Perioperative surgical site infection
) after pediatric spine
fusion is a recognized complication with rates between 0.5% and 1.6% in adolescent idiopathic scoliosis
and up to 22% in “high risk
” patients. Significant variation in the approach to infection
prophylaxis has been well documented. The purpose of this initiative is to develop a consensus-based “Best Practice” Guideline
(BPG), informed by both the available evidence in the literature and expert opinion, for high-risk pediatric patients undergoing spine
fusion. For the purpose of this effort, high risk
was defined as anything other than a primary fusion in a patient with idiopathic scoliosis
without significant comorbidities. The ultimate goal of this initiative is to decrease the wide variability in SSI
prevention strategies in this area, ultimately leading to improved patient outcomes
and reduced health care costs.
An expert panel composed of 20 pediatric spine
surgeons and 3 infectious disease specialists from North America, selected for their extensive experience in the field of pediatric spine
surgery, was developed. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were as follows: (1) surveyed for current practices; (2) presented with a detailed systematic review of the relevant literature; (3) given the opportunity to voice opinion collectively; and (4) asked to vote regarding preferences privately. Round 1 was conducted using an electronic survey. Initial results were compiled and discussed face-to-face. Round 2 was conducted using the Audience Response System, allowing participants to vote for (strongly support or support) or against inclusion of each intervention. Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible. Repeat voting for consensus was performed.
Consensus was reached to support 14 SSI
prevention strategies and all participants agreed to implement the BPG in their practices. All agreed to participate in further studies assessing implementation and effectiveness of the BPG. The final consensus driven BPG for high-risk pediatric spine
surgery patients includes: (1) patients should have a chlorhexidine skin wash the night before surgery; (2) patients should have preoperative urine cultures obtained; (3) patients should receive a preoperative Patient Education Sheet; (4) patients should have a preoperative nutritional assessment; (5) if removing hair, clipping is preferred to shaving; (6) patients should receive perioperative intravenous cefazolin; (7) patients should receive perioperative intravenous prophylaxis for gram-negative bacilli; (8) adherence to perioperative antimicrobial regimens should be monitored; (9) operating room access should be limited during scoliosis
surgery (whenever practical); (10) UV lights need NOT be used in the operating room; (11) patients should have intraoperative wound irrigation; (12) vancomycin powder should be used in the bone graft and/or the surgical site; (13) impervious dressings are preferred postoperatively; (14) postoperative dressing changes should be minimized before discharge to the extent possible.
In conclusion, we present a consensus-based BPG consisting of 14 recommendations for the prevention of SSIs after spine
surgery in high-risk pediatric patients. This can serve as a tool to reduce the variability in practice in this area and help guide research priorities in the future. Pending such data, it is the unsubstantiated opinion of the authors of the current paper that adherence to recommendations in the BPG will not only decrease variability in practice but also result in fewer SSI
in high-risk children undergoing spinal fusion.
Level of Evidence: