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Building Consensus: Development of a Best Practice Guideline (BPG) for Surgical Site Infection (SSI) Prevention in High-risk Pediatric Spine Surgery

Vitale, Michael G. MD, MPH*; Riedel, Matthew D. BA*; Glotzbecker, Michael P. MD; Matsumoto, Hiroko MA*; Roye, David P. MD*; Akbarnia, Behrooz A. MD; Anderson, Richard C.E. MD, FACS, FAAP§; Brockmeyer, Douglas L. MD; Emans, John B. MD; Erickson, Mark MD; Flynn, John M. MD#; Lenke, Lawrence G. MD**; Lewis, Stephen J. MD††; Luhmann, Scott J. MD**; McLeod, Lisa M. MD, MSCE‡‡; Newton, Peter O. MD§§; Nyquist, Ann-Christine MD, MSPH∥∥,¶¶; Richards, B. Stephens III MD##; Shah, Suken A. MD***; Skaggs, David L. MD†††; Smith, John T. MD‡‡‡; Sponseller, Paul D. MD, MBA§§§; Sucato, Daniel J. MD##; Zeller, Reinhard D. MD∥∥∥; Saiman, Lisa MD, MPH¶¶¶,###

Journal of Pediatric Orthopaedics: July/August 2013 - Volume 33 - Issue 5 - p 471–478
doi: 10.1097/BPO.0b013e3182840de2

Background: Perioperative surgical site infection (SSI) 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.

Methods: 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.

Results: 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.

Conclusions: 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: Not applicable.

Departments of *Orthopaedic Surgery

§Neurological Surgery

¶¶¶Pediatrics, Columbia University

###Department of Infection Prevention & Control, New York-Presbyterian Hospital, New York, NY

Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA

Department of Orthopaedic Surgery, University of San Diego and San Diego Center for Spinal Disorders

§§Department of Orthopaedic Surgery, Children’s Hospital of San Diego, San Diego

†††Department of Orthopaedic Surgery, Children’s Hospital Los Angeles, Los Angeles, CA

Department of Neurological Surgery, Primary Children’s Medical Center

‡‡‡Pediatric Orthopaedic Associates, Salt Lake City, UT

Department of Orthopaedic Surgery, University of Colorado, Denver

∥∥Department of Pediatrics, University of Colorado

¶¶Department of Infection Prevention and Control, Children’s Hospital Colorado, Aurora, CO

#Department of Orthopaedic Surgery, University of Pennsylvania

‡‡Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA

**Department of Orthopaedic Surgery, Washington University, St. Louis, MO

††Department of Orthopaedic Surgery, Toronto Western Hospital

∥∥∥Department of Orthopaedic Surgery, Hospital for Sick Children, Toronto, ON, Canada

##Department of Orthopaedic Surgery, Texas Scottish Rite Hospital, Dallas, TX

***Department of Orthopaedic Surgery, AI DuPont Hospital for Children, Wilmington, DE

§§§Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, MD

Supported by a grant from the Orthopaedic Research and Education Fund (OREF) as well as a grant from the Doris Duke Charitable Foundation to Columbia University College of Physicians and Surgeons to fund Clinical Research Fellow, M.D.R.

The authors declare no conflict of interest.

Reprints: Hiroko Matsumoto, MA, Department of Orthopaedic Surgery, Columbia University Medical Center, 600 West 168th Street, 7th Floor, New York, NY 10032. E-mail:

© 2013 by Lippincott Williams & Wilkins