An evidence-based clinical guideline for antibiotic prophylaxis in spine surgery

doi:10.1016/j.spinee.2013.06.030

The Spine Journal

Volume 13, Issue 10, October 2013, Pages 1387-1392

https://doi.org/10.1016/j.spinee.2013.06.030 Get rights and content

Abstract

Background context

The North American Spine Society's (NASS) Evidence-Based Clinical Guideline on Antibiotic Prophylaxis in Spine Surgery provides evidence-based recommendations to address key clinical questions regarding the efficacy and the appropriate antibiotic prophylaxis protocol to prevent surgical site infections in patients undergoing spine surgery. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of June 2011.

Purpose

Provide an evidence-based educational tool to assist spine surgeons in preventing surgical site infections.

Study design

Systematic review and evidence-based clinical guideline.

Methods

This guideline is a product of the Antibiotic Prophylaxis in Spine Surgery Work Group of NASS Evidence-Based Guideline Development Committee. The work group consisted of neurosurgeons and orthopedic surgeons who specialize in spine surgery and are trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE (PubMed), ACP Journal Club, Cochrane Database of Systematic Reviews Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, EMBASE (Drugs and Pharmacology), and Web of Science to identify articles published since the search performed for the original guideline. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.

Results

Sixteen clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by the strength of the supporting literature, which was stratified by levels of evidence.

Conclusions

The clinical guideline for antibiotic prophylaxis in spine surgery has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients undergoing spine surgery. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.

Introduction

In an attempt to improve and evaluate the knowledge base concerning the efficacy and appropriate protocol for antibiotic prophylaxis in spine surgery, the Antibiotic Prophylaxis in Spine Surgery Work Group of the North American Spine Society (NASS) Evidence-Based Clinical Guideline Development Committee updated the 2007 evidence-based clinical guideline on the topic. The Institute of Medicine has defined a clinical guideline as “systematically developed statements to assist practitioner and patient decisions about health care for specific clinical situations” [1].

The application of the principles of evidence-based medicine (EBM) to guideline development helps to create an explicit linkage between the final recommendations in the guideline and the evidence on which these recommendations are based [2]. When using the principles of EBM, the clinical literature is extensively searched to answer specific questions about a disease state or medical condition. The literature that is identified in the search is then rated as to its scientific merit using levels of evidence, determined by specific rule sets that apply to human and clinical investigations. The specific questions asked are then answered using studies of the highest possible levels of evidence that have been obtained from the searches. As a final step, the answers to the clinical questions are reformulated as recommendations that are assigned grades of strength related to the best clinical evidence available at the time of answering each question. The intent of the grade of recommendation is to indicate the strength of the evidence used by the work group in answering the question asked.

Section snippets

Methods

For this clinical guideline, the guideline development process was broken down into 11 steps:

Step 1: Guideline participants, trained in the principles of EBM, carefully reviewed the key questions and content of the 2007 guideline to determine if any questions needed to be updated or any new questions added.

Step 2: Work group members were assigned to a set of clinical questions.

Step 3: Work group members reviewed the original search parameters used in the 2007 guideline, and as necessary,

Efficacy

Question 1: For patients undergoing spine surgery, does antibiotic prophylaxis result in decreased infection rates compared to patients who do not receive prophylaxis?

Preoperative prophylactic antibiotics are suggested to decrease infection rates in patients undergoing spine surgery [4], [5], [6].

Grade of Recommendation: B

For a typical uncomplicated lumbar laminotomy and discectomy, a single preoperative dose of antibiotics is suggested to decrease the risk of infection and/or discitis [6], [7]

Discussion

This evidence-based clinical guideline for antibiotic prophylaxis in spine surgery has several functions. It is an educational tool for both clinicians and patients, and as such, this particular guideline is intended to assist spine surgeons in preventing surgical site infections. This guideline also serves to focus and rate the clinical data on this topic. An evidence-based guideline such as this allows a physician access to the best and most current evidence and reduces the burden of “keeping

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Cited by (91)

Optimal time window for initiating cefuroxime surgical antimicrobial prophylaxis in spinal fusion surgery: a nested case-control study
2024, Spine Journal
Surgical site infections (SSI) are one of the common complications following spinal fusion surgery. Unfortunately, several studies had shown conflicting results regarding optimal timing of surgical antimicrobial prophylaxis (SAP) administration. Due to limitations in population homogeneity and sample size, these studies have not provided significant statistical correlations or clear practical recommendations.
The purpose of the study was to investigate the impact of timing of cefuroxime SAP on the risk of SSI in patients undergoing spinal fusion surgery, and to determine the optimal timing of administration.
Retrospective nested case-control study.
We retrospectively analyzed consecutive patients who underwent spinal fusion surgery at our institution between October 2011 and October 2021.
In the current study, the primary outcome measure was SSI.
This was a retrospective nested case-control study. All consecutive patients who underwent spinal fusion surgery at our institution between October 2011 and October 2021 formed a retrospective cohort. For each SSI case, 2 controls free of SSI at the time of the index date of their corresponding case were selected, matched by age, sex, and calendar year. Electronic record and radiographic data were reviewed retrospectively in electronic database. SAP related data included timing of administration, preoperative dose, intraoperative second dose, and postoperative use. To examine the effects of mismatched variables, we further adjusted for possible confounding factors using conditional logistic regression models. Subsequently, subgroup analyses were conducted to assess the robustness of the statistical associations.
According to the pre-planned statistical scheme and matching factors, we matched 236 controls for these SSI cases, and the subsequent statistical analysis was performed on these 354 patients. After adjusting for confounding factors, the results indicated that the risk of SSI was 70% higher in the group receiving SAP 31 to 60 minutes before incision compared to the group receiving SAP 0 to 30 minutes before incision (OR=1.732, 95%CI 1.031–2.910, p=.038). Additionally, the risk of SSI was 150% higher in the group receiving SAP 61 to 120 minutes before incision compared to the group receiving SAP 0 to 30 minutes before incision (OR=2.532, 95%CI 1.250–5.128, p=.010). In subgroup analysis, this statistical trend persisted for both deformity surgeries and different SSI classifications.
Administering cefuroxime SAP within 30 minutes before skin incision significantly reduces the risk of SSI, whether they are deep or superficial, in spinal fusion surgery. This pattern remains consistent among spinal deformity patients.
Antibiotic use in spine surgery: A narrative review based in principles of antibiotic stewardship
2023, North American Spine Society Journal
A growing emphasis on antibiotic stewardship has led to extensive literature regarding antibiotic use in spine surgery for surgical prophylaxis and the treatment of spinal infections.
This article aims to review principles of antibiotic stewardship, evidence-based guidelines for surgical prophylaxis and ways to optimize antibiotics use in the treatment of spinal infections.
A narrative review of several society guidelines and spine surgery literature was conducted.
Antibiotic stewardship in spine surgery requires multidisciplinary investment and consistent evaluation of antibiotic use for drug selection, dose, duration, drug-route, and de-escalation. Developing effective surgical prophylaxis regimens is a key strategy in reducing the burden of antibiotic resistance. For treatment of primary spinal infection, the diagnostic work-up is vital in tailoring effective antibiotic therapy. The future of antibiotics in spine surgery will be highly influenced by improving surgical technique and evidence regarding the role of bacteria in the pathogenesis of degenerative spinal pathology.
Incorporating evidence-based guidelines into regular practice will serve to limit the development of resistance while preventing morbidity from spinal infection. Further research should be conducted to provide more evidence for surgical site infection prevention and treatment of spinal infections.
Protective effect of teriparatide against vancomycin-induced cytotoxicity in osteoblasts
2023, Journal of Orthopaedic Science
Citation Excerpt :
To our knowledge, there are no reports on the mechanism underlying the cytotoxic effects of VCM on osteoblasts. High local VCM concentrations used routinely are fraught with cytotoxicity in osteoblasts, contributing to non-union after spinal surgery [2]. Therefore, concomitantly administered drugs promoting osteogenesis may ameliorate these cytotoxic effects in osteoblasts.
Intrawound vancomycin powder is effective in preventing surgical site infection after spine surgery. In a previous study, vancomycin-induced cytotoxicity in osteoblasts was investigated in vitro, and vitamin D3 was verified to be a candidate drug aiding recovery from vancomycin-induced cytotoxicity. The treatment practices involving osteogenesis-promoting drugs vary widely. Teriparatide, an anabolic agent, highly promotes bone formation by inducing osteoblast activation, increasing bone formation and mineral density, and preventing vertebral fractures. Hence, teriparatide may be administered in combination with vancomycin.
MC3T3-E1 cells were cultured in minimum essential medium supplemented with 10% fetal bovine serum at 37 °C in a humidified incubator containing 5% CO₂. The experimental concentrations of vancomycin (2500, 5000, and 7500 μg/mL) were determined based on previous reports and our preliminary experiments. Teriparatide (100 ng/mL) was administered concomitantly to prevent cytotoxicity in osteoblasts, using pulsed vancomycin for 24 h (measured at 1, 3, and 7 days). Cell numbers and morphological changes in cells treated with vancomycin or vancomycin plus 100 ng/mL teriparatide were measured. Osteoblast differentiation was assessed using alkaline phosphatase staining, alkaline phosphatase activity, and alizarin red S staining.
Teriparatide showed a recovery effect when vancomycin (7500 μg/mL) was administered only for 24 h. Microscopic examination revealed that teriparatide had a protective effect on osteoblasts exposed to 7500 μg/mL vancomycin. Addition of teriparatide led to the recovery of alkaline phosphatase staining and alizarin red staining.
Vancomycin-induced cytotoxicity in osteoblasts could be inhibited by administering teriparatide concomitantly with vancomycin.
Use of prophylactic perioperative antibiotics for lumbar spinal fusions: A nationwide population-based cohort study
2023, Journal of Infection and Public Health
Perioperative prophylactic antibiotic (PPA) use in spine surgery is known to reduce the rate of surgical site infections. In the past decade, several evidence-based guidelines have been published and surveillance systems to monitor the proper use of antimicrobials had been adapted by many institutes.
To report the trends of PPA prescription in lumbar fusion surgeries nationwide in the Republic of Korea.
This is a nationwide registry study. Using the population-based data from the Republic of Korea provided by the Korean Health Insurance Review and Assessment Service, data of all lumbar spinal fusion surgeries performed between 2010 and 2018 in adult patients (age ≥19 years) were reviewed.
The most frequently used antibiotics were first-generation cephalosporins, which accounted for 38.2 % of total PPA prescriptions and were prescribed in 58.96 % of lumbar fusion surgeries. A gradual increase in prescription trends was observed. The second most frequently used PPAs were second-generation cephalosporins, which showed decrease in use from 2016. The frequency of vancomycin prescriptions gradually increased over the observation period and showed an almost four-fold increase in 2018 compared to 2010. First- and second-generation cephalosporins were prescribed less frequently to patients with renal disease.
The pattern of PPA use has changed remarkably over the observation period. Furthermore, specific differences in PPA prescriptions were observed among patients with certain co-morbidities.
Clinical outcome of postoperative surgical site infections in patients with posterior thoracolumbar and lumbar instrumentation
2022, Journal of Hospital Infection
Postoperative surgical site infection (SSI) is associated with high rates of disability, especially following instrumented spinal surgeries. The management of implant-associated SSI is challenging. This study analysed data from hospital databases to assess the incidence and characteristics related to postoperative SSI after posterior thoracolumbar and lumbar instrumentation.
Patient demographics, infection characteristics, details of treatment and perioperative factors were reviewed (January 2010–December 2020). Oswestry Disability Index (ODI), Patient Health Questionnaire-9 (PHQ-9) and Visual Analogue Scale (VAS) scores for back and leg pain were analysed preoperatively and postoperatively until final follow-up.
Of the 27,881 procedures collected from the databases, 521 (1.8%) patients were diagnosed with SSI. Of these, 191 (36.7%) patients underwent at least one revision surgery for SSI. The infection rate was significantly higher in patients with lumbar spinal stenosis than in patients with scoliosis or kyphosis (P<0.01). The most commonly isolated pathogen was meticillin-susceptible Staphylococcus aureus (43.4%). The rate of complications secondary to antibiotic treatment was 7.8%, and long-term antibiotic suppression was reported in 15.2% of patients. Instrumentation was retained in 175 (91.6%) patients, and all SSIs were controlled without recurrence during follow-up.
Analysis of 27,881 patients showed an average SSI rate of 1.8%. Patients with deep wound SSI can be treated successfully in most cases with retention of instrumentation. Early diagnosis, positive revision surgery with strict irrigation, thorough debridement and a long-term course of antibiotics are critical to eradicate infection, retain implants, decrease morbidity and achieve wound healing.
10-Year Trends in the Surgical Management of Patients with Spinal Metastases: A Scoping Review
2022, World Neurosurgery
Spinal metastases are present in approximately 20% of patients with cancer, giving a risk for neurologic dysfunction and instability. In already frail patients, surgeons strive to improve quality of life. Our goal was to review a 10-year trend in the surgical management of spinal metastases.
A scoping review was performed systematically using PubMed to assess trends in surgical treatment for spinal metastases. The search terms used were: metastas∗, "neoplasm metastasis"[Mesh], "Spine"[Mesh], spine, spinal, “vertebral column,” “vertebral body,” laser, robot, radiofrequency, screws, fixation, “separation surgery,” corpectomy, vertebrectomy, spondylectomy, vertebroplasty, kyphoplasty, surgery, “open surgery,” “mini open surgery,” “minimally invasive surgery,” endoscopy, thoracoscopy, corpectom∗, vertebrectom∗, spondylectom∗, “en bloc,” and MIS. The variables of interest were neurologic improvement, tumor recurrence, reoperation, and overall survival.
A total of 2132 articles were found within the primary query. Fifty-six studies were selected for final review. The results were organized into main surgical practices: decompression, mechanical stabilization, and pain management. For separation surgery, clinical outcomes were overall 1-year survival, 40.7%–78.4%; recurrence rate, 4.3%–22%; reoperation, 5%; and complications, 5.4%–14%. For corpectomy, clinical outcomes were overall 1-year survival, 30%–92%; reoperation, 1.1%–50%; and recurrence rate, of 1.1%–28%. Complications and reoperations with spinal instrumentation were 0%–13.6% and 0%–15%, respectively. Cement augmentation achieved pain reduction rates of 56%–100%, neurologic improvement/stability 84%–100%, and complication rates 6%–56%. Laser achieved local tumor control rate of 71%–82% at 1 year follow-up, reoperation rate of 15%–31%, and complication rate of 5%–26%.
Minimally invasive techniques for decompression and stabilization seem to be the preferred method to surgically treat metastatic spine disease, with good outcomes. More research with high level of evidence is required to support the long-term outcomes of these approaches.

View all citing articles on Scopus

: FDA device/drug status: Not applicable.

: Author disclosures: WOS: Nothing to disclose. JLB: Support for travel to meetings for the study or other purposes: NASS (A). RF: Nothing to disclose. PGM: Support for travel to meetings for the study or other purposes: NASS (A).

: The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

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Review ArticleAn evidence-based clinical guideline for antibiotic prophylaxis in spine surgery

Abstract

Background context

Purpose

Study design

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Efficacy

Discussion

Surg Neurol

Surg Neurol

J Orthop Sci

J Orthop Sci

Crossing the Quality Chasm: A new health system for the 21st century

Does evidence-based medicine help the development of clinical practice guidelines?

Chest

Consensus development methods, and their use in clinical guideline development

Health Technol. Assessment

Efficacy of prophylactic antibiotic therapy in spinal surgery: a meta-analysis

Neurosurgery

Prophylactic antibiotics in elective orthopedic surgery: a prospective study of 1591 cases

South Med J

Perioperative prophylactic cephazolin in spinal surgery—a double-blind placebo-controlled trial

J. Bone Joint Surg.-br. Vol

Cefuroxime prophylaxis is effective in noninstrumented spine surgery: a double-blind, placebo-controlled study

Spine (Phila Pa 1976)

Spondylodiscitis after lumbar discectomy. Incidence and a proposal for prophylaxis

Spine (Phila Pa 1976)

Appropriateness of antibiotic selection and use in laminectomy and microdiskectomy

Am J Hosp Pharm

Spondylodiscitis after lumbar disk surgery

Neuro-surg Rev

Postoperative wound infection after instrumentation of thoracic and lumbar fractures

J Orthop Trauma

Review Article
An evidence-based clinical guideline for antibiotic prophylaxis in spine surgery