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Evidence-based Care Bundles for Preventing Surgical Site Infections in Spinal Instrumentation Surgery

Yamada, Koji MD, PhD; Abe, Hiroaki MD; Higashikawa, Akiro MD, PhD; Tonosu, Juichi MD; Kuniya, Takashi MD; Nakajima, Koji MD; Fujii, Haruko; Niwa, Kazuki MD; Shinozaki, Tomohiro PhD; Watanabe, Kenichi MD; Sakae, Tanaka MD, PhD§; Okazaki, Hiroshi MD, PhD

doi: 10.1097/BRS.0000000000002709

Study Design. A retrospective study, using prospectively collected data.

Objective. The aim of this study was to evaluate the impact of evidence-based care bundles for preventing surgical site infections (SSIs) in spinal instrumentation surgery.

Summary of Background Data. About half of all SSIs are preventable via evidence-based methods. For successful SSI prevention, the bacterial load must be minimized, and methicillin-resistant Staphylococcus aureus (MRSA) protection must be maximized. However, it is difficult to cover all of these requirements by single preventative method.

Methods. We screened consecutive patients scheduled for spinal instrumentation surgeries at a single tertiary referral hospital for high surgical, SSI, and MRSA colonization risks. Evidence-based care bundles were implemented for high-risk patients and included 1) additional vancomycin prophylaxis, 2) diluted povidone-iodine irrigation, and 3) nasal and body decontamination. Patient demographics, comorbidities, operative features, and SSIs reported to the Japanese Nosocomial Infections Surveillance system were prospectively obtained in the same method by the same assessor and were used for the analyses. The results were compared before and after the application of the bundle.

Results. There were 1042 spinal instrumentation surgeries (741 before and 301 after care bundles) performed from November 2010 to December 2015. Of 301 surgeries, 57 cases (18.9%) received care bundles. There were no significant differences in patient backgrounds before and after the intervention. The SSI rate decreased significantly from 3.8% to 0.7% (P < 0.01) after the intervention, with an overall 82% relative risk reduction. A significant protective effect was observed in the multivariate analysis (adjusted odds ratio 0.18, 95% confidence interval: 0.04–0.77, P = 0.02). There were no MRSA-related SSIs among those that received care bundles, even though MRSA was the predominant pathogen in the study population.

Conclusion. Evidence-based care bundles, applied in selected high-risk spinal instrumentation cases, minimized bacterial load, maximized MRSA protection, and significantly reduced SSI rates without topical vancomycin powder.

Level of Evidence: 4

Department of Orthopaedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, Kanagawa, Japan

Department of Infectious Diseases, Infection Control Office, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, Kanagawa, Japan

Department of Biostatistics, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan

§Department of Orthopedic Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan.

Address correspondence and reprint requests to Koji Yamada, MD, PhD, Department of Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki City, Kanagawa Prefecture 211-8510, Japan; E-mail:

Received 20 March, 2018

Accepted 20 April, 2018

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

No relevant financial activities were performed outside the realm of the submitted work.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.