s deemed preventable, such as [[surgical site infection]]s. ====== Surgical site infection prevention in neurosurgery ====== {{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1zE4u0gG5jvyhiiv8bwQk1d03VZE7xfpKXZprZu1Kpo3ZCeMpX/?limit=15&utm_campaign=pubmed-2&fc=20250307170408}} ---- Surgical site [[infection]]s (SSIs) are a significant concern in neurosurgery due to the potential for devastating [[complication]]s, including [[meningitis]], [[brain abscess]], [[osteomyelitis]], and [[hardware]] infections. Preventing SSIs requires a [[multidisciplinar]]y approach involving [[perioperative]] measures, [[sterile]] techniques, and [[postoperative]] management. Below is an evidence-based framework for SSI prevention in [[neurosurgical procedure]]s. ===== Preoperative Measures ===== **Patient [[Optimization]]** - **[[Screening]] & Eradication of Carriers:** - Nasal [[decolonization]] with **[[mupirocin]]** and **[[chlorhexidine]] bathing** in patients colonized with *[[Staphylococcus aureus]]*. - **Glycemic Control:** - Maintain blood [[glucose]] <180 mg/dL in diabetic patients. - **[[Nutrition]]al Optimization:** - Correct [[hypoalbuminemia]] and address [[malnutrition]] preoperatively. - **Smoking Cessation:** - Encourage cessation at least 4 weeks before surgery to improve wound healing. - **Preoperative Antibiotic Prophylaxis:** - **First-line:** [[Cefazolin]] 2 g IV (3 g if ≥120 kg) within 60 minutes before incision. - **Beta-lactam allergy:** [[Clindamycin]] or [[vancomycin]]. - **MRSA colonization:** Vancomycin in addition to cefazolin. - **Redosing:** Repeat [[antibiotic]]s in procedures lasting >4 hours or with excessive [[blood loss]]. ===== Intraoperative Strategies ===== **Sterile Techniques & Infection Control** - **Standardized Surgical Preparation:** - Skin antisepsis with **[[chlorhexidine]]-alcohol** (preferred over povidone-iodine). - Avoid hair removal if unnecessary; if needed, use clippers instead of razors. - **Strict Aseptic Technique:** - Proper hand [[hygiene]], sterile gloves, and gowning. - Double gloving for CSF-contact procedures. - Limiting operating room (OR) traffic to reduce [[contamination]]. - **Intraoperative Antibiotics:** - Ensure redosing if the surgery is prolonged (>4 hours) or excessive bleeding occurs. - **Minimize Operative Time & Tissue Trauma:** - Precise [[hemostasis]] and reduced retraction to minimize [[tissue]] [[damage]]. - **Use of Antimicrobial-Impregnated Devices:** - **[[Ventriculostomy]] catheters:** Silver- or antibiotic-coated catheters reduce external ventricular drain (EVD) infections. - **[[Dural substitute]]s:** Prefer autologous dura or antimicrobial-treated synthetic substitutes. - **CSF Leak Prevention:** - Ensure a **watertight dural closure** and use sealants where needed. - **Normothermia:** - Maintain patient temperature to prevent hypothermia-induced immune suppression. ===== Postoperative Management ===== **[[Wound Care]]** - **Dressing Management:** - Use occlusive or antimicrobial dressings for 48–72 hours. - Avoid frequent dressing changes to prevent contamination. - **Early Drain Removal** - External drains (EVD, lumbar drains) should be removed **as soon as clinically feasible** (preferably within 5 days). - **Antibiotic Duration:** - Prophylactic antibiotics should be **discontinued within 24 hours postoperatively** unless there is an active infection. ### **Monitoring & Early Intervention** - **Regular Wound Inspections:** - Monitor for signs of SSI (erythema, swelling, discharge, fever). - **Early Diagnosis & Treatment:** - Consider MRI with contrast if deep infection is suspected. - CSF analysis if meningitis or ventriculitis is a concern. --- ===== Special Considerations in High-Risk Patients ===== - **Cranioplasties & Hardware-Implant Procedures:** - Antibiotic-impregnated bone cement for cranioplasty. - Consider staged procedures in cases of contaminated wounds. - **Spinal Instrumentation:** - Extended antibiotic coverage in high-risk spinal fusion cases. - Local vancomycin powder application in spine surgery may reduce infection rates. - **Reoperations:** - Higher risk of SSI; meticulous debridement and wound closure are essential. ===== Conclusion ===== A **multimodal** approach incorporating **preoperative screening, strict intraoperative [[sterile]] techniques, and vigilant postoperative care** significantly reduces SSIs in neurosurgery. Implementing **evidence-based guidelines and standard protocols** in neurosurgical [[practice]] ensures optimal patient outcomes and reduces morbidity related to infections. ---- A study found that patient [[body mass index]] and [[male]] sex were associated with an increased risk of SSI. Operating room personnel turnover, a modifiable, work flow-related factor, was an independent variable positively correlated with SSI ((Wathen C, Kshettry VR, Krishnaney A, Gordon SM, Fraser T, Benzel EC, Modic MT, Butler S, Machado AG. The Association Between Operating Room Personnel and Turnover With Surgical Site Infection in More Than 12 000 Neurosurgical Cases. Neurosurgery. 2016 Dec;79(6):889-894. PubMed PMID: 27465846. )). ===== Triclosan-containing sutures ===== [[Triclosan-containing sutures]] ===== References =====