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Perioperative Antibiotic Use for Spinal Surgery Procedures in US Children's Hospitals

McLeod, Lisa M., MD, MSCE*; Keren, Ron, MD, MPH*,†; Gerber, Jeffrey, MD, PhD*,‡; French, Benjamin, PhD; Song, Lihai, MS*; Sampson, Norma R., MS§; Flynn, John, MD§; Dormans, John P., MD§

doi: 10.1097/BRS.0b013e318289b690

Study Design. Retrospective cohort study using the Pediatric Health Information System database.

Objective. To describe longitudinal patterns of prophylactic antibiotic use and determinants of antibiotic choice for spinal fusion surgical procedures performed at US children's hospitals.

Summary of Background Data. Surgical site infections (SSIs) account for a significant proportion of post–spinal surgery complications, particularly among children with complex conditions such as neuromuscular disease. Antimicrobial prophylaxis with intravenous cefazolin or cefuroxime has been a standard practice, but postoperative infections caused by organisms resistant to these antibiotics are increasing in prevalence. Studies describing the choice of antibiotic prophylaxis for pediatric spinal surgery are lacking.

Methods. We included children 6 months to 18 years of age discharged from 37 US children's hospitals between January 1, 2006, and June 30, 2009, with (1) an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure code indicating a spinal fusion and (2) combinations of diagnosis codes indicating adolescent idiopathic scoliosis (AIS) (n = 5617) or neuromuscular scoliosis (NMS) (n = 3633). After identifying antibiotics ordered on the operative day, we described variation in broad-spectrum antibiotic use over time and measured associations between patient/surgery characteristics and antibiotic choice.

Results. Prophylactic antibiotic choice varied across hospitals and over time. Broad-spectrum antibiotics were used in 37% of AIS and 52% of NMS operations. Seven (19%) hospitals used broad-spectrum coverage for more 80% of all cases. For NMS procedures, broad-spectrum antibiotic use was associated with patient characteristics known to be associated with high SSI risk. Use of vancomycin and broad gram-negative agents increased over time.

Conclusion. Broad-spectrum antimicrobial prophylaxis varied across hospitals and was often associated with known risk factors for SSI. These results highlight the need for future studies comparing the effectiveness of various prophylaxis strategies, particularly in high-risk subgroups. This research can inform the development of best practice for SSI prevention in spinal fusion procedures.

Level of Evidence: 3

Prophylactic antibiotic use for spinal fusions performed at 37 US children's hospitals from 2006 to 2009 was highly variable. Prophylaxis with vancomycin or broad-spectrum gram-negative agents increased over time and was most common in procedures involving children with characteristics known to be associated with high SSI risk.

*Department of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA

Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA

Division of Pediatric Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA; and

§Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA.

Address correspondence and reprint requests to Lisa M. McLeod, MD, MSCE, 3535 Market St, Ste 1509, Philadelphia, PA 19104; E-mail:

Acknowledgment date: June 12, 2012. Revision date: August 24, 2012. Acceptance date: August 26, 2012.

The device(s)/drug(s) is/are FDA approved or approved by corresponding national agency for this indication.

This project was funded in part by grants from the Pennsylvania Department of Public Health Health Research Formula Fund, and the Kerr Family Foundation. Funders had no involvement in the conceptualization, execution or interpretation of this research.

Relevant financial activities outside the submitted work: board membership, consultancy, employment, expert testimony, grants, royalties.

© 2013 Lippincott Williams & Wilkins, Inc.