Spine Surgical Site Infection-1.pptx scrubbing

Surgical site

1. Spine Surgical Site Infection ---- DEPARTEMEN ORTOPEDI DAN TRAUMATOLOGI FK UNHAS Supervisor: dr. Fadlyansyah Farid, MARS, Sp.OT   Presenter: dr. Muh . Nur Anshari S.

2. SSI after spinal surgery is the 3rd most common complication in spinal surgery, after pneumonia and UTI It can be superficial or deep site infection Can worsen the patient's condition, prolong hospital stay, affect the patient's prognosis, and even lead to death, causing additional physical, mental, and economic burdens The management focuses on a multilevel comprehensive prevention strategy, including risk factors identification and perioperative prevention Introduction Wang, X., Lin, Y., Yao, W.  et al.  Surgical site infection in spinal surgery: a bibliometric analysis.  J Orthop Surg Res   18 , 337 (2023). https://doi.org/10.1186/s13018-023-03813-6

3. Epidemiology Incidence ranges from 0.5 to 18.8% Highest incidence (13%) was reported in neuromuscular scoliosis A 2019 meta-analysis reported a pooled SSI incidence of 3.1% among 22,475 patients White AJ, Fiani B, Jarrah R, Momin AA, Rasouli J. Surgical Site Infection Prophylaxis and Wound Management in Spine Surgery. Asian Spine J. 2022 Jun;16(3):451-461. doi : 10.31616/asj.2020.0674. Chahoud J, Kanafani Z and Kanj SS (2014) Surgical site infections following spine surgery: eliminating the controversies in the diagnosis. Front. Med. 1:7. doi : 10.3389/fmed.2014.00007

4. Risk Factor Surgical invasiveness index Type of fusion performed Implants use Revision intervention Site of surgery Omission of drain usage post spine surgery Administered fraction of inspired oxygen <50% Operative duration above 3h Instrumentation alloy from stainless steel Diabetes Cigarette smoking Obesity Steroid use Alcohol abuse Extremes of ages Peri-operative transfusion of blood products ASA score >3, Pre-operative factors Surgical factors Chahoud J, Kanafani Z and Kanj SS (2014) Surgical site infections following spine surgery: eliminating the controversies in the diagnosis.  Front. Med.  1:7. doi : 10.3389/fmed.2014.00007 White AJ, Fiani B, Jarrah R, Momin AA, Rasouli J. Surgical Site Infection Prophylaxis and Wound Management in Spine Surgery. Asian Spine J. 2022 Jun;16(3):451-461.

5. Etiology Microbial Etiology Staphylococcus aureus (37,9-50%), Staphylococcus epidermidis (22.7%), methicillin-resistant Staphylococcus species (23.1%). Gram-negative organisms (Pseudomonas aeruginosa, E. coli, and Proteus species) Propionibacterium acnes Chahoud J, Kanafani Z and Kanj SS (2014) Surgical site infections following spine surgery: eliminating the controversies in the diagnosis.  Front. Med.  1:7. doi : 10.3389/fmed.2014.00007 White AJ, Fiani B, Jarrah R, Momin AA, Rasouli J. Surgical Site Infection Prophylaxis and Wound Management in Spine Surgery. Asian Spine J. 2022 Jun;16(3):451-461. Surgical site infection following spine surgery usually occurs through direct inoculation during the surgical procedure. The other two possible routes of infection are hematogenous spread and early post-operative contamination.

6. Preoperative Interventions Nasal Staphylococcus aureus culture Preoperative chlorhexidine showers Antimicrobial surgical preparation Prevention Intraoperative Interventions Antibiotics Intraoperative Warming Vancomycin powder White AJ, Fiani B, Jarrah R, Momin AA, Rasouli J. Surgical Site Infection Prophylaxis and Wound Management in Spine Surgery. Asian Spine J. 2022 Jun;16(3):451-461. Postoperative Interventions Intrawound drains Negative pressure wound therapy Surgical incision dressing

7. Prevention White AJ, Fiani B, Jarrah R, Momin AA, Rasouli J. Surgical Site Infection Prophylaxis and Wound Management in Spine Surgery. Asian Spine J. 2022 Jun;16(3):451-461. Intervention Recommendation Preoperative Nasal culture for MRSA/MSSA Swab at least 5 days prior to surgery Topical muciprocin and CHG shower if positive Preoperative CHG shower Demonstrates benefit in shorter procedures Antimicrobial surgical site preparation Chlorhexidine may be slightly favored over povidone-iodine Intraoperative Antibiotic prophylaxis 1 g cefazolin approximately 2 hours prior to surgery or earlier Clindamycin is an acceptable alternative Redosing may be necessary in long procedures Intraoperative warming Intraoperative normothermia is optimal Vancomycin powder Intrasite vancomycin powder is recommended as a safe and inexpensive option for SSI prevention Postoperative Wound drains Limited evidence for SSI prevention May be useful in SSI management Negative pressure wound therapy Evidence for efficacy in SSI management Emerging evidence for efficacy in SSI prevention Traditional wound dressings Silver and Aquaphor dressings both have antimicrobrial properties and may accelerate wound healing Prevena wound management system Unique dressing that reduces SSI prevalence

8. Clinical Presentation Back pain, (2 days to over 3 months post-intervention), usually can radiate Pain is characteristically localized, continuous, and not relieved by pain medications wound drainage and constitutional symptoms such as fever, fatigue, and weight loss. Localized tenderness, warmth, erythema, and edema at the site of surgery with or without purulent wound drainage. Purulent wound drainage occurs in around two-third of SSIs with instrumentation and is the most frequent indicative sign of instrumented spine surgery infections. Symptoms Physical Examination 01 02 Chahoud J, Kanafani Z and Kanj SS (2014) Surgical site infections following spine surgery: eliminating the controversies in the diagnosis. Front. Med. 1:7. doi: 10.3389/fmed.2014.00007

9. Clinical Presentation WBC is elevated in <50% of SSI cases, thus making it an unreliable diagnostic marker ESR and CRP levels increase post-op rendering the differentiation between infected and non-infected patients problematic in the early post-op window period CRP levels peak on day 3 and decrease to normal baseline between days 10 - 14 post-op ESR levels are highest at around 14 days and do not normalize until approximately 6 weeks after surgery This distinctive rapid decrease in SAA in non-infected cases is very helpful in eliminating one of the controversies surrounding the diagnosis of early SSI Blood culture Gram stain and culture of wound swabs or aspirated fluid are recommended in superficial Laboratory Tests 03 Chahoud J, Kanafani Z and Kanj SS (2014) Surgical site infections following spine surgery: eliminating the controversies in the diagnosis. Front. Med. 1:7. doi: 10.3389/fmed.2014.00007

10. Clinical Presentation MRI remains the technique of choice X-ray, but lacks sensitivity. Between 4-6 weeks post-op is a decrease in intervertebral height. Other plain radio film manifestations, including osteolysis, deformity, and endplate destruction, are only expected to appear >6 weeks CT scan imaging can be used to assess bony destruction and spinal stability with great precision. It can aid in planning transcutaneous aspiration and in the surgical approach Imaging 04 Chahoud J, Kanafani Z and Kanj SS (2014) Surgical site infections following spine surgery: eliminating the controversies in the diagnosis. Front. Med. 1:7. doi: 10.3389/fmed.2014.00007

11. Chahoud J, Kanafani Z and Kanj SS (2014) Surgical site infections following spine surgery: eliminating the controversies in the diagnosis. Front. Med. 1:7. doi: 10.3389/fmed.2014.00007

12. Treatment typically involves multiple debridements due to the intricate structure of the biofilm, antibiotics can only eradicate the planktonic and outer-layer bacteria I n severe cases Early debridement Intravenous antibiotics Implant removal Wang, X., Lin, Y., Yao, W.  et al.  Surgical site infection in spinal surgery: a bibliometric analysis.  J Orthop Surg Res   18 , 337 (2023). https://doi.org/10.1186/s13018-023-03813-6

13. Treatment for Deep SSI The primary method of irrigation for acute infection was gravity/manual pouring of fluids For acute thoracolumbar infections, prior to closure, topical glycopeptides (e.g., vancomycin powder) Irrigation & Debridement Management of bone graft Management of hardware Topical Antibiotics & Closure Sarraj M, Alqahtani A, Thornley P, Koziarz F, Bailey CS, Freire-Archer M, Bhanot K, Kachur E, Bhandari M, Oitment C. Management of deep surgical site infections of the spine: a Canadian nationwide survey. J Spine Surg 2022;8(4):443-452. doi : 10.21037/jss-22-47 Bone graft, especially allograft, may be considered a nidus for infection and risk factor for infection recurrence Some suggest higher rates of reoperation and death with removal of hardware at initial washout

14. Example This is a case of a 62-year-old woman with a history of osteoporotic multiple vertebral collapses treated with posterior stabilisation with screws and rods from D3 to D12. She was a very thin patient with almost no subcutaneous fat (figure 1). The second operation was an extension of stabilisation to the cervical level (figure 2). Figure 1. Patient came with severe kyphosis and evident spinal instrumentation at the subcutaneous level. Figure 2. Extension of stabilisation to the cervical level Dobran  M, Mancini F, Nasi D , et al . A case of deep infection after instrumentation in dorsal spinal surgery: the management with antibiotics and negative wound pressure without removal of fixation. Case Reports  2017

15. Example Due to the dehiscence of the cranial end of the wound, cervical instrumentation was removed and the dorsal rods were cut at T4–T5 level and bilateral T3–T4 screws were removed as well (figure 3). On removal of stitches 12 days from surgery, the wound reopened (figure 4). The cultural examination of the wound was found to be positive for Staphylococcus aureus Figure 3. Wound dehiscence after extension of stabilisation to the cervical level Figure 4. Wound dehiscence after the second surgical procedure of cervical instrumentation removal Dobran  M, Mancini F, Nasi D , et al . A case of deep infection after instrumentation in dorsal spinal surgery: the management with antibiotics and negative wound pressure without removal of fixation. Case Reports  2017

16. Example After 2 weeks of antibiotic therapy (piperacillin sodium/tazobactam sodium 500 mg /two times a day), a revision of the surgical wound was performed using a myocutaneous trapezius muscle flap Figure 5. Revision of the surgical wound with a myocutaneous trapezius muscle flap Figure 8. Wound closure after 2 months of VAC. VAC, vacuum-assisted closure Dobran  M, Mancini F, Nasi D , et al . A case of deep infection after instrumentation in dorsal spinal surgery: the management with antibiotics and negative wound pressure without removal of fixation. Case Reports  2017

17. Conclusion SSI following spine surgery is a major cause of increased morbidity A high index of suspicion should be kept in the first 3 months after the procedure. The diagnosis is usually suspected based on the symptoms and physical exam findings. L aboratory and imaging speed up the confirmation of the diagnosis and the recovery of the offending organisms, which would allow early targeted therapy

18. A 73-year-old female with lumbar spinal stenosis, and diabetes mellitus was having persistent pain in her waist and intermittent claudication. MRI revealed lumbar spinal stenosis of L4–5. TLIF was performed, clinical symptoms improved. The patient, however, developed serious hypokalemia and hypoalbuminemia due to vomiting. She discharged 1 week later during which sweat soaked dressing because of hot weather. At 2 weeks postoperative, spontaneous dehiscence of the surgical wound and purulent exudate from the opened portion of the wound were observed. The test that should be done to determine the cause is … Debridement as soon as possible Administration of IV antibiotics Plain radiograph Blood test Albumin levels

19. 2. A case of surgical site infection of the lumbar spine with unabsorbed sutures as seen in the picture. The management of this patient is … Debridement as soon as possible Wound dressings and oral antibiotic Irrigation and drainage Observation and follow up in 2 weeks Closure of the wound