Speaker provides updated guidelines for surgical site infection in pediatric spine surgery
Click Here to Manage Email Alerts
Key takeaways:
- Patients with a risk for infection greater than 5% should be considered high risk for surgical site infections.
- Surgeons do not need to remove spinal implants when treating certain types of acute infections.
LAS VEGAS — A presentation here provided updated consensus-based best practice guidelines for defining high risk and preventing, diagnosing and treating surgical site infections in high-risk pediatric spine surgery cases.
“Surgical site infection is a common problem in high-risk pediatric spine surgery and also a great source of morbidity or an issue or expense, return to hospital, reoperation and burden for the patient and the family,” Suken A. Shah, MD, vice chair of the department of orthopedic surgery, division chief of the Spine and Scoliosis Center and clinical fellowship director at Nemours Children’s Health in Delaware, told Healio about results presented at the American Academy of Orthopaedic Surgeons Annual Meeting. “To make this procedure successful, we would like to limit the number of infections that these patients get. So, the effort was how can we make care better, how can we reduce the surgical site infection rate and what is the best way to tackle that.”
Panel consensus
To develop an updated, consensus-based best practice guideline on defining, preventing, diagnosing and treating surgical site infection (SSI) risk in pediatric spine surgery, Daniel Badin, MD, Shah, Paul D. Sponseller, MD, and colleagues performed a systematic review of the available literature prior to selecting an expert panel of 21 pediatric spine surgeons from the Harms Study Group. Using the Delphi process and survey rounds, researchers surveyed the expert panel for current practices, presented the panel with the systematic review, provided the panel with the opportunity to voice opinions through a live discussion session and asked the panel to vote regarding preferences privately.
“Agreement more than 70% was considered consensus,” Badin, an orthopedic resident and research fellow in the department of pediatric orthopaedics at Johns Hopkins, said in his presentation at the AAOS Annual Meeting. “Near-consensus items were discussed again and revised if feasible to achieve consensus.”
Badin noted the panel came to consensus on 49 best practice guideline items, including 17 items for defining high SSI risk, 17 items for preventing SSI, six items for diagnosing SSI and nine items for treating SSI. All 21 experts also agreed to publication and implementation of the guidelines in their practice, according to Badin.
Badin noted that the experts agreed that patients with a risk for infection greater than 5% would be considered high risk for SSI.
Certain patient factors may cause patients to be at higher risk for SSI, according to Shah. He noted some of these factors include patients who are on steroids, who are nonambulatory, incontinent, have a neuromuscular condition, have a large curve or are fused at the pelvis, and surgeons can use risk-severity score calculators to determine if a patient is considered high risk.
“If I were to use machine learning and feed all of these variables into a computer, a computer can calculate a risk severity score,” Shah said.
Prevention, treatment of SSIs
For preoperative prevention of SSI, the panel agreed that patients should receive preoperative IV antibiotics against gram-negative and positive pathogens within 30 minutes of incision, according to Badin. He also noted patients who are incontinent or at increased risk for urinary tract infection may have urine cultures performed and, if positive, treatment prescribed. Badin added vancomycin should be routinely used intraoperatively and postoperative antibiotics should be given for only 24 hours. The panel also agreed that an occlusive or vacuum-type dressing should be used postoperatively, Badin said.
“For diagnosis, they agreed that deep wound aspiration is helpful in diagnosing SSI and that there is no role for imaging for the specific purpose of SSI in the acute phase,” he said.
When it comes to treatment of SSIs, Badin noted irrigation and debridement should be performed and the entire wound should be opened for irrigation and debridement instead of partially opened.
The panel agreed that a drain or vacuum-assisted closure should be used to remove the infection and patients should be prescribed prolonged antibiotics, according to Shah. However, Shah noted it is not necessary for surgeons to remove the spinal implants.
“If we take the implants out, their spine will collapse and they are going to end up needing more extensive surgery anyway,” Shah said. “So, we do not feel that removing the implants, which was a common practice in the old days, is necessary anymore, because antibiotics are better and our ability to treat these infections is better.”
References:
- Badin D, et al. J Pediatr Orthop. 2022;doi:10.1097/BPO.0000000000002255.
- Badin D, et al. Paper 323. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting. March 7-11, 2023; Las Vegas.
Collapse
Badin D, et al. Paper 323. Presented at: American Academy of Orthopedic Surgeons Annual Meeting. March 7-11, 2023; Las Vegas.
Click Here to Manage Email Alerts