Risk factors for deep surgical site infection following thoracolumbar spinal surgery

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OBJECTIVE

Surgical site infection (SSI) following spine surgery causes major morbidity and greatly impedes functional recovery. In the modern era of advanced operative techniques and improved perioperative care, SSI remains a problematic complication that may be reduced with institutional practices. The objectives of this study were to 1) characterize the SSI rate and microbial etiology following spine surgery for various thoracolumbar diseases, and 2) identify risk factors that were associated with SSI despite current perioperative management.

METHODS

All patients treated with thoracic or lumbar spine operations on the neurosurgery service at the University of California, San Francisco from April 2012 to April 2016 were formally reviewed for SSI using the National Healthcare Safety Network (NHSN) guidelines. Preoperative risk variables included age, sex, BMI, smoking, diabetes mellitus (DM), coronary artery disease (CAD), ambulatory status, history of malignancy, use of preoperative chlorhexidine gluconate (CHG) showers, and the American Society of Anesthesiologists (ASA) classification. Operative variables included surgical pathology, resident involvement, spine level and surgical technique, instrumentation, antibiotic and steroid use, estimated blood loss (EBL), and operative time. Multivariable logistic regression was used to evaluate predictors for SSI. Odds ratios and 95% confidence intervals were reported.

RESULTS

In total, 2252 consecutive patients underwent thoracolumbar spine surgery. The mean patient age was 58.6 ± 13.8 years and 49.6% were male. The mean hospital length of stay was 6.6 ± 7.4 days. Sixty percent of patients had degenerative conditions, and 51.9% underwent fusions. Sixty percent of patients utilized presurgery CHG showers. The mean operative duration was 3.7 ± 2 hours, and the mean EBL was 467 ± 829 ml. Compared to nonfusion patients, fusion patients were older (mean 60.1 ± 12.7 vs 57.1 ± 14.7 years, p < 0.001), were more likely to have an ASA classification > II (48.0% vs 36.0%, p < 0.001), and experienced longer operative times (252.3 ± 120.9 minutes vs 191.1 ± 110.2 minutes, p < 0.001). Eleven patients had deep SSI (0.49%), and the most common causative organisms were methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus. Patients with CAD (p = 0.003) or DM (p = 0.050), and those who were male (p = 0.006), were predictors of increased odds of SSI, and presurgery CHG showers (p = 0.001) were associated with decreased odds of SSI.

CONCLUSIONS

This institutional experience over a 4-year period revealed that the overall rate of SSI by the NHSN criteria was low at 0.49% following thoracolumbar surgery. This was attributable to the implementation of presurgery optimization, and intraoperative and postoperative measures to prevent SSI across the authors’ institution. Despite prevention measures, having a history of CAD or DM, and being male, were risk factors associated with increased SSI, and presurgery CHG shower utilization decreased SSI risk in patients.

ABBREVIATIONS ASA = American Society of Anesthesiologists; CAD = coronary artery disease; CHG = chlorhexidine gluconate; CI = confidence interval; DM = diabetes mellitus; EBL = estimated blood loss; LOS = length of stay; MIS = minimally invasive surgery; MRSA = methicillin-resistant Staphylococcus aureus; MRSE = methicillin-resistant Staphylococcus epidermidis; MSSA = methicillin-sensitive S. aureus; MSSE = methicillin-sensitive S. epidermidis; NHSN = National Healthcare Safety Network; OR = odds ratio; SSI = surgical site infection.
Article Information

Contributor Notes

Correspondence Hansen Deng: University of Pittsburgh Medical Center, Pittsburgh, PA. hdneurosurg@gmail.com.INCLUDE WHEN CITING Published online November 1, 2019; DOI: 10.3171/2019.8.SPINE19479.

H.D. and A.K.C. contributed equally to this work.

Disclosures Dr. A. K. Chan reports support of non–study-related clinical or research effort from Orthofix. Dr. Dhall reports being a consultant to DePuy Synthes. Dr. Clark reports being a consultant to NuVasive. Dr. Chou reports being a consultant to Medtronic and Globus, and receiving a small royalty from Globus. Dr. Ames reports being a consultant to DePuy Synthes, Medtronic, Stryker, Medicrea, K2M, and Biomet Zimmer; receiving royalties from Stryker, Biomet Zimmer, DePuy Synthes, NuVasive, Next Orthosurgical, K2M, and Medicrea; conducting research for Titan Spine, DePuy Synthes, and ISSG; being on the editorial board of Operative Neurosurgery; receiving grant funding from SRS; being on the Executive Committee of ISSG; and being the director of Global Spine Analytics. Dr. Mummaneni reports being a consultant to DePuy Spine, Globus, and Stryker; direct stock ownership in Spinicity/ISD; receiving statistical analysis for study/writing or editorial assistance on the manuscript from ISSG; receiving support of non–study-related clinical or research effort from the NREF; receiving royalties from DePuy Spine, Thieme Publishing, and Springer Publishing; and receiving honoraria from Spineart.
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