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Timing of Preoperative Antibiotic Prophylaxis: A Modifiable Risk Factor for Deep Surgical Site Infections After Pediatric Spinal Fusion

Milstone, Aaron M. MD*†; Maragakis, Lisa L. MD, MPH†‡; Townsend, Timothy MD*; Speck, Kathleen MPH†; Sponseller, Paul MD§; Song, Xiaoyan PhD†‡; Perl, Trish M. MD, MSc†‡

Pediatric Infectious Disease Journal: August 2008 - Volume 27 - Issue 8 - pp 704-708
doi: 10.1097/INF.0b013e31816fca72
Original Studies

Background: Deep surgical site infections (SSI) after spinal fusion are healthcare-associated infections that result in increased morbidity, hospital stay, and health care costs. Risk factors for these infections among children are poorly characterized.

Methods: We performed a case-control study nested within a cohort of all children, from birth to 18 years of age, who underwent spinal fusion at Johns Hopkins Hospital between July 1, 2000 and June 30, 2006.

Results: Thirty-six deep SSI were identified. The incidence of deep SSI was 3.4%. Infection was diagnosed a median of 15 days after surgery (interquartile range, 9–28). Significant risk factors for deep SSI included inappropriate timing of preoperative antibiotic prophylaxis, previous spine surgery, presence of a complex underlying medical condition, age, >10 vertebrae fused, and an increased estimated blood loss per kilogram body weight. After controlling for previous spine surgery, number of vertebrae fused, and complex underlying medical condition, inappropriate timing of preoperative antibiotic prophylaxis administration was a significant independent risk factor for deep SSI (odds ratio: 3.5; 95% confidence interval: 1.7–7.3; P = 0.001).

Discussion: Timing of preoperative antibiotic prophylaxis is an independent and modifiable risk factor for deep SSI after pediatric spinal fusion. Our findings suggest that all pediatric patients undergoing pediatric spinal fusion should have preoperative antibiotic prophylaxis given within 60 minutes before incision to reduce the risk of SSI and the morbidity and costs associated with hardware removal and repeat spinal fusion.

From the *Department of Pediatrics, Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine; †Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital; ‡Department of Medicine, Division of Infectious Diseases; and §Department of Orthopedics, Johns Hopkins University School of Medicine, Baltimore, MD.

Accepted for publication February 21, 2008.

A. M. was supported by a Pediatric Infectious Diseases Society Fellowship Award funded by an educational grant from AstraZeneca Pharmaceuticals and a Johns Hopkins Clinical Research Career Development Grant K12 RR023266. L. M. was supported by a Research Scientist Development Award, Grant 5 K01 CI000300, from The Centers for Disease Control and Prevention. T. P. is supported by CDC Grant UR8/CCU315092.

Address for correspondence: Aaron M. Milstone, MD, JHH, Pediatric Infectious Diseases, 200 North Wolfe St./Room 3141 Baltimore, MD 21287. E-mail:

© 2008 Lippincott Williams & Wilkins, Inc.