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Preoperative Versus Extended Postoperative Antimicrobial Prophylaxis of Surgical Site Infection During Spinal Surgery: A Comprehensive Systematic Review and Meta-Analysis.

ABSTRACT: INTRODUCTION:Surgical site infection (SSI) following spinal surgery is a major source of postoperative morbidity. Although studies have demonstrated perioperative antimicrobial prophylaxis (AMP) to be beneficial in the prevention of SSI among spinal surgery patients, consensus is lacking over whether preoperative or extended postoperative AMP is most efficacious. To date, no meta-analysis has investigated the comparative efficacy of these two temporally variable AMP protocols in spinal surgery. We undertook a systemic review and meta-analysis to determine whether extended postoperative AMP is associated with a difference in the rate of SSI occurrence among adult patients undergoing spinal surgery. METHODS:Embase and MEDLINE databases were systematically searched for clinical trials and cohort studies directly comparing SSI rates among adult spinal surgery patients receiving either preoperative or extended postoperative AMP. Quality of evidence of the overall study population was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group approach. Random effects meta-analyses were performed utilizing both pooled and stratified data based on instrumentation use. RESULTS:Five studies met inclusion criteria. No individual study demonstrated a significant difference in the rate of SSI occurrence between preoperative and extended postoperative AMP protocols. The GRADE quality of evidence was low. Among the overall cohort of 2824 patients, 96% underwent lumbar spinal surgery. Pooled SSI rates were 1.38% (26/1887) for patients receiving extended postoperative AMP and 1.28% (12/937) for patients only receiving preoperative AMP. The risk of SSI development among patients receiving extended postoperative AMP was not significantly different from the risk of SSI development among patients only receiving preoperative AMP [RR (risk ratio), 1.11; 95% CI (confidence interval) 0.53-2.36; p?=?0.78]. The difference in risk of SSI development when comparing extended postoperative AMP to preoperative AMP was also not significant for both instrumented (RR, 0.92; 95% CI 0.15-5.75; p?=?0.93) and non-instrumented spinal surgery (RR, 1.25; 95% CI 0.49-3.17; p?=?0.65). There was no evidence of heterogeneity of treatment effects for all meta-analyses. CONCLUSION:Preoperative AMP appears to provide equivalent protection against SSI development when compared to extended postoperative AMP. Prudent antibiotic use is also known to decrease hospital length of stay, healthcare expenditure, and risk of complications. However, until higher-quality evidence becomes available regarding AMP in spinal surgery, surgeons should continue to exercise discretion and clinical judgment when weighing the effects of patient comorbidities and complications before determining the optimal duration of perioperative AMP.

SUBMITTER: Phillips BT

PROVIDER: S-EPMC7467442 | biostudies-literature | 2020 Jun

REPOSITORIES: biostudies-literature

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Preoperative Versus Extended Postoperative Antimicrobial Prophylaxis of Surgical Site Infection During Spinal Surgery: A Comprehensive Systematic Review and Meta-Analysis.

Phillips Blaine T BT Sheldon Emma S ES Orhurhu Vwaire V Ravinsky Robert A RA Freiser Monika E ME Asgarzadeh Morteza M Viswanath Omar O Kaye Alan D AD Roguski Marie M

Advances in therapy 20200515 6

<h4>Introduction</h4>Surgical site infection (SSI) following spinal surgery is a major source of postoperative morbidity. Although studies have demonstrated perioperative antimicrobial prophylaxis (AMP) to be beneficial in the prevention of SSI among spinal surgery patients, consensus is lacking over whether preoperative or extended postoperative AMP is most efficacious. To date, no meta-analysis has investigated the comparative efficacy of these two temporally variable AMP protocols in spinal s ...[more]

PMID: 32415484

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Project description:ImportanceUse of postoperative antimicrobial prophylaxis is common in pediatric surgery despite consensus guidelines recommending discontinuation following incision closure. The association between postoperative prophylaxis use and surgical site infection (SSI) in children undergoing surgical procedures remains poorly characterized.ObjectiveTo evaluate whether use of postoperative surgical prophylaxis is correlated with SSI rates in children undergoing nonemergent surgery.Design, setting, and participantsThis is a multicenter cohort study using 30-day postoperative SSI data from the American College of Surgeons' Pediatric National Surgical Quality Improvement Program (ACS NSQIP-Pediatric) augmented with antibiotic-use data obtained through supplemental medical record review from June 2019 to June 2021. This study took place at 93 hospitals participating in the ACS NSQIP-Pediatric Surgical Antibiotic Prophylaxis Stewardship Collaborative. Participants were children (<18 years of age) undergoing nonemergent surgical procedures. Exclusion criteria included antibiotic allergies, conditions associated with impaired immune function, and preexisting infections requiring intravenous antibiotics at time of surgery.ExposuresContinuation of antimicrobial prophylaxis beyond time of incision closure.Main outcomes and measuresThirty-day postoperative rate of incisional or organ space SSI. Hierarchical regression was used to estimate hospital-level odds ratios (ORs) for SSI rates and postoperative prophylaxis use. SSI measures were adjusted for differences in procedure mix, patient characteristics, and comorbidity profiles, while use measures were adjusted for clinically related procedure groups. Pearson correlations were used to examine the associations between hospital-level postoperative prophylaxis use and SSI measures.ResultsForty thousand six hundred eleven patients (47.3% female; median age, 7 years) were included, of which 41.6% received postoperative prophylaxis (hospital range, 0%-71.2%). Odds ratios (ORs) for postoperative prophylaxis use ranged 190-fold across hospitals (OR, 0.10-19.30) and ORs for SSI rates ranged 4-fold (OR, 0.55-1.90). No correlation was found between use of postoperative prophylaxis and SSI rates overall (r = 0.13; P = .20), and when stratified by SSI type (incisional SSI, r = 0.08; P = .43 and organ space SSI, r = 0.13; P = .23), and surgical specialty (general surgery, r = 0.02; P = .83; urology, r = 0.05; P = .64; plastic surgery, r = 0.11; P = .35; otolaryngology, r = -0.13; P = .25; orthopedic surgery, r = 0.05; P = .61; and neurosurgery, r = 0.02; P = .85).Conclusions and relevanceUse 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.

Project description:ImportanceWorld Health Organization guidelines recommend administering surgical antimicrobial prophylaxis (SAP), including cefuroxime, within 120 minutes prior to incision. However, data from clinical settings supporting this long interval is limited.ObjectiveTo assess whether earlier vs later timing of administration of cefuroxime SAP is associated with the occurrence of surgical site infections (SSI).Design, setting, and participantsThis cohort study included adult patients who underwent 1 of 11 major surgical procedures with cefuroxime SAP, documented by the Swissnoso SSI surveillance system between January 2009 and December 2020 at 158 Swiss hospitals. Data were analyzed from January 2021 to April 2023.ExposuresTiming of cefuroxime SAP administration before incision was divided into 3 groups: 61 to 120 minutes before incision, 31 to 60 minutes before incision, and 0 to 30 minutes before incision. In addition, a subgroup analysis was performed with time windows of 30 to 55 minutes and 10 to 25 minutes as a surrogate marker for administration in the preoperating room vs in the operating room, respectively. The timing of SAP administration was defined as the start of the infusion obtained from the anesthesia protocol.Main outcomes and measuresOccurrence of SSI according to Centers for Disease Control and Prevention definitions. Mixed-effects logistic regression models adjusted for institutional, patient, and perioperative variables were applied.ResultsOf 538 967 surveilled patients, 222 439 (104 047 men [46.8%]; median [IQR] age, 65.7 [53.9-74.2] years), fulfilled inclusion criteria. SSI was identified in 5355 patients (2.4%). Cefuroxime SAP was administered 61 to 120 minutes prior to incision in 27 207 patients (12.2%), 31 to 60 minutes prior to incision in 118 004 patients (53.1%), and 0 to 30 minutes prior to incision in 77 228 patients (34.7%). SAP administration at 0 to 30 minutes was significantly associated with a lower SSI rate (adjusted odds ratio [aOR], 0.85; 95% CI, 0.78-0.93; P < .001), as was SAP administration 31 to 60 minutes prior to incision (aOR, 0.91; 95% CI, 0.84-0.98; P = .01) compared with administration 61 to 120 minutes prior to incision. Administration 10 to 25 minutes prior to incision in 45 448 patients (20.4%) was significantly associated with a lower SSI rate (aOR, 0.89; 95% CI, 0.82-0.97; P = .009) vs administration within 30 to 55 minutes prior to incision in 117 348 patients (52.8%).Conclusions and relevanceIn this cohort study, administration of cefuroxime SAP closer to the incision time was associated with significantly lower odds of SSI, suggesting that cefuroxime SAP should be administrated within 60 minutes prior to incision, and ideally within 10 to 25 minutes.

Project description:Study designRetrospective hospital-registry study.ObjectiveTo characterize the microbial epidemiology of surgical site infection (SSI) in spinal fusion surgery and the burden of resistance to standard surgical antibiotic prophylaxis.Summary of background dataSSI persists as a leading complication of spinal fusion surgery despite the growth of enhanced recovery programs and improvements in other measures of surgical quality. Improved understandings of SSI microbiology and common mechanisms of failure for current prevention strategies are required to inform the development of novel approaches to prevention relevant to modern surgical practice.MethodsSpinal fusion cases performed at a single referral center between January 2011 and June 2019 were reviewed and SSI cases meeting National Healthcare Safety Network criteria were identified. Using microbiologic and procedural data from each case, we analyzed the anatomic distribution of pathogens, their differential time to presentation, and correlation with methicillin-resistant Staphylococcus aureus screening results. Susceptibility of isolates cultured from each infection were compared with the spectrum of surgical antibiotic prophylaxis administered during the index procedure on a per-case basis. Susceptibility to alternate prophylactic agents was also modeled.ResultsAmong 6727 cases, 351 infections occurred within 90 days. An anatomic gradient in the microbiology of SSI was observed across the length of the back, transitioning from cutaneous (gram-positive) flora in the cervical spine to enteric (gram-negative/anaerobic) flora in the lumbosacral region (correlation coefficient 0.94, P < 0.001). The majority (57.5%) of infections were resistant to the prophylaxis administered during the procedure. Cephalosporin-resistant gram-negative infection was common at lumbosacral levels and undetected methicillin-resistance was common at cervical levels.ConclusionIndividualized infection prevention strategies tailored to operative level are needed in spine surgery. Endogenous wound contamination with enteric flora may be a common mechanism of infection in lumbosacral fusion. Novel approaches to prophylaxis and prevention should be prioritized in this population.Level of Evidence: 3.

Project description:ImportanceCigarette smoking is a risk factor for many perioperative complications, including surgical site infection (SSI). The duration of abstinence from smoking required to reduce this risk is unknown.ObjectivesTo evaluate if abstinence from smoking on the day of surgery is associated with a decreased frequency of SSI in patients who smoke cigarettes and to confirm that smoking is significantly independently associated with SSI when adjustment is made for potentially relevant covariates, such as body mass index.Design, setting, and participantsIn this observational, nested, matched case-control study, 2 analyses were performed at an academic referral center in the upper Midwest. Cases included all patients undergoing elective surgical procedures at Mayo Clinic, Rochester, Minnesota, between January 1, 2009, and July 31, 2014 (inclusive) who subsequently developed an SSI. Controls for both analyses were matched on age, sex, and type of surgery.ExposuresSmoking status and preoperative exhaled carbon monoxide level, assessed by nurses in the preoperative holding area. Patients were classified as smoking on the day of surgery if they self-reported smoking or if their preoperative exhaled carbon monoxide level was 10 ppm or higher.Main outcomes and measuresSurgical site infection after a surgical procedure at Mayo Clinic, Rochester, as identified by routine clinical surveillance using National Healthcare Safety Network criteria.ResultsOf the 6919 patients in the first analysis, 3282 (47%) were men and 3637 (53%) were women; median age (interquartile range) for control and SSI cases was 60 (48-70). Of the 392 patients in the second analysis, 182 (46%) were men and 210 (54%) were women; median age (interquartile range) for controls was 53 (45-49) and for SSI cases was 51 (45-60). During the study period, approximately 2% of surgical patients developed SSI annually. Available for the first analysis (evaluating the influence of current smoking status) were 2452 SSI cases matched to 4467 controls. The odds ratio for smoking and SSI was 1.51 (95% CI, 1.20-1.90; P < .001), which remained statistically significant after adjusting for covariates. In the second analysis (evaluating the influence of smoking on the day of surgery), there were 137 SSI cases matched to 255 controls. The odds ratio for smoking on the day of surgery and SSI was 1.96 (95% CI, 1.23-3.13; P < .001), which remained statistically significant after adjusting for covariates. Preoperative exhaled carbon monoxide level was not associated with the frequency of SSI, suggesting that the association between smoking on the day of surgery and SSI was not related to preoperative exhaled carbon monoxide levels.Conclusions and relevanceCurrent smoking is associated with the development of SSI, and smoking on the day of surgery is independently associated with the development of SSI. These data cannot distinguish whether abstinence per se reduces risk or whether it is associated with other factors that may be causative.

Project description:BackgroundWorldwide, approximately one in six inpatient antibiotic prescriptions are for surgical-infection prophylaxis, including postoperative prophylaxis. The WHO recommends against prolonged postoperative antibiotics to prevent surgical-site infection. However, in many low- and middle-income countries, postoperative antibiotic prophylaxis is common due to perceptions that it protects against surgical-site infection and data informing recommendations against antibiotic administration are largely derived from high-income countries. The aim of this study was to describe postoperative antibiotic-prescribing patterns and related surgical-site infection rates in hospitals in low- and middle-income countries.MethodsPatients from 19 hospitals in Ethiopia, Madagascar, India, and Bolivia with wound class I and II operations were included. Data on antibiotic administration, indication, surgical-site infection, length of hospital stay, and adherence to perioperative infection-prevention standards were collected by trained personnel. The association between postoperative antibiotic prophylaxis for greater than or equal to 24 h and surgical-site infection was analysed via modified robust Poisson regression, controlling for patient and procedural factors and degree of adherence to perioperative infection-prevention practices.ResultsOf 8714 patients, 92.9% received antibiotics for prophylaxis after surgery and 27.7% received antibiotics for greater than or equal to 24 h. Patients receiving postoperative prophylaxis for greater than or equal to 24 h did not have lower surgical-site infection rates (Relative risk 1.09 (95% c.i. 0.89 to 1.33); P = 0.399), but the length of hospital stay was 1.4 days longer (P < 0.001).ConclusionProlonged postoperative antibiotics did not reduce surgical-site infection, but pervasive use was associated with a longer length of hospital stay, in resource-limited healthcare systems. With the growing threat of antimicrobial resistance, surgical initiatives to implement antimicrobial stewardship programmes in low- and middle-income countries are critical.

Project description:ObjectiveTo investigate whether oral antimicrobial prophylaxis as an adjunct to intravenous antibiotic prophylaxis reduces surgical site infections after elective colorectal surgery.DesignMulticentre, randomised, double blind, placebo controlled trial.Setting11 university and non-university hospitals in France between 25 May 2016 and 8 August 2019.Participants926 adults scheduled for elective colorectal surgery.InterventionPatients were randomised to receive either a single 1 g dose of ornidazole (n=463) or placebo (n=463) orally 12 hours before surgery, in addition to intravenous antimicrobial prophylaxis before surgical incision.Main outcome measuresThe primary outcome was the proportion of patients with surgical site infection within 30 days after surgery. Secondary outcomes included individual types of surgical site infections and major postoperative complications (Clavien-Dindo classification grade 3 or higher) within 30 days after surgery.ResultsOf the 960 patients who were enrolled, 926 (96%) were included in the analysis. The mean age of participants was 63 years and 554 (60%) were men. Surgical site infection within 30 days after surgery occurred in 60 of 463 patients (13%) in the oral prophylaxis group and 100 of 463 (22%) in the placebo group (absolute difference -8.6%, 95% confidence interval -13.5% to -3.8%; relative risk 0.60, 95% confidence interval 0.45 to 0.80). The proportion of patients with deep infections was 4.8% in the oral prophylaxis group and 8.0% in the placebo group (absolute difference -3.2%, 95% confidence interval -6.4% to -0.1%). The proportion of patients with organ space infections was 5.0% in the oral prophylaxis group and 8.4% in the placebo group (absolute difference -3.4%, -6.7% to -0.2%). Major postoperative complications occurred in 9.1% patients in the oral prophylaxis group and 13.6% in the placebo group (absolute difference -4.5%, -8.6% to -0.5%).ConclusionAmong adults undergoing elective colorectal surgery, the addition of a single 1 g dose of ornidazole compared with placebo before surgery significantly reduced surgical site infections.Trial registrationClinicalTrials.gov NCT02618720.

Dataset Information

Preoperative Versus Extended Postoperative Antimicrobial Prophylaxis of Surgical Site Infection During Spinal Surgery: A Comprehensive Systematic Review and Meta-Analysis.

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Preoperative Versus Extended Postoperative Antimicrobial Prophylaxis of Surgical Site Infection During Spinal Surgery: A Comprehensive Systematic Review and Meta-Analysis.

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