The seasonality of postoperative infection in spine surgery

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  • 1 Rothman Institute of Orthopedics, and
  • 2 Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
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Object

Studies from many disciplines have found an association with the summer months, elevated temperature, humidity, and an increased rate of infection. The “July effect,” a hypothesis that the inexperience of new house staff at the beginning of an academic year leads to an increase in wound complications, has also been considered. Finally, an increase in trauma-related admissions in the summer months is likely to result in an increased incidence of postoperative infections. Two previous studies revealed mixed results concerning perioperative spinal wound infections in the summer months. The purpose of this study was to determine the months and/or seasons of the year that display significant fluctuation of postoperative infection rate in spine surgery. Based on the idea that infection rates are susceptible to seasonal factors, the authors hypothesized that spinal infections would increase during the summer months.

Methods

Inclusion criteria were all spine surgery cases at a single tertiary referral institution between January 2005 and December 2009; 8122 cases were included. Patients presenting with a contaminated wound or active infection were excluded. Infection rates were calculated on a monthly and seasonal basis and compared.

Results

A statistically significant increase in the infection rate was present on both a seasonal and monthly basis (p = 0.03 and p = 0.024) when looking at the seasonal change from spring to summer. A significant decrease in the infection rate was seen on a seasonal basis during the change from fall to winter (p = 0.04). The seasonal rate of infection was highest in the summer (4.1%) and decreased to the lowest point in the spring (2.8%) (p = 0.03).

Conclusions

At the authors' institution, spine surgeries performed during the summer and fall months were associated with a significantly higher incidence of wound infection compared with the winter and spring. These data support the existence of a seasonal effect on perioperative spinal infection rates, which may be explained by seasonal variation in weather patterns and house staff experience, among other factors.

Abbreviations used in this paper:OR = operating room; SSI = surgical site infection.

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Contributor Notes

Address correspondence to: Alexander Vaccaro, M.D., Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, Pennsylvania 19107. email: alexvaccaro3@aol.com.

Please include this information when citing this paper: published online November 2, 2012; DOI: 10.3171/2012.10.SPINE12572.

  • 1

    Al-Hasan MN, , Lahr BD, , Eckel-Passow JE, & Baddour LM: Seasonal variation in Escherichia coli bloodstream infection: a population-based study. Clin Microbiol Infect 15:947950, 2009

    • Search Google Scholar
    • Export Citation
  • 2

    Bakaeen FG, , Huh J, , LeMaire SA, , Coselli JS, , Sansgiry S, & Atluri PV, : The July effect: impact of the beginning of the academic cycle on cardiac surgical outcomes in a cohort of 70,616 patients. Ann Thorac Surg 88:7075, 2009

    • Search Google Scholar
    • Export Citation
  • 3

    Banco SP, , Vaccaro AR, , Blam O, , Eck JC, , Cotler JM, & Hilibrand AS, : Spine infections: variations in incidence during the academic year. Spine (Phila Pa 1976) 27:962965, 2002

    • Search Google Scholar
    • Export Citation
  • 4

    Barry WA, & Rosenthal GE: Is there a July phenomenon? The effect of July admission on intensive care mortality and length of stay in teaching hospitals. J Gen Intern Med 18:639645, 2003

    • Search Google Scholar
    • Export Citation
  • 5

    Birkmeyer JD, , Siewers AE, , Finlayson EV, , Stukel TA, , Lucas FL, & Batista I, : Hospital volume and surgical mortality in the United States. N Engl J Med 346:11281137, 2002

    • Search Google Scholar
    • Export Citation
  • 6

    Birkmeyer JD, , Stukel TA, , Siewers AE, , Goodney PP, , Wennberg DE, & Lucas FL: Surgeon volume and operative mortality in the United States. N Engl J Med 349:21172127, 2003

    • Search Google Scholar
    • Export Citation
  • 7

    Birkmeyer JD, , Sun Y, , Goldfaden A, , Birkmeyer NJ, & Stukel TA: Volume and process of care in high-risk cancer surgery. Cancer 106:24762481, 2006

    • Search Google Scholar
    • Export Citation
  • 8

    Blam OG, , Vaccaro AR, , Vanichkachorn JS, , Albert TJ, , Hilibrand AS, & Minnich JM, : Risk factors for surgical site infection in the patient with spinal injury. Spine (Phila Pa 1976) 28:14751480, 2003

    • Search Google Scholar
    • Export Citation
  • 9

    Dhaliwal AS, , Chu D, , Deswal A, , Bozkurt B, , Coselli JS, & Lemaire SA, : The July effect and cardiac surgery: the effect of the beginning of the academic cycle on outcomes. Am J Surg 196:720725, 2008

    • Search Google Scholar
    • Export Citation
  • 10

    Dimar JR, , Fisher C, , Vaccaro AR, , Okonkwo DO, , Dvorak M, & Fehlings M, : Predictors of complications after spinal stabilization of thoracolumbar spine injuries. J Trauma 69:14971500, 2010

    • Search Google Scholar
    • Export Citation
  • 11

    El-Gindi S, , Aref S, , Salama M, & Andrew J: Infection of intervertebral discs after operation. J Bone Joint Surg Br 58:114116, 1976

  • 12

    Englesbe MJ, , Pelletier SJ, , Magee JC, , Gauger P, , Schifftner T, & Henderson WG, : Seasonal variation in surgical outcomes as measured by the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP). Ann Surg 246:456465, 2007

    • Search Google Scholar
    • Export Citation
  • 13

    Fallon WF Jr, , Wears RL, & Tepas JJ III: Resident supervision in the operating room: does this impact on outcome?. J Trauma 35:556562, 1993

    • Search Google Scholar
    • Export Citation
  • 14

    Fisman DN, , Lim S, , Wellenius GA, , Johnson C, , Britz P, & Gaskins M, : It's not the heat, it's the humidity: wet weather increases legionellosis risk in the greater Philadelphia metropolitan area. J Infect Dis 192:20662073, 2005

    • Search Google Scholar
    • Export Citation
  • 15

    Ford AA, , Bateman BT, , Simpson LL, & Ratan RB: Nationwide data confirms absence of ‘July phenomenon’ in obstetrics: it's safe to deliver in July. J Perinatol 27:7376, 2007

    • Search Google Scholar
    • Export Citation
  • 16

    Ford LT, & Key JA: Postoperative infection of intervertebral disc space. South Med J 48:12951303, 1955

  • 17

    Freeman JT, , Anderson DJ, & Sexton DJ: Seasonal peaks in Escherichia coli infections: possible explanations and implications. Clin Microbiol Infect 15:951953, 2009

    • Search Google Scholar
    • Export Citation
  • 18

    Hambraeus A: Aerobiology in the operating room—a review. J Hosp Infect 11:Suppl A 6876, 1988

  • 19

    Inaba K, , Recinos G, , Teixeira PG, , Barmparas G, , Talving P, & Salim A, : Complications and death at the start of the new academic year: is there a July phenomenon?. J Trauma 68:1922, 2010

    • Search Google Scholar
    • Export Citation
  • 20

    Jarvis WR: Selected aspects of the socioeconomic impact of nosocomial infections: morbidity, mortality, cost, and prevention. Infect Control Hosp Epidemiol 17:552557, 1996

    • Search Google Scholar
    • Export Citation
  • 21

    Jawad A, , Heritage J, , Snelling AM, , Gascoyne-Binzi DM, & Hawkey PM: Influence of relative humidity and suspending menstrua on survival of Acinetobacter spp. on dry surfaces. J Clin Microbiol 34:28812887, 1996

    • Search Google Scholar
    • Export Citation
  • 22

    Kestle JR, , Cochrane DD, & Drake JM: Shunt insertion in the summer: is it safe?. J Neurosurg 105:3 Suppl 165168, 2006

  • 23

    Kirkland KB, , Briggs JP, , Trivette SL, , Wilkinson WE, & Sexton DJ: The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 20:725730, 1999

    • Search Google Scholar
    • Export Citation
  • 24

    Lidwell OM: Clean air at operation and subsequent sepsis in the joint. Clin Orthop Relat Res (211) 91102, 1986

  • 25

    Lindholm TS, & Pylkkanen P: Discitis following removal of intervertebral disc. Spine (Phila Pa 1976) 7:618622, 1982

  • 26

    Loffeld A, , Davies P, , Lewis A, & Moss C: Seasonal occurrence of impetigo: a retrospective 8-year review (1996–2003). Clin Exp Dermatol 30:512514, 2005

    • Search Google Scholar
    • Export Citation
  • 27

    Mangram AJ, , Horan TC, , Pearson ML, , Silver LC, & Jarvis WR: Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 204:250280, 1999

    • Search Google Scholar
    • Export Citation
  • 28

    Maragakis LL, , Cosgrove SE, , Martinez EA, , Tucker MG, , Cohen DB, & Perl TM: Intraoperative fraction of inspired oxygen is a modifiable risk factor for surgical site infection after spinal surgery. Anesthesiology 110:556562, 2009

    • Search Google Scholar
    • Export Citation
  • 29

    McDonald LC, , Banerjee SN, & Jarvis WR: Seasonal variation of Acinetobacter infections: 1987–1996. Nosocomial Infections Surveillance System. Clin Infect Dis 29:11331137, 1999

    • Search Google Scholar
    • Export Citation
  • 30

    Mermel LA, , Machan JT, & Parenteau S: Seasonality of MRSA infections. PLoS ONE 6:e17925, 2011

  • 31

    Olsen MA, , Mayfield J, , Lauryssen C, , Polish LB, , Jones M, & Vest J, : Risk factors for surgical site infection in spinal surgery. J Neurosurg 98:2 Suppl 149155, 2003

    • Search Google Scholar
    • Export Citation
  • 32

    Olsen MA, , Nepple JJ, , Riew KD, , Lenke LG, , Bridwell KH, & Mayfield J, : Risk factors for surgical site infection following orthopaedic spinal operations. J Bone Joint Surg Am 90:6269, 2008

    • Search Google Scholar
    • Export Citation
  • 33

    Perencevich EN, , McGregor JC, , Shardell M, , Furuno JP, , Harris AD, & Morris JG Jr, : Summer peaks in the incidences of gram-negative bacterial infection among hospitalized patients. Infect Control Hosp Epidemiol 29:11241131, 2008

    • Search Google Scholar
    • Export Citation
  • 34

    Phillips J, , Beam S, , Brinker A, , Holquist C, , Honig P, & Lee LY, : Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm 58:18351841, 2001

    • Search Google Scholar
    • Export Citation
  • 35

    Pilgaard S: Discitis (closed space infection) following removal of lumbar inervertebral disc. J Bone Joint Surg Am 51:713716, 1969

  • 36

    Schuster JM, , Rechtine G, , Norvell DC, & Dettori JR: The influence of perioperative risk factors and therapeutic interventions on infection rates after spine surgery: a systematic review. Spine (Phila Pa 1976) 35:9 Suppl S125S137, 2010

    • Search Google Scholar
    • Export Citation
  • 37

    Scott RM: Editorial. Summer shunt surgery. J Neurosurg 105:3 Suppl 163164, 2006

  • 38

    Sponseller PD, , LaPorte DM, , Hungerford MW, , Eck K, , Bridwell KH, & Lenke LG: Deep wound infections after neuromuscular scoliosis surgery: a multicenter study of risk factors and treatment outcomes. Spine (Phila Pa 1976) 25:24612466, 2000

    • Search Google Scholar
    • Export Citation
  • 39

    Stolke D, , Sollmann WP, & Seifert V: Intra- and postoperative complications in lumbar disc surgery. Spine (Phila Pa 1976) 14:5659, 1989

  • 40

    Stout CL, , Chapman JR, , Scoglietti VC, , Long EL, , Vaughn DM, & Abercrombie CL, : “July Effect:” an evaluation of a level I teaching hospital's trauma service seasonal mortality rates. Am Surg 74:878879, 2008

    • Search Google Scholar
    • Export Citation
  • 41

    Taplin D, , Zaias N, & Rebell G: Environmental influences on the microbiology of the skin. Arch Environ Health 11:546550, 1965

  • 42

    Watters WC III, , Baisden J, , Bono CM, , Heggeness MH, , Resnick DK, & Shaffer WO, : Antibiotic prophylaxis in spine surgery: an evidence-based clinical guideline for the use of prophylactic antibiotics in spine surgery. Spine J 9:142146, 2009

    • Search Google Scholar
    • Export Citation
  • 43

    Whitecloud TS III, , Butler JC, , Cohen JL, & Candelora PD: Complications with the variable spinal plating system. Spine (Phila Pa 1976) 14:472476, 1989

    • Search Google Scholar
    • Export Citation
  • 44

    Wright TE, , Orr RJ, , Haberkern CM, & Walbergh EJ: Complications during spinal anesthesia in infants: high spinal blockade. Anesthesiology 73:12901292, 1990

    • Search Google Scholar
    • Export Citation
  • 45

    Yaghoubian A, , de Virgilio C, , Chiu V, & Lee SL: “July effect” and appendicitis. J Surg Educ 67:157160, 2010

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