Surgical Site Infection Following Neuromuscular Posterior Spinal Fusion Fell 72% After Adopting the 2013 Best Practice Guidelines

Stephen R. Stephan, MD; Kenneth D. Illingworth, MD; Kavish Gupta, MD; Lindsay M. Andras, MD; David L. Skaggs, MD, MMM

Disclosures

Spine. 2021;46(17):1147-1153. 

In This Article

Abstract and Introduction

Abstract

Study Design: Retrospective cohort study.

Objective: The purpose of this study is to investigate the incidence of surgical site infection in neuromuscular scoliosis (NMS) patients at a tertiary children's hospital before and after the implementation of strategies mentioned in the 2013 Best Practice Guideline.

Summary of Background Data: Patients with NMS are at high risk for surgical site infection following spine surgery. In 2013, a Best Practice Guideline for surgical site infection prevention in high-risk pediatric spine surgery patients reported strategies to decrease incidence. To date, no studies have looked at the efficacy of these strategies.

Methods: A retrospective review of surgical site infection in NMS patients was performed. NMS patients undergoing primary posterior spinal fusion from January 2008 to December 2012 (Group 1) and January 2014 to December 2018 (Group 2) were included, with 2013 excluded as a transition year. The primary outcome was incidence of surgical site infection within 1 year of surgery, as defined by the Centers for Disease Control and National Healthcare Safety Network. All patients had at least 1 year of documented follow-up.

Results: One hundred ninety eight patients were included, 62 in Group 1 and 136 in Group 2. Age, BMI, sex, fusion to pelvis, preoperative Cobb angle, incontinence, drain use, blood loss, surgical time, and other perioperative values were similar (P > 0.05). Deep surgical site infection occurred in 10 (16.1%) patients in Group 1 and six (4.4%) patients in Group 2 (P = 0.005). Thirteen (59.1%) identified organisms were gram-negative, with 11 (84.6%) isolated from Group 1 (P = 0.047). Polymicrobial infections accounted for six (37.5%) infections overall.

Conclusion: The incidence of surgical site infection in NMS patients decreased significantly (16.1% vs. 4.4%) after the implementation of the strategies mentioned in the 2013 Best Practice Guideline. Further studies are required to continue to decrease the incidence in this high-risk population.

Level of Evidence: 3

Introduction

Pediatric patients undergoing posterior spinal fusion with instrumentation (PSF) for scoliosis are at risk for infections. Infections lead to prolonged hospital stays, reoperations and readmissions, revision surgery, increased healthcare costs, and emotional distress.[1–4] Numerous studies have demonstrated infection rates for primary PSF to range from 1% to almost 40%,[5–12] depending on the underlying etiology of scoliosis.

Surgical site infections have been shown to be more common in children with non-idiopathic etiologies, particularly neuromuscular scoliosis (NMS). Studies have reported infection rates as high as 24%.[4,9,11,13–16] These children commonly have severe scoliosis, which necessitate larger exposures, increased blood loss, and longer surgical times,[2,5,17] with a limited ability to cope with surgical stress. Risk factors include inadequate prophylactic antibiotic dosing, fusion to pelvis, preoperative malnutrition, and neurologic function.[4,5,12,18–20] This high-risk population was the focus of a Best Practice Guideline (BPG) in 2013 by Vitale et al,[21] where a consensus to support 14 perioperative strategies to prevent surgical site infections was reached.

The purpose of this study is to investigate the efficacy of the strategies mentioned in the BPG in NMS patients undergoing primary PSF. Our primary outcome was incidence of deep surgical site infection requiring surgical intervention within 1 year of surgery, comparing the 4 years before and after the implementation of the BPG strategies.

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