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      Risk factors for surgical site infection following lumbar spinal surgery: a meta-analysis

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          To identify risk factors for surgical site infection (SSI) in patients who had undergone lumbar spinal surgery.


          Studies published in PubMed, Web of Science, and Embase were systematically reviewed to determine risk factors for SSI following lumbar spinal surgery. Results are expressed as risk ratios (RRs) with 95% CIs and weighted mean difference (WMD) with 95% CI. A fixed-effect or random-effect model was used to pool the estimates according to heterogeneity among the studies included.


          Sixteen studies involving 13,393 patients were included in this meta-analysis. Pooled estimates suggested that diabetes (RR 2.19, 95% CI 1.43–3.36; P<0.001), obesity (RR 2.87, 95% CI 1.62–5.09; P<0.001), BMI (WMD 1.32 kg/m 2, 95% CI 0.39–2.25; P=0.006), prolonged operating time (WMD 24.96 minutes, 95% CI 14.77–35.15; P<0.001), prolonged hospital stay (WMD 2.07 days, 95% CI 0.28–3.87; P=0.024), hypertension (RR 1.28, 95% CI 1.08–1.52; P=0.005), and previous surgery (RR 2.06, 95% CI 1.39–3.06; P<0.001) were independent risk factors for SSI in patients who had undergone lumbar spine surgery. Current smoking (RR 0.89, 95% CI 0.75–1.06; P=0.178), American Society of Anesthesiologists grade >2 (RR 2.63, 95% CI 0.84–8.27; P=0.098), increased age (WMD 1.43 years, 95% CI −1.15 to 4.02; P=0.278), COPD (RR 1.21, 95% CI 0.68–2.17; P=0.521), cardiovascular disease (RR 1.63, 95% CI 0.40–6.70; P=0.495), rheumatoid arthritis (RR 1.76, 95% CI 0.53–5.90; P=0.359), and osteoporosis (RR 1.91, 95% CI 0.79–4.63; P=0.152) were not risk factors for postoperative SSI.


          Our results identified several important factors that increased the risk of postoperative SSI. Knowing these risk factors, surgeons could adequately analyze and evaluate risk factors in patients and then develop prevention measurements to reduce the rate of SSI.

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          Most cited references 37

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          The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection.

          Randomized, controlled trials have shown that prophylactic antibiotics are effective in preventing surgical-wound infections. However, it is uncertain how the timing of antibiotic administration affects the risk of surgical-wound infection in actual clinical practice. We prospectively monitored the timing of antibiotic prophylaxis and studied the occurrence of surgical-wound infections in 2847 patients undergoing elective clean or "clean-contaminated" surgical procedures at a large community hospital. The administration of antibiotics 2 to 24 hours before the surgical incision was defined as early; that during the 2 hours before the incision, as preoperative; that during the 3 hours after the incision, as perioperative; and that more than 3 but less than 24 hours after the incision, as postoperative. Of the 1708 patients who received the prophylactic antibiotics preoperatively, 10 (0.6 percent) subsequently had surgical-wound infections. Of the 282 patients who received the antibiotics perioperatively, 4 (1.4 percent) had such infections (P = 0.12; relative risk as compared with the preoperatively treated group, 2.4; 95 percent confidence interval, 0.9 to 7.9). Of 488 patients who received the antibiotics postoperatively, 16 (3.3 percent) had wound infections (P less than 0.0001; relative risk, 5.8; 95 percent confidence interval, 2.6 to 12.3). Finally, of 369 patients who had antibiotics administered early, 14 (3.8 percent) had wound infections (P less than 0.0001; relative risk, 6.7; 95 percent confidence interval, 2.9 to 14.7). Stepwise logistic-regression analysis confirmed that the administration of antibiotics in the preoperative period was associated with the lowest risk of surgical-wound infection. We conclude that in surgical practice there is considerable variation in the timing of prophylactic administration of antibiotics and that administration in the two hours before surgery reduces the risk of wound infection.
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            Risk factors for infection after spinal surgery.

            A retrospective case control analysis of 48 cases of postoperative infection following spinal procedures. Spinal procedures that became infected after surgery were analyzed to identify the significance of preoperative and intraoperative risk factors. Characterization of the nature and timing of the infections was also performed. The rate of postoperative infection following spinal surgery varies widely depending on the nature of the procedure and the patient's diagnosis. Preoperative comorbidities and risk factors also influence the likelihood of infection. A review of 1629 procedures performed on 1095 patients revealed that a postoperative infection developed in 48 patients (4.4%). Data regarding preoperative and intraoperative risk factors were gathered from patient charts for these and a randomly selected control group of 95 uninfected patients. For analysis, these patient groups were further divided into adult and pediatric subgroups, with an age cutoff of 18 years. Preoperative risk factors reviewed included smoking, diabetes, previous surgery, previous infection, steroid use, body mass index, and alcohol abuse. Intraoperative factors reviewed included staging of procedures, estimated blood loss, operating time, and use of allograft or instrumentation. The majority of infections occurred during the early postoperative period (less than 3 months). Age >60 years, smoking, diabetes, previous surgical infection, increased body mass index, and alcohol abuse were statistically significant preoperative risk factors. The most likely procedure to be complicated by an infection was a combined anterior/posterior spinal fusion performed in a staged manner under separate anesthesia. Infections were primarily monomicrobial, although 5 patients had more than 4 organisms identified. The most common organism cultured from the wounds was Staphylococcus aureus. All patients were treated with surgical irrigation and débridement, and appropriate antibiotics to treat the cultured organism. Aggressive treatment of patients undergoing complex or prolonged spinal procedures is essential to prevent and treat infections. Understanding a patient's preoperative risk factors may help the physician to optimize a patient's preoperative condition. Additionally, awareness of critical intraoperative parameters will help to optimize surgical treatment. It may be appropriate to increase the duration of prophylactic antibiotics or implement other measures to decrease the incidence of infection for high risk patients.
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              Risk factors for deep surgical site infections after spinal fusion.

              Surgical site infections (SSI) are undesired and troublesome complications after spinal surgery. The reported infection rates range from 0.7 to 11.9%, depending on the diagnosis and the complexity of the procedure. Besides operative factors, patient characteristics could also account for increased infection rates. Because the medical, economic and social costs of SSI are enormous, any significant reduction in risks will pay dividends. The purpose of this study is to compare patients who developed deep SSI following lumbar or thoracolumbar spinal fusion with a randomly selected group of patients who did not develop this complication in order to identify changeable risk factors. With a case-control analysis nested in a historical cohort of patients who had had a spinal fusion between January 1999 and December 2008, we identified 36 cases with deep SSI (CDC criteria). Information regarding patient-level and surgical-level risk factors was derived from standardized but routinely recorded data and compared with those acquired in a random selection of 135 uninfected patients. Univariate analyses and a multivariate logistic regression were performed. The overall rate of infection in 1,615 procedures (1,568 patients) was 2.2%. A positive history of spinal surgery was associated with an almost four times higher infection rate (OR = 3.7, 95% BI = 1.6-8.6). The risk of SSI increased with the number of levels fused, patients with diabetes had an almost six times higher risk and smokers had more than a two times higher risk for deep SSI. The most common organism cultured was Staphylococcus aureus. All infected patients underwent at least one reoperation, including an open débridement and received appropriate antibiotics to treat the organism. Patients who had had a previous spinal surgery are a high-risk group for infection compared with those that never had surgery. Total costs associated with preventive measures are substantial and should be compensated by health care insurance companies by means of separate clinical pathways. High-risk patients should be informed about the increased risk of complications.

                Author and article information

                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                31 October 2018
                : 14
                : 2161-2169
                Department of Spine Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China, 18910160203@ 123456163.com
                Author notes
                Correspondence: Lin Zhang, Department of Spine Surgery, Beijing Shijitan Hospital, Capital Medical University, No.10, Tieyi Road, Yangfangdian, Haidian District, Beijing 100038, China, Tel +86 189 1016 0203, Email 18910160203@ 123456163.com
                © 2018 Zhang and Li. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Original Research


                meta-analysis, risk factors, surgical site infection, lumbar spinal surgery


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