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Du JY, Lovecchio FC, Kazarian G, Clohisy J, Pajak A, Kaidi A, Knopp R, Akosman I, Johnson M, Nakarai H, Dash A, Samuel JT, Cunningham ME, Kim HJ. Decisional regret following corrective adult spinal deformity surgery: a single institution study of incidence and risk factors. Spine Deform 2024; 12:775-783. [PMID: 38289505 DOI: 10.1007/s43390-023-00790-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/04/2023] [Indexed: 05/04/2024]
Abstract
PURPOSE To assess the characteristics and risk factors for decisional regret following corrective adult spinal deformity (ASD) surgery at our hospital. METHODS This is a retrospective cohort study of a single-surgeon ASD database. Adult patients (> 40 years) who underwent ASD surgery from May 2016 to December 2020 with minimum 2-year follow-up were included (posterior-only, ≥ 4 levels fused to the pelvis) (n = 120). Ottawa decision regret questionnaires, a validated and reliable 5-item Likert scale, were sent to patients postoperatively. Regret scores were defined as (1) low regret: 0-39 (2) medium to high regret: 40-100. Risk factors for medium or high decisional regret were identified using multivariate models. RESULTS Ninety patients were successfully contacted and 77 patients consented to participate. Nonparticipants were older, had a higher incidence of anxiety, and higher ASA class. There were 7 patients that reported medium or high decisional regret (9%). Ninety percentage of patients believed that surgery was the right decision, 86% believed that surgery was a wise choice, and 87% would do it again. 8% of patients regretted the surgery and 14% believed that surgery did them harm. 88% of patients felt better after surgery. On multivariate analysis, revision fusion surgery was independently associated with an increased risk of medium or high decisional regret (adjusted odds ratio: 6.000, 95% confidence interval: 1.074-33.534, p = 0.041). CONCLUSIONS At our institution, we found a 9% incidence of decisional regret. Revision fusion was associated with increased decisional regret. Estimates for decisional regret should be based on single-institution experiences given differences in patient populations.
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Affiliation(s)
- Jerry Y Du
- Hospital for Special Surgery, New York City, NY, 535 E 70th St.10021, USA.
| | | | - Gregory Kazarian
- Hospital for Special Surgery, New York City, NY, 535 E 70th St.10021, USA
| | - John Clohisy
- Hospital for Special Surgery, New York City, NY, 535 E 70th St.10021, USA
| | - Anthony Pajak
- Hospital for Special Surgery, New York City, NY, 535 E 70th St.10021, USA
| | - Austin Kaidi
- Hospital for Special Surgery, New York City, NY, 535 E 70th St.10021, USA
| | - Rachel Knopp
- Hospital for Special Surgery, New York City, NY, 535 E 70th St.10021, USA
| | - Izzet Akosman
- Hospital for Special Surgery, New York City, NY, 535 E 70th St.10021, USA
| | - Mitchell Johnson
- Hospital for Special Surgery, New York City, NY, 535 E 70th St.10021, USA
| | - Hiroyuki Nakarai
- Hospital for Special Surgery, New York City, NY, 535 E 70th St.10021, USA
| | - Alexander Dash
- Hospital for Special Surgery, New York City, NY, 535 E 70th St.10021, USA
| | - Justin T Samuel
- Hospital for Special Surgery, New York City, NY, 535 E 70th St.10021, USA
| | | | - Han Jo Kim
- Hospital for Special Surgery, New York City, NY, 535 E 70th St.10021, USA
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Sergesketter AR, Langdell HC, Shammas RL, Geng Y, Atia AN, Rezak K, Sisk GC, Hollenbeck ST, Phillips BT. Efficacy of Prophylactic Postoperative Antibiotics in Tissue Expander-Based Breast Reconstruction: A Propensity Score-Matched Analysis. Plast Reconstr Surg 2024; 153:496e-504e. [PMID: 37335554 DOI: 10.1097/prs.0000000000010825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Conflicting evidence exists regarding the utility of prophylactic postoperative antibiotics in tissue expander (TE)-based breast reconstruction. This study evaluated the risk of surgical-site infection between patients receiving 24 hours of perioperative antibiotics alone versus prolonged postoperative antibiotics within a propensity score-matched cohort. METHODS Patients undergoing TE-based breast reconstruction receiving 24 hours of perioperative antibiotics alone were propensity score-matched 1:3 to patients receiving postoperative antibiotics based on demographics, comorbidities, and treatment factors. Incidence of surgical-site infection was compared based on duration of antibiotic prophylaxis. RESULTS Of a total of 431 patients undergoing TE-based breast reconstruction, postoperative antibiotics were prescribed in 77.2%. Within this cohort, 348 were included for propensity matching (no antibiotics, 87 patients; antibiotics, 261 patients). After propensity score matching, there was no significant difference in incidence of infection requiring intravenous (no antibiotics, 6.9%; antibiotics, 4.6%; P = 0.35) or oral antibiotics (no antibiotics, 11.5%; antibiotics, 16.1%; P = 0.16). In addition, rates of unplanned reoperation ( P = 0.88) and 30-day readmission ( P = 0.19) were similar. After multivariate adjustment, prescription of postoperative antibiotics was not associated with a reduction in surgical-site infection (OR, 0.5; 95% CI, -0.3 to 1.3; P = 0.23). CONCLUSIONS Within a propensity score-matched cohort accounting for patient comorbidities and receipt of adjuvant therapies, prescription of postoperative antibiotics after TE-based breast reconstruction conferred no improvement in rates of TE infection, reoperation, or unplanned health care use. These data underscore the need for multicenter randomized trials on the utility of antibiotic prophylaxis in TE-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
| | - Hannah C Langdell
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University
| | - Ronnie L Shammas
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University
| | | | - Andrew N Atia
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University
| | - Kristen Rezak
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University
| | - Geoffroy C Sisk
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University
| | - Scott T Hollenbeck
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University
| | - Brett T Phillips
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University
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Rocos B, Kato S, Lewis SJ, Shaffrey CI, Lenke LG. Antibiotic Use in Adult Spine Deformity Surgery: Results From the AO Spine Surveillance of the Management of Patients With Adult Spine Deformity. Global Spine J 2023:21925682231201240. [PMID: 37683295 DOI: 10.1177/21925682231201240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023] Open
Abstract
STUDY DESIGN Cross-sectional international survey with literature review. OBJECTIVES To evaluate the evidence for these strategies and to understand the current trends in prophylactic antibiotic use during ASD surgery through an international survey. METHODS An online survey was conducted among international AO Spine members regarding the peri-operative management of patients with ASD. The details of perioperative systemic and topical antibiotic use were solicited. Descriptive data were summarized for the responding surgeons who perform at least 10 long-segment fusions of >5 levels extending to the pelvis annually. RESULTS The literature supports the use of prophylactic antibiotic effective against gram positive organisms. The use of topical vancomycin remains debated, and there is limited evidence for topical tobramycin use. A total of 116 responses were received. 74 (64%) surgeons use topical vancomycin, most usually deep to the fascia only 45 (61%). The most usual dose used is 1-2 g. 4 (3%) surgeons use topical tobramycin deep to fascia. Following surgery, 90 (78%) surgeons use prophylactic cephalosporin with 3 (3%) using cloxacillin, 5 (4%) using ciprofloxacin and 9 (8%) using vancomycin and 6 (5%) using clindamycin either in addition or alone. CONCLUSIONS The present survey identifies a trend towards systemic and topical antibiotic prophylaxis primarily targeted at gram positive pathogens. The use of topical tobramycin, proposedly effective against gram negative infections, remains uncommon. There is a lack of consensus in the selection of perioperative antibiotic prophylaxis, thus a prospective study of the rates of infection with each strategy would be useful to inform guidelines.
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Affiliation(s)
- Brett Rocos
- Division of Spine Surgery, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- AO Knowledge Forum Deformity, Davos, Switzerland
| | - So Kato
- AO Knowledge Forum Deformity, Davos, Switzerland
- Department of Orthopaedic Surgery, The University of Tokyo, Tokyo, Japan
| | - Stephen J Lewis
- AO Knowledge Forum Deformity, Davos, Switzerland
- Department of Orthopaedic Surgery, Toronto Western Hospital, Schroeder Arthritis Institute, University of Toronto, Toronto, ON, Canada
| | - Christopher I Shaffrey
- Division of Spine Surgery, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- AO Knowledge Forum Deformity, Davos, Switzerland
| | - Lawrence G Lenke
- AO Knowledge Forum Deformity, Davos, Switzerland
- Department of Orthopedic Spine Surgery, The Spine Hospital, Columbia University Medical Center, New York, NY, USA
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Conaway W, Lambrechts MJ, D'Antonio ND, Karamian BA, DiMaria S, Mao J, Canseco JA, Rihn J, Kurd MF, Woods BI, Kaye ID, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. MRSA Prophylaxis in Spine Surgery Decreases Postoperative Infections. Clin Spine Surg 2023; 36:E153-E159. [PMID: 36127778 DOI: 10.1097/bsd.0000000000001396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 08/17/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To compare infection rates before and after the implementation of a quality improvement protocol focused on methicillin-resistant Staphylococcus aureus (MRSA) screening and decolonization in patients undergoing lumbar fusion and/or decompression. SUMMARY OF BACKGROUND DATA Prior studies have demonstrated MRSA infections comprise a sizable portion of SSIs. Additional studies are required to improve our understanding of the risks and benefits of MRSA decolonization with vancomycin prophylaxis. METHODS A retrospective cohort analysis was conducted on patients who underwent spinal fusion or laminectomy before (2008-2011) and after (2013-2016) the implementation of an MRSA screening and treatment protocol. Odds ratios for MRSA, methicillin-sensitive Staphylococcus aureus (MSSA), and Vancomycin-resistant Enterococcus (VRE) infection before and after screening was calculated. Multivariate analysis assessed demographic characteristics as potential independent predictors of infection. RESULTS A total of 8425 lumbar fusion and 2558 lumbar decompression cases met inclusion criteria resulting in a total cohort of 10,983 patients. There was a significant decrease in the overall rate of infections ( P <0.001), MRSA infections ( P <0.001), and MSSA infections ( P <0.001) after protocol implementation. Although VRE infections after protocol implementation were not significantly different ( P =0.066), VRE rates as a percentage of all postoperative infections were substantially increased (0 vs. 3.36%, P =0.007). On multivariate analysis, significant predictors of the infection included younger age (OR=0.94[0.92-0.95]), shorter length of procedure (OR=1.00[0.99-1.00]), spinal fusion (OR=18.56[8.22-53.28]), higher ASA class (OR=5.49[4.08-7.44]), male sex (OR=1.61[1.18-2.20]), and history of diabetes (OR=1.58[1.08-2.29]). CONCLUSION The implemented quality improvement protocol demonstrated that preoperative prophylactically treating MRSA colonized patients decreased the rate of overall infections, MSSA infections, and MRSA infections. In addition, younger age, male sex, diabetic status, greater ASA scores, and spinal fusions were risk factors for postoperative infection.
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Affiliation(s)
- William Conaway
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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Calderwood MS, Anderson DJ, Bratzler DW, Dellinger EP, Garcia-Houchins S, Maragakis LL, Nyquist AC, Perkins KM, Preas MA, Saiman L, Schaffzin JK, Schweizer M, Yokoe DS, Kaye KS. Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023; 44:695-720. [PMID: 37137483 PMCID: PMC10867741 DOI: 10.1017/ice.2023.67] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
| | - Deverick J. Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina, United States
| | - Dale W. Bratzler
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | | | | | - Lisa L. Maragakis
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Ann-Christine Nyquist
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Kiran M. Perkins
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Michael Anne Preas
- University of Maryland Medical System, Baltimore, Maryland, United States
| | - Lisa Saiman
- Columbia University Irving Medical Center and NewYork–Presbyterian Hospital, New York, New York, United States
| | - Joshua K. Schaffzin
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Marin Schweizer
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, University of Iowa, Iowa City, Iowa
| | - Deborah S. Yokoe
- University of California-San Francisco, San Francisco, California, United States
| | - Keith S. Kaye
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
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Sonbol AM, Baabdullah AM, Mohamed MAA, Kassab FN. Intrawound low-dose vancomycin is superior to high-dose in controlling the risk of wound dehiscence in spine surgeries. Medicine (Baltimore) 2023; 102:e33369. [PMID: 37058065 PMCID: PMC10101275 DOI: 10.1097/md.0000000000033369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 03/07/2023] [Indexed: 04/15/2023] Open
Abstract
Wound complications in spine surgeries are common and serious. This study aimed to determine the risk of wound dehiscence with a low-dose of intrawound vancomycin compared to that with a high-dose and no-vancomycin and its effectiveness in the prevention of surgical site infection. Patients were categorized into 3 groups. The first group did not receive any intrawound vancomycin. In the second, patients received a high-dose of vancomycin (1 g). The third group included patients who received a low-dose of intrawound vancomycin (250 mg). Patient demographics, clinical data, and surgical data were also collected. Multivariate linear regression analysis was used to examine factors associated with dehiscence or infection. Of the 391 patients included in our study, 56 (14.3%) received a high-dose of intrawound vancomycin, 126 (32.2%) received a low-dose, and 209 (53.5%) did not receive any treatment. The overall incidence of wound dehiscence was 6.14% (24 out of 391 patients). Wound dehiscence was significantly higher (P = .039) in the high-dose vancomycin group than in the low-dose vancomycin group. The overall incidence of postoperative infection was 2.05% (8 patients) and no statistically significant differences were observed between the low-dose and high-dose vancomycin groups. Patients with higher body mass index were more likely to experience wound dehiscence and postoperative infection, irrespective of the dose of vancomycin used. The use of low-dose intrawound vancomycin (250 mg) resulted in less wound dehiscence compared with high-dose vancomycin. Further trials are required to evaluate the effectiveness of the low-dose in preventing postoperative infections.
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Affiliation(s)
- Ahmed M. Sonbol
- Musculoskeletal Center of Excellence, International Medical Center, Jeddah, Saudi Arabia
| | - Ayman M. Baabdullah
- Musculoskeletal Center of Excellence, International Medical Center, Jeddah, Saudi Arabia
| | | | - Farid N. Kassab
- Musculoskeletal Center of Excellence, International Medical Center, Jeddah, Saudi Arabia
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Efficacy and safety of intrawound antibiotics in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis: a nationwide database study. Spine Deform 2023; 11:313-318. [PMID: 36178631 DOI: 10.1007/s43390-022-00585-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 09/10/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE To assess the efficacy and safety of intrawound antibiotics in posterior fusions for adolescent idiopathic scoliosis (AIS). METHODS The NSQIP-Pediatric databases 2016-2018 were utilized. Patients 10 years of age or older with AIS who underwent posterior fusion were selected and divided into two cohorts based on the receipt of intrawound antibiotics. Patient characteristics and complications were compared. Multivariate analyses were performed to determine the efficacy and safety of intrawound antibiotics. RESULTS A total of 4203 patients received intrawound antibiotics while 879 patients did not. The intrawound antibiotic group had longer constructs, higher blood loss, and longer operative times, factors historically associated with higher infection rates. Those that received intrawound antibiotics had SSI rate of 0.69%, while its counterpart had 0.57% (p = 0.689). The reoperation rates were 1.12% and 1.25% (p = 0.735), for those with and without intrawound antibiotics, respectively. In multivariate analyses, intrawound antibiotics use was not found to be a significant predictor for SSI, any complications, reoperation and readmission. CONCLUSION The current study represents the largest AIS surgery cohort studied to evaluate the efficacy of intrawound antibiotics. Our analysis failed to demonstrate association between the use of intrawound antibiotics and reduction in SSI. While other studies have reported seroma, wound dehiscence and renal failure with the practice, we did not observe an increased rate of such complications. This study highlights the difficulty of understanding the role for individual infection prevention measures in current surgical settings, where the SSI rate for the control group was substantially lower than 1%.
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Hu W, Wang H, Wu X, Shi X, Ma H, Zhang K, Gao Y. Does the Microflora of Surgery Site Infection Change After Prophylactic Use of Vancomycin Powder in the Spine Surgery. Infect Drug Resist 2023; 16:105-113. [PMID: 36636373 PMCID: PMC9831077 DOI: 10.2147/idr.s390837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/22/2022] [Indexed: 01/06/2023] Open
Abstract
Study Design Retrospective cohort study. Objective This study aimed to investigate the characteristics of microflora in patients with deep spinal surgical site infection (SSI) after prophylactic use of vancomycin powder (VP). Methods A retrospective analysis was performed on patients after spinal surgery. Patients were grouped according to whether VP use and only patients with deep SSI were included in this study. General information of the patients, the dose of vancomycin, bacterial culture results, drug sensitivity test results, and SSI treatment methods were recorded. The differences of microflora between the two groups were analyzed, and the sensitivity of bacteria in the +VP group to antibiotics was analyzed. Results The infection rate in the +VP group was 4.9% (56/1124) vs 6.3% (93/1476) in the No-VP group (P < 0.05). The proportion of Gram-positive bacteria (GPB) in the +VP SSIs was 55.4% vs.74.1% in the No-VP group (P < 0.05). The percentage of Gram-negative bacteria (GNB) in the +VP SSIs was 46.4% vs.30.1% in the No-VP group (P < 0.05). More dose of VP cannot decrease the SSI, but the proportion of GNB in VP >1g SSIs was higher (59.0% vs 32.4%, P < 0.05). In the +VP SSIs, all of the GNB cultured were sensitive to meropenem, and linezolid covered most of the GPB cultured. Conclusion Local use of vancomycin powder can reduce the incidence of SSI, but this may lead to changes in the bacterial flora. Once the SSI occurs, the case of GNB infection may be increased. The more dose of VP cannot decrease SSI but may increase the rate of GNB in the +VP SSIs. Once infections still occur after VP use, antibiotics covering GNB may be added. These findings may help guide choice of empiric antibiotics while awaiting culture data.
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Affiliation(s)
- Weiran Hu
- Department of Spine and Spinal Cord Surgery, Henan Provincial People’s Hospital, Zhengzhou, People’s Republic of China,Department of Spine and Spinal Cord Surgery, People’s Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Hongqiang Wang
- Department of Spine and Spinal Cord Surgery, Henan Provincial People’s Hospital, Zhengzhou, People’s Republic of China,Department of Spine and Spinal Cord Surgery, People’s Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Xiaonan Wu
- Department of Spine and Spinal Cord Surgery, Henan Provincial People’s Hospital, Zhengzhou, People’s Republic of China,Department of Spine and Spinal Cord Surgery, People’s Hospital of Henan University, Zhengzhou, People’s Republic of China
| | - Xinge Shi
- Department of Spine and Spinal Cord Surgery, Henan Provincial People’s Hospital, Zhengzhou, People’s Republic of China,Department of Spine and Spinal Cord Surgery, People’s Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Haohao Ma
- Department of Spine and Spinal Cord Surgery, Henan Provincial People’s Hospital, Zhengzhou, People’s Republic of China,Department of Spine and Spinal Cord Surgery, People’s Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Kai Zhang
- Department of Spine and Spinal Cord Surgery, Henan Provincial People’s Hospital, Zhengzhou, People’s Republic of China,Department of Spine and Spinal Cord Surgery, People’s Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Yanzheng Gao
- Department of Spine and Spinal Cord Surgery, Henan Provincial People’s Hospital, Zhengzhou, People’s Republic of China,Department of Spine and Spinal Cord Surgery, People’s Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China,Correspondence: Yanzheng Gao, Department of Spine and Spinal Cord Surgery, Henan Provincial People’s Hospital, No. 7, Wei Wu Road, Zhengzhou, 450003, People’s Republic of China, Email
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Komnos GA, Chalatsis G, Mitrousias V, Hantes ME. Postoperative Infection after Anterior Cruciate Ligament Reconstruction: Prevention and Management. Microorganisms 2022; 10:microorganisms10122349. [PMID: 36557602 PMCID: PMC9781783 DOI: 10.3390/microorganisms10122349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/12/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Infection following anterior cruciate ligament (ACL) reconstruction can be one of the most debilitating complications following ACL reconstruction. Its reported incidence is around 1%. Utilization of vancomycin for presoaking the graft is considered an established method for infection prevention. The role of other agents, such as gentamycin needs further investigation. Staphylococci are the predominant causative pathogens, while particular attention should be paid to fungal infections due to their long-standing, occult process. Recent data demonstrate that hamstrings autograft may be at an elevated risk of being contaminated leading to subsequent septic arthritis. Diagnosis is set by clinical and laboratory findings and is usually confirmed by intraoperative cultures. Treatment varies, mainly depending on the intraoperative assessment. Satisfactory outcomes have been reported with both graft retaining and removal, and the decision is made upon the arthroscopic appearance of the graft and the characteristics of the infection. Of note, early management seems to lead to superior results, while persistent infection should be managed with graft removal in an attempt to protect the articular cartilage and the knee function.
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Başak AT, Çakıcı N, Özbek MA, Hekimoğlu M, Çerezci Ö, Ates O, Oktenoglu T, Sasani M, Özer AF. A Combined Diagnosis and Treatment Algorithm for Spine Infection Management: A Single-Center Experience. Cureus 2022; 14:e28251. [PMID: 36158394 PMCID: PMC9490500 DOI: 10.7759/cureus.28251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2022] [Indexed: 12/04/2022] Open
Abstract
Background and objective Spinal infection (SI) is an infectious disease affecting the vertebral column, spinal cord, and adjacent structures. The infection can occur following interventions or spontaneously. The aim of this study was to highlight the importance of employing a methodological approach for the accurate and rapid diagnosis of SI and to share information on the most effective treatment method, which involves using a diagnostic-treatment algorithm that can help with SI management. Methodology This study included 50 patients diagnosed with SI between 2016 and 2020. The treatment follow-up period was limited to six months, and the study was conducted as a retrospective cohort analysis. The sample consisted of 22 female patients and 28 male patients, and the mean age of the patients was 50.2 years. All patients received diagnosis and treatment according to the algorithm described in this article. Results In the study group, 60% of patients had an infection in the lumbar spine, 4% in the thoracal spine, 12% in the cervical spine, and 8% in the sacral spine. Previously operated patients were diagnosed on the 30.16th day on average. A total of 19 patients (38%) had no history of undergoing surgery. Radiologically, the most common finding was spondylodiscitis/discitis (32%). Osteomyelitis was detected in one (2%) patient. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most commonly isolated organism in culture results and was detected in 13 patients (26%). The culture results of 12 patients (24%) were negative. The number of patients with active SI who were unstable and stabilized at the time of diagnosis was 11 (22%), and stabilization materials were removed in two patients (4%). In the 6th month of control, the patients did not have any complaints, signs of an infection, or unstable vertebral column. Conclusions We conclude that the combined algorithm we recommend for the diagnosis and treatment of patients with SI can prevent negative deviation and is an effective treatment for this condition.
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Severyns M, Hostalrich FX, Flurin L, Vendeuvre T, Germaneau A, Turmel JM, Cabié A, Benchikh El-Fegoun A. Surgical Site Infections after Spinal Surgery in a Tropical Area: A Prospective Monocentric Observational Study. Am J Trop Med Hyg 2022; 107:457-462. [PMID: 35895422 PMCID: PMC9393452 DOI: 10.4269/ajtmh.21-1329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/24/2022] [Indexed: 08/03/2023] Open
Abstract
To date, no study has described the microbiological profile of surgical site infections (SSIs) after spine surgery in a tropical environment. The main objective of this study is to describe the microbiology and the risk factors of SSI after spinal surgery in a tropical climate. Our hypothesis is that the microbiology of SSIs in tropical areas is different to what is mainly described in temperate countries. As a consequence, the recommendation for antibiotic prophylaxis administered in the operative room, which mainly relays on the literature, might not be adequate in such countries. We included 323 consecutive patients who underwent a spinal intervention between 2017 and 2019, with a 2-year minimum follow-up. Objective ISO criteria were established in accordance with the criteria accepted by the Center of Disease Control in Atlanta. The identification of risk factors for SSI was carried out by uni- and multivariate analysis with a significance threshold of P < 0.05. The incidence of SSI was 7.7%. A total of 54.8% were in favor of a predominantly digestive origin of germs with an average of 1.68 bacteria found by ISO. Inadequate antibiotic prophylaxis was found in 54.8%. Age and body mass index were found to be independent risk factors for SSI. We report here an unusual microbiological profile of SSI with a predominance of gram-negative bacteria and a low proportion of Staphylococcus aureus and Staphylococcus epidermidis.
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Affiliation(s)
- Mathieu Severyns
- Orthopaedic and Traumatologic Department, CHU Martinique, Fort-de-France, France
- Pprime Institute, University of Poitiers, Poitiers, France
| | | | - Laure Flurin
- Divisions of Clinical Microbiology and Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | | | | | - Jean-Marie Turmel
- Infectious Diseases Department, CHU Martinique, Fort-de-France, France
| | - André Cabié
- Infectious Diseases Department, CHU Martinique, Fort-de-France, France
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12
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Jin Y, Liu A, Overbey JR, Medikonda R, Feghali J, Krishnan S, Ishida W, Pairojboriboon S, Gokaslan ZL, Wolinsky JP, Theodore N, Bydon A, Sciubba DM, Witham TF, Lo SFL. Risk factors for surgical intervention in patients with primary spinal infection on initial presentation. J Neurosurg Spine 2022; 37:283-291. [PMID: 35120318 DOI: 10.3171/2021.12.spine21811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 12/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Treatment of primary spinal infection includes medical management with or without surgical intervention. The objective of this study was to identify risk factors for the eventual need for surgery in patients with primary spinal infection on initial presentation. METHODS From January 2010 to July 2019, 275 patients presented with primary spinal infection. Demographic, infectious, imaging, laboratory, treatment, and outcome data were retrospectively reviewed and collected. Thirty-three patients were excluded due to insufficient follow-up (≤ 90 days) or death prior to surgery. RESULTS The mean age of the 242 patients was 58.8 ± 13.6 years. The majority of the patients were male (n = 130, 53.7%), White (n = 150, 62.0%), and never smokers (n = 132, 54.5%). Fifty-four patients (22.3%) were intravenous drug users. One hundred fifty-four patients (63.6%) ultimately required surgery while 88 (36.4%) never needed surgery during the duration of follow-up. There was no significant difference in age, gender, race, BMI, or comorbidities between the surgery and no-surgery groups. On univariate analysis, the presence of an epidural abscess (55.7% in the no-surgery group vs 82.5% in the surgery group, p < 0.0001), the median spinal levels involved (2 [interquartile range (IQR) 2-3] in the no-surgery group vs 3 [IQR 2-5] in the surgery group, p < 0.0001), and active bacteremia (20.5% in the no-surgery vs 35.1% in the surgery group, p = 0.02) were significantly different. The cultured organism and initial laboratory values (erythrocyte sedimentation rate, C-reactive protein, white blood cell count, creatinine, and albumin) were not significantly different between the groups. On multivariable analysis, the final model included epidural abscess, cervical or thoracic spine involvement, and number of involved levels. After adjusting for other variables, epidural abscess (odds ratio [OR] 3.04, 95% confidence interval [CI] 1.64-5.63), cervical or thoracic spine involvement (OR 2.03, 95% CI 1.15-3.61), and increasing number of involved levels (OR 1.16, 95% CI 1.01-1.35) were associated with greater odds of surgery. Fifty-two surgical patients (33.8%) underwent decompression alone while 102 (66.2%) underwent decompression with fusion. Of those who underwent decompression alone, 2 (3.8%) of 52 required subsequent fusion due to kyphosis. No patient required hardware removal due to persistent infection. CONCLUSIONS At time of initial presentation of primary spinal infection, the presence of epidural abscess, cervical or thoracic spine involvement, as well as an increasing number of involved spinal levels were potential risk factors for the eventual need for surgery in this study. Additional studies are needed to assess for risk factors for surgery and antibiotic treatment failure.
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Affiliation(s)
- Yike Jin
- 1Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Ann Liu
- 1Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Jessica R Overbey
- 2Department of Population Health Science and Policy, Mount Sinai Hospital, New York, New York
| | - Ravi Medikonda
- 1Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - James Feghali
- 1Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sonya Krishnan
- 3Division of Infectious Diseases, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Wataru Ishida
- 1Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Ziya L Gokaslan
- 4Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Jean-Paul Wolinsky
- 5Department of Neurosurgery, Northwestern University, Chicago, Illinois; and
| | - Nicholas Theodore
- 1Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Ali Bydon
- 1Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Daniel M Sciubba
- 1Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
- 6Department of Neurosurgery, North Shore University Hospital, Manhasset, New York
| | - Timothy F Witham
- 1Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sheng-Fu L Lo
- 1Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
- 6Department of Neurosurgery, North Shore University Hospital, Manhasset, New York
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13
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Du JY, Dumaine AM, Klyce W, Miyanji F, Sponseller PD, Glotzbecker MP. Use of Vancomycin Powder in Spinal Deformity Surgery in Cerebral Palsy Patients is Associated With Proteus Surgical Site Infections. J Pediatr Orthop 2022; 42:280-284. [PMID: 35153286 DOI: 10.1097/bpo.0000000000002079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Surgical site infection (SSI) rates in pediatric spinal deformity surgery for cerebral palsy (CP) patients are higher than that in idiopathic scoliosis. The use of vancomycin powder is associated with decreased risk of SSI in neuromuscular patients. Prior studies in adult and pediatric early-onset scoliosis patients have shown that vancomycin powder alters microbacterial profile in patients that develop SSI. However, the effects of topical vancomycin powder on microbiology in spinal deformity surgery for CP patients has not been studied. METHODS An international multicenter database of CP neuromuscular scoliosis patients was used in this retrospective cohort study. All patients that underwent posterior spinal instrumented fusion for CP neuromuscular scoliosis from 2008 to 2019 were queried, and 50 cases complicated by postoperative SSI were identified. Intraoperative antibiotic details were documented in 49 cases (98.0%). Microbiology details were documented in 45 cases (91.8%). Microbiology for patients that received topical vancomycin powder were compared with patients that did not. A multivariate regression model was used to control for potential confounders. RESULTS There were 45 patients included in this study. There were 27 males (60.0%) and 18 females (40.0%). Mean age at surgery was 14.8±2.4 years. There were 24 patients that received topical vancomycin powder (53.3%). The mean time from index surgery to SSI was 4.3±11.3 months.On univariate analysis of microbiology cultures by vancomycin powder cohort, there were no significant differences in culture types. Proteus spp. trended on significance with association with vancomycin powder use (P=0.078). When controlling for potential confounders on multivariate analysis, intraoperative topical vancomycin powder was associated with increased risk for proteus infection (adjusted odds ratio: 262.900, 95% confidence interval: 1.806-38,267.121, P=0.028). DISCUSSION In CP patients undergoing pediatric spinal deformity surgery, the use of vancomycin powder was independently associated with increased risk for proteus infections. Further study into antibiotic regimens for spinal deformity surgery in the CP population should be performed. LEVEL OF EVIDENCE Level III-retrospective cohort study.
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Affiliation(s)
- Jerry Y Du
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospitals/University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Anne M Dumaine
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospitals/University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Walter Klyce
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospitals/University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Firoz Miyanji
- Department of Orthopaedics, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Paul D Sponseller
- Division of Orthopaedics, Johns Hopkins Children's Center, Baltimore, MD
| | - Michael P Glotzbecker
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospitals/University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
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14
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Figueroa F, Figueroa D, Calvo R, Vaisman A, Nuñez M, Putnis S. Vancomycin Presoaking of the Graft Appears to Prevent Infection After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. HSS J 2022; 18:138-144. [PMID: 35087344 PMCID: PMC8753556 DOI: 10.1177/15563316211011682] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/20/2021] [Indexed: 02/03/2023]
Abstract
Background: Vancomycin presoaking of the graft has been shown to decrease infection rates in some case series of anterior cruciate ligament (ACL) reconstruction. Purpose: We sought to substantiate the efficacy of vancomycin presoaked grafts for the prevention of infection after ACL reconstruction. Methods: We performed a systematic review of Medline and OVID to assess the incidence of postoperative infection in studies comparing patients undergoing ACL reconstruction with the use of vancomycin presoaked ACL grafts and a control group of patients undergoing ACL reconstruction without the use of presoaked grafts. The efficacy of vancomycin presoaking was calculated using the Agresti-Coull confidence interval. Relative risk (RR) was calculated for every study and the total sample. Results: The 11 studies that met inclusion criteria comprised 24,298 patients. In patients with vancomycin presoaking of the graft, 1 infection was reported in 8764 cases (0.01% rate). In the studies with control groups that did not have vancomycin presoaked grafts, there were 125 infections in 15,534 ACL reconstructions (0.8% rate). The efficacy of vancomycin presoaking in preventing infection after ACL reconstruction was 99.9% (0.999%-1.000% CI). The overall RR obtained was 0.07 (0.03-0.16 CI). All included studies were retrospective cohort studies (level III). Conclusions: Vancomycin presoaking of the graft has been shown to decrease infection rates after ACL reconstruction in studies of low evidence level. This suggests the need for prospective randomized controlled trials addressing this issue so that recommendations on the routine use of vancomycin presoaking of ACL grafts can be made with confidence.
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Affiliation(s)
- Francisco Figueroa
- Clinica Alemana and Universidad del Desarrollo, Vitacura, Chile,Hospital Sotero del Rio, Santiago, Chile,Francisco Figueroa, MD, Clinica Alemana and Universidad del Desarrollo, Vitacura, Santiago, MD, Chile.
| | - David Figueroa
- Clinica Alemana and Universidad del Desarrollo, Vitacura, Chile
| | - Rafael Calvo
- Clinica Alemana and Universidad del Desarrollo, Vitacura, Chile
| | - Alex Vaisman
- Clinica Alemana and Universidad del Desarrollo, Vitacura, Chile,Hospital Padre Hurtado, Santiago, Chile
| | - Marilaura Nuñez
- Clinica Alemana and Universidad del Desarrollo, Vitacura, Chile
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15
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Schär RT, Jesse CM, Montalbetti M, Söll N, Lutz K, Steinsiepe V, Branca M, Raabe A, Zimmerli S. Negligible Systemic Uptake of Suprafascial Vancomycin Powder Following Instrumented Posterior Spinal Fusion-Preliminary Results From A Randomized Clinical Trial (VANCO Trial). Neurosurgery 2021; 89:967-972. [PMID: 34528089 DOI: 10.1093/neuros/nyab362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/03/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Intrawound vancomycin powder is an emerging strategy to reduce surgical site infections (SSIs) in spine surgery. However, there are concerns relating to its safety profile and toxicity. Data on systemic uptake of suprafascially administered vancomycin powder following instrumented spinal fusion is lacking. OBJECTIVE To study the systemic uptake and safety of suprafascially administered vancomycin powder in the early postoperative phase following open instrumented posterior spinal fusion. METHODS This was a substudy of an ongoing randomized clinical trial. Eligible adult patients were randomized 1:1 to either receive suprafascial vancomycin powder before wound closure or not to receive vancomycin powder. Serum vancomycin levels were assessed on postoperative days 1 and 2, serum creatinine levels were measured pre- and post-operatively. Adverse events up to 6 wk following surgery were recorded. RESULTS Among 34 randomized patients (mean age 62 yr, range 31-84 yr; 18 [53%] women), 17 received vancomycin powder. No detectable serum vancomycin levels (>4.0 mg/L) were found. Proportion of adverse events per patient in the vancomycin and control group, respectively, were 29.4% (5/17) vs 11.8% (2/17) (OR 3.12; 95% CI, 0.52; 19.38; P = .398). No patient had nephrotoxicity or ototoxicity in either group. CONCLUSION Suprafascial vancomycin powder in open instrumented spinal fusion surgery is safe and results in negligible systemic uptake. Final results of the VANCO Trial need to be awaited for conclusive data on the efficacy of vancomycin for SSI prevention and its impact on wound healing.
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Affiliation(s)
- Ralph T Schär
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - C Marvin Jesse
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matteo Montalbetti
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicole Söll
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katharina Lutz
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Valentin Steinsiepe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Zimmerli
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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16
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Dumaine AM, Du JY, Parent S, Sturm P, Sponseller P, Glotzbecker MP. Use of Vancomycin Powder in the Surgical Treatment of Early Onset Scoliosis Is Associated With Different Microbiology Cultures After Surgical Site Infection. J Pediatr Orthop 2021; 41:e702-e705. [PMID: 34354031 DOI: 10.1097/bpo.0000000000001924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The use of vancomycin powder has been shown to decrease risk of surgical site infection (SSI) in early onset scoliosis (EOS). While there is potential benefit in SSI reduction, there is also theoretical risk in creating increased bacterial resistance to standard treatment regimens. However, the effects of topical vancomycin powder on microbiology in these patients has not been studied. METHODS A multicenter database for EOS patients was retrospectively analyzed. All patients that underwent surgical treatment with traditional growing rods, magnetically controlled growing rods, vertical expandable prosthetic titanium rib, and Shilla for EOS performed after 2010 were identified (n=1115). Patients that sustained at least 1 SSI after guided growth surgery were assessed (n=104, 9.3%). Patients with culture and antibiotic details were included (n=55). Patients that received vancomycin powder at index surgery were compared with patients that did not. A multivariate regression model was used to control for potential confounders. RESULTS There were 55 patients included in this study, including 26 males (47%) and 29 females (53%). Mean age at index surgery was 7.2±6.9 years. Vancomycin powder was utilized in 18 cases (33%). Mean time from index surgery to SSI was 2.0±1.3 years. There were 2 cases of wound dehiscence (4%), 7 cases of superficial infection (13%), and 46 cases of deep infection (84%).There were significant differences in overall microbiology results between vancomycin and no vancomycin cohorts (P=0.047). On univariate analysis, the vancomycin powder cohort had a significantly high incidence of cultures without growth (n=7, 39% vs. n=4, 11%, relative risk: 2.063, 95% confidence interval: 0.927-4.591, P=0.028). This association remained significant on multivariate analysis (adjusted odds ratio: 9.656, 95% confidence interval: 1.743-53.494, P=0.009). CONCLUSIONS In EOS patients undergoing procedures complicated by SSI, the use of vancomycin powder was independently associated with increased risk of no culture growth. Surgeons and infectious disease physicians should be aware and adjust diagnostic and treatment strategies appropriately. LEVEL OF EVIDENCE Level III-retrospective cohort study.
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Affiliation(s)
- Anne M Dumaine
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospitals/University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland
| | - Jerry Y Du
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospitals/University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland
| | - Stefan Parent
- Division of Orthopaedics, University of Montreal, Montreal, Qc, Canada
| | - Peter Sturm
- Division of Orthopaedics, Cincinnati Children's Hospital, Cincinnati, OH
| | - Paul Sponseller
- Division of Orthopaedics, Johns Hopkins Children's Center, Baltimore, MD
| | - Michael P Glotzbecker
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospitals/University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland
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17
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Amelot A, Riche M, Latreille S, Degos V, Carpentier A, Mathon B, Korinek AM. Antimicrobial prophylaxis in noninstrumented spine surgery: a prospective study to determine efficacy and drawbacks. J Neurosurg Spine 2021:1-10. [PMID: 34243156 DOI: 10.3171/2020.11.spine201891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 11/23/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to evaluate the roles of perioperative antibiotic prophylaxis in noninstrumented spine surgery (NISS), both in postoperative infections and the impact on the selection of resistant bacteria. To the authors' knowledge, only one prospective study recommending preoperative intravenous (IV) antibiotics for prophylaxis has been published previously. METHODS Two successive prospective IV antibiotic prophylaxis protocols were used: from 2011 to 2013 (group A: no prophylactic antibiotic) and from 2014 to 2016 (group B: prophylactic cefazolin). Patient infection rates, infection risk factors, and bacteriological status were determined. RESULTS In total, 2250 patients (1031 in group A and 1219 in group B) were followed for at least 1 year. The authors identified 72 surgical site infections, 51 in group A (4.9%) and 21 in group B (1.7%) (p < 0.0001). A multiple logistic regression hazard model identified male sex (HR 2.028, 95% CI 1.173-3.509; p = 0.011), cervical laminectomy (HR 2.078, 95% CI 1.147-3.762; p = 0.016), and postoperative CSF leak (HR 43.782, 95% CI 10.9-189.9; p < 0.0001) as independent predictive risk factors of infection. In addition, preoperative antibiotic prophylaxis was the only independent favorable factor (HR 0.283, 95% CI 0.164-0.488; p < 0.0001) that significantly reduced infections for NISS. Of 97 bacterial infections, cefazolin-resistant bacteria were identified in 26 (26.8%), with significantly more in group B (40%) than in group A (20.9%) (p = 0.02). CONCLUSIONS A single dose of preoperative cefazolin is effective and mandatory in preventing surgical site infections in NISS. Single-dose antibiotic prophylaxis has an immediate impact on cutaneous flora by increasing cefazolin-resistant bacteria.
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Affiliation(s)
- Aymeric Amelot
- 1Department of Neurosurgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris.,2Department of Neurosurgery, Bretonneau Hospital, Hopitaux de Tours
| | - Maximilien Riche
- 1Department of Neurosurgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris
| | - Samuel Latreille
- 3Department of Neuro-anesthesiology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris; and
| | - Vincent Degos
- 3Department of Neuro-anesthesiology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris; and.,4Sorbonne University, Paris, France
| | - Alexandre Carpentier
- 1Department of Neurosurgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris.,4Sorbonne University, Paris, France
| | - Bertrand Mathon
- 1Department of Neurosurgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris.,4Sorbonne University, Paris, France
| | - Anne-Marie Korinek
- 3Department of Neuro-anesthesiology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris; and
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18
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Buchalter DB, Teo GM, Kirby DJ, Schwarzkopf R, Aggarwal VK, Long WJ. Does the Organism Profile of Periprosthetic Joint Infections Change With a Topical Vancomycin Powder and Dilute Povidone-Iodine Lavage Protocol? J Arthroplasty 2021; 36:S314-S319. [PMID: 33526397 DOI: 10.1016/j.arth.2020.12.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/14/2020] [Accepted: 12/22/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND While vancomycin powder and dilute povidone-iodine (VIP) is associated with fewer total joint arthroplasty (TJA) periprosthetic joint infections (PJI), its effect on PJI organism profiles is unclear. This study evaluates primary TJA PJI organism profiles before and after the implementation of a VIP protocol. METHODS In total, 18,299 primary TJAs performed at a university-affiliated, not-for-profit orthopedic hospital from before (1/2012-12/2013) and after (1/2016-12/2019) a VIP protocol was initiated were reviewed to identify deep PJIs that occurred within 90 days of the index arthroplasty as defined by the Musculoskeletal Infection Society guidelines. Demographics, overall organism incidence (n/TJAs), and relative organism incidence (n/PJIs) from the two cohorts were compared. RESULTS In total, 103 TJA PJIs were identified (pre-VIP: 32/3982; VIP: 71/14,317). Following the introduction of VIP, the overall and relative incidence of coagulase-negative staphylococcal TJA PJIs significantly decreased (overall: 0.20% to 0.04%, P = .004; relative: 25.00% to 8.45%, P = .031). In response, the relative incidence of MSSA TJA PJIs significantly increased (18.75% to 40.85%, P = .042). Broken down by arthroplasty type, VIP was associated with a significantly lower overall incidence of coagulase-negative staphylococcal total knee arthroplasty (TKA) PJIs (0.27% to 0.06%, P = .015), a significantly lower overall incidence of MRSA TKA PJIs (0.18% to 0.03%, P = .031), and a nonsignificant decrease in the overall incidence of gram-negative TKA PJIs (0.18% to 0.04%, P = .059). No organism profile changes were found in total hip arthroplasty PJIs. CONCLUSION VIP is not associated with more difficult to treat primary TJA PJIs. While promising, these findings require a prospective randomized controlled trial for confirmation. LEVEL OF EVIDENCE Level III, Retrospective cohort study.
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Affiliation(s)
| | - Greg M Teo
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - David J Kirby
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Vinay K Aggarwal
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - William J Long
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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19
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White AJ, Fiani B, Jarrah R, Momin AA, Rasouli J. Surgical Site Infection Prophylaxis and Wound Management in Spine Surgery. Asian Spine J 2021; 16:451-461. [PMID: 34167274 PMCID: PMC9260408 DOI: 10.31616/asj.2020.0674] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/11/2021] [Indexed: 11/30/2022] Open
Abstract
Surgical site infection (SSI) is a potentially devastating complication of spinal surgery that increases patient morbidity and healthcare costs. SSIs have complex and multifactorial etiologies; therefore, there are numerous opportunities for prevention and risk mitigation. The aim of this narrative review was to describe the incidence, risk factors, and outcomes of SSIs in spine surgery with an emphasis on postoperative wound care. We list and describe the preoperative, intraoperative, and postoperative evidence-based interventions that can be applied to potentially prevent SSI after spinal surgery.
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Affiliation(s)
- Alexandra J White
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Ryan Jarrah
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Arbaz A Momin
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Jonathan Rasouli
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
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20
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Han W, Zhang L, Yu LJ, Wang JQ. Effect of Local Delivery of Vancomycin and Tobramycin on Bone Regeneration. Orthop Surg 2021; 13:1654-1661. [PMID: 34124847 PMCID: PMC8313164 DOI: 10.1111/os.13020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 03/18/2021] [Accepted: 03/21/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE A bone defect rat model was established to investigate the osteogenic effect of local delivery two antibiotics (vancomycin and tobramycin powder) on bone regeneration. METHODS Twenty-four Sprague-Dawley (SD) male rats (6 to 8 weeks, 200 to 250 g) were used in this study. All these rats were randomly divided into four groups. Based on dose conversion between rat and human via body surface area, the rat dose of two antibiotics was 88μg/g and 176 μg/g for vancomycin and tobramycin, respectively. Con group (no antibiotic), Van group (vancomycin, 88 μg/g), Tob group (tobramycin 176 μg/g), and Van+Tob group (vancomycin 88μg/g combined with tobramycin 176 μg/g). A 5.0-mm full-thickness standardized mandibular bone defect was performed with a drill in each rat and different antibiotic powders were placed over the bone defect space, respectively. All these animals were sacrificed after 12 weeks post-operation. The mandible bones were harvested for further radiographic and histologic analysis. The bone volume/total volume (BV/TV) ratio, bone volume (BV), and bone fractional area (BFA) in the defect area via micro-computed tomography (μCT scanning) were further analyzed. Then, we performed a histological assessment via hematoxylin and eosin (H&E) and Masson's trichrome staining to analyze bone regeneration and also analyze the number of osteoblasts per filed. RESULTS There were no postoperative deaths, signs of vancomycin-related or tobramycin-related toxicity, or signs of systemic illness in any of the four groups. All wounds healed well, and no complications or surgical site infection were observed in all rats. From the μCT scans analyses, there was less bone regeneration in the Van group than in the Con group (BV/TV: F = 64.29, R2 = 0.9602; P = 0.0052; BFA: F = 76.17, R2 = 0.9662, P = 0.0007; BV: F = 194.4, R2 = 0.9865, P = 0.0022). However, when the tobramycin and vancomycin were combined, an increase in bone defect re-ossification was found in the Van+Tob group than in the Van group (BV/TV: F = 64.29, R2 = 0.9602, P = 0.0033; BFA: F = 76.17, R2 = 0.9662, P = 0.0006; BV: F = 194.4, R2 = 0.9865, P = 0.0033). Routine H&E and Masson staining supported the finding of μCT scanning. Quantitative indices confirmed that both the bone regeneration and the number of osteoblasts per filed in the defect area was higher in the Van+Tob group than in the Van group (percentage of bone tissue: F = 145.7, R2 = 0.9562, P = 0.0008; number of osteoblasts per file; F = 67.3, R2 = 0.9098, P < 0.0001). There was no significant difference between the Con group and the Van+Tob group on the number of osteoblasts each field (F = 145.7, R2 = 0.9562, P > 0.9999). CONCLUSION For bone defect, local application of vancomycin combined with tobramycin was recommended over vancomycin alone. This animal study presents data suggesting that the use of local delivery of vancomycin and tobramycin should be investigated further in clinical studies.
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Affiliation(s)
- Wei Han
- Department of Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Lei Zhang
- Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University, Shenyang, China
| | - Ling-Jia Yu
- Department of Orthopaedics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jun-Qiang Wang
- Department of Traumatology, Beijing Jishuitan Hospital, Beijing, China
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Intrawound Antibiotic Powder in Acetabular Fracture Open Reduction Internal Fixation Does Not Reduce Surgical Site Infections. J Orthop Trauma 2021; 35:198-204. [PMID: 32890070 DOI: 10.1097/bot.0000000000001943] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the risks of surgical site infection (SSI) and postoperative complications after acetabular fracture open reduction internal fixation (ORIF) in patients receiving topical intrawound antibiotic powder compared with those not receiving antibiotic powder (control group). DESIGN Retrospective cohort. SETTING Level I trauma center. PATIENTS AND INTERVENTION We reviewed 789 acetabular fracture ORIF cases from 2010 to 2019 at our institution, with mean follow-up of 18 months (3-112 months). Overall, 326 patients comprised the control group and 463 received topical antibiotic powder (294 vancomycin and 169 vancomycin/tobramycin). MAIN OUTCOME MEASUREMENT The study groups were compared for risk of SSI, seroma formation, wound dehiscence, acute kidney injury (AKI), and other postoperative complications. RESULTS There were 63 total SSI (8.0%), 50 (6.3%) deep SSI and 13 suprafascial SSI (1.6%) cases. There was no difference in the risk of total SSI (8.3% vs. 7.8%, P = 0.80) or deep SSI (6.1% vs. 6.5%, P = 0.64). This was confirmed by multivariate analysis adjusting for covariates (odds ratio = 0.93; 95% confidence interval, 0.52-1.67; P = 0.80). Similar results were demonstrated when comparing the control group with the vancomycin and vancomycin/tobramycin subgroups. The control group and antibiotic powder groups had similar risks of all outcomes of interest, including seroma formation (1.8% vs. 1.7%, P = 1.00), wound dehiscence (1.2% vs. 2.2%, P = 0.42), total AKI (5.2% vs. 8.2%, P = 0.12), and RIFLE classification AKI (injury; 0.9% vs. 2.2%, P = 0.50). CONCLUSIONS The addition of topical intrawound antibiotic powder, whether vancomycin alone or vancomycin/tobramycin before closure, does not reduce the risk of SSI after acetabular fracture ORIF compared with standard normal saline irrigation alone. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Figueroa F, Figueroa D, Calvo R, Vaisman A, Espregueira-Mendes J. Vancomycin presoaking of hamstring autografts to prevent infection in anterior cruciate ligament reconstruction: a narrative review. EFORT Open Rev 2021; 6:211-216. [PMID: 33841920 PMCID: PMC8025705 DOI: 10.1302/2058-5241.6.200059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hamstring autograft use has been linked to an increased risk of infection after anterior cruciate (ACL) reconstruction compared to other grafts. The absolute reason for this remains unclear, with contamination after harvesting and preparation of the graft being the most accepted hypothesis. Using the rationale that a contaminated graft could be the main factor in postoperative septic arthritis and in an effort to maximize the antibiotic efficacy of the graft, the Vancomycin presoaking technique was developed. It has shown success in decreasing the infection rate in ACL reconstruction. In recent years, an important number of research articles using this protocol have appeared, but the technique is still not widely implemented. Recent literature shows that Vancomycin presoaking of the graft has shown a successful decrease in the infection rate after hamstring autograft ACL reconstruction. It has also shown efficacy decreasing the infection rate in other types of grafts (patellar tendon, quadriceps tendon, allograft) and also in patients with concomitant ligament procedures or open surgeries. Despite the positive effects of Vancomycin presoaking reducing the infection rate after ACL reconstruction, the lack of prospective randomized control trials and the heterogeneity of the different studies mean it is not feasible to recommend Vancomycin presoaking of the graft universally for every ACL reconstruction patient.
Cite this article: EFORT Open Rev 2021;6:211-216. DOI: 10.1302/2058-5241.6.200059
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Affiliation(s)
- Francisco Figueroa
- Clinica Alemana-Universidad del Desarrollo, Santiago, Chile.,Hospital Sotero del Rio, Santiago, Chile
| | - David Figueroa
- Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Rafael Calvo
- Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Alex Vaisman
- Clinica Alemana-Universidad del Desarrollo, Santiago, Chile.,Hospital Padre Hurtado, Santiago, Chile
| | - João Espregueira-Mendes
- Clínica do Dragão, Espregueira-Mendes Sports Centre - FIFA Medical Centre of Excellence, Portugal; Dom Henrique Research Centre, Portugal; 3B's Research Group - Biomaterials, Biodegradables and Biomimetics, University of Minho, Portugal; ICVS/3B's-PT Government Associate Laboratory, Portugal; Orthopaedics Department of Minho University, Portugal
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Ushirozako H, Hasegawa T, Yamato Y, Yoshida G, Yasuda T, Banno T, Arima H, Oe S, Mihara Y, Yamada T, Ide K, Watanabe Y, Nakai K, Imada T, Matsuyama Y. Impact of intrawound vancomycin powder on prevention of surgical site infection after posterior spinal surgery. J Neurosurg Spine 2021; 34:656-664. [PMID: 34874533 DOI: 10.3171/2020.8.spine20992] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 08/17/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical site infection (SSI) after posterior spinal surgery is one of the severe complications that may occur despite administration of prophylactic antibiotics and the use of intraoperative aseptic precautions. The use of intrawound vancomycin powder for SSI prevention is still controversial, with a lack of high-quality and large-scale studies. The purpose of this retrospective study using a propensity score-matched analysis was to clarify whether intrawound vancomycin powder prevents SSI occurrence after spinal surgery. METHODS The authors analyzed 1261 adult patients who underwent posterior spinal surgery between 2010 and 2018 (mean age 62.3 years; 506 men, 755 women; follow-up period at least 1 year). Baseline and surgical data were assessed. After a preliminary analysis, a propensity score model was established with adjustments for age, sex, type of disease, and previously reported risk factors for SSI. The SSI rates were compared between patients with intrawound vancomycin powder treatment (vancomycin group) and those without (control group). RESULTS In a preliminary analysis of 1261 unmatched patients (623 patients in the vancomycin group and 638 patients in the control group), there were significant differences between the groups in age (p = 0.041), body mass index (p = 0.013), American Society of Anesthesiologists classification (p < 0.001), malnutrition (p = 0.001), revision status (p < 0.001), use of steroids (p = 0.019), use of anticoagulation (p = 0.033), length of surgery (p = 0.003), estimated blood loss (p < 0.001), and use of instrumentation (p < 0.001). There was no significant difference in SSI rates between the vancomycin and control groups (21 SSIs [3.4%] vs 33 SSIs [5.2%]; OR 0.640, 95% CI 0.368-1.111; p = 0.114). Using a one-to-one propensity score-matched analysis, 444 pairs of patients from the vancomycin and control groups were selected. There was no significant difference in the baseline and surgical data, except for height (p = 0.046), between both groups. The C-statistic for the propensity score model was 0.702. In the score-matched analysis, 12 (2.7%) and 24 (5.4%) patients in the vancomycin and control groups, respectively, developed SSIs (OR 0.486, 95% CI 0.243-0.972; p = 0.041). There were no systemic complications related to the use of vancomycin. CONCLUSIONS The current study showed that intrawound vancomycin powder was useful in reducing the risk of SSI after posterior spinal surgery by half, without adverse events. Intrawound vancomycin powder use is a safe and effective procedure for SSI prevention.
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Affiliation(s)
| | | | - Yu Yamato
- 2Department of Orthopedic Surgery and Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka
| | | | - Tatsuya Yasuda
- 3Department of Orthopaedic Surgery, Iwata City Hospital, Iwata, Shizuoka; and
| | | | | | - Shin Oe
- 2Department of Orthopedic Surgery and Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka
| | | | | | | | | | | | - Takaaki Imada
- 4Department of Orthopaedic Surgery, Omaezaki Municipal Hospital, Omaezaki, Shizuoka, Japan
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Intraoperative Tobramycin Powder Prevents Enterobacter cloacae Surgical Site Infections in a Rabbit Model of Internal Fixation. J Orthop Trauma 2021; 35:35-40. [PMID: 32516196 DOI: 10.1097/bot.0000000000001859] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the efficacy of intraoperative tobramycin powder in preventing surgical site infection (SSI) and implant colonization with Enterobacter cloacae in a rabbit fixation model. Gram-negative rods, particularly Enterobacter species, comprise an increasing percentage of SSI at our institution. METHODS Eighteen New Zealand White rabbits underwent surgical fixation of the left tibia with implantation of a plate and screws. The surgical site and implant were inoculated with 1 × 107 CFUs E. cloacae. The selected E. cloacae isolate was resistant to tobramycin and capable of forming biofilms. Nine rabbits received 125 mg tobramycin powder directly into the surgical site, overlying the implant. The control group was untreated. Fourteen days postinfection, the tibiae and implants were explanted. Radiographs were taken with and without the implants in place. One tibia from each group was examined after hematoxylin and eosin staining. The remaining tibiae and implants were morselized or sonicated, respectively, and plated on agar to determine infection burden. Data were analyzed with Fisher exact tests and Mann-Whitney U tests. RESULTS No bone infection or implant colonization occurred in the tobramycin-treated group. In the control group, 7 of 8 rabbits developed bone infections (P = 0.001), and 4 of 8 implants were colonized (P = 0.07). No gross disruption of the normal bone architecture was observed in either group. CONCLUSIONS Intraoperative tobramycin powder applied at the time of contamination prevented bone infection with E. cloacae in this rabbit fixation model. The results are encouraging because the E. cloacae isolate was tobramycin-resistant, demonstrating the utility of intraoperative powdered antibiotics.
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Kerbel YE, Kirchner GJ, Sunkerneni AR, Lieber AM, Moretti VM, Khalsa AS, Levine MJ. The Cost-Effectiveness of Vancomycin Powder in Lumbar Laminectomy. Global Spine J 2021; 11:28-33. [PMID: 32875834 PMCID: PMC7734260 DOI: 10.1177/2192568219888451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Break-even cost analysis. OBJECTIVE The goal of this study is to examine the cost-effectiveness of vancomycin powder for preventing infection following lumbar laminectomy. METHODS The product cost of vancomycin powder was obtained from our institution's purchasing records. Infection rates and revision costs for lumbar laminectomy and lumbar laminectomy with fusion were obtained from the literature. A break-even analysis was then performed to determine the absolute risk reduction (ARR) in infection rate to make prophylactic application of vancomycin powder cost-effective. Analysis of lumbar laminectomy with fusion was performed for comparison. RESULTS Costing $3.06 per gram at our institution, vancomycin powder was determined to be cost-effective in lumbar laminectomy if the infection rate of 4.2% decreased by an ARR of 0.015%. Laminectomy with fusion was also determined to be cost-effective at the same cost of vancomycin powder if the infection rate of 8.5% decreased by an ARR of 0.0034%. The current highest cost reported in the literature, $44.00 per gram of vancomycin powder, remained cost-effective with ARRs of 0.21% and 0.048% for laminectomy and laminectomy with fusion, respectively. Varying the baseline infection rate did not influence the ARR for either procedure when the analysis was performed using the product cost of vancomycin at our institution. CONCLUSIONS This break-even analysis demonstrates that prophylactic vancomycin powder can be highly cost-effective for lumbar laminectomy. At our institution, vancomycin powder is economically justified if it prevents at least one infection out of 6700 lumbar laminectomy surgeries.
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Affiliation(s)
| | - Gregory J. Kirchner
- Drexel University, Philadelphia, PA, USA,Gregory J. Kirchner, Department of Orthopedic Surgery, Drexel University College of Medicine, 245 N 15th Street, MS 420, Philadelphia, PA 19102, USA.
| | | | | | - Vincent M. Moretti
- Philadelphia Veteran’s Affairs Hospital, Philadelphia, PA, USA,The University of Pennsylvania, Philadelphia, PA, USA
| | | | - Marc J. Levine
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
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26
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Wang Y, Li Z, Cao X, Zhou C, Jin Y. Postoperative antibiotic management strategy for febrile patient with posterior cranial fossa tumor resection: Retrospective clinical study. J Clin Neurosci 2020; 80:80-86. [PMID: 33099373 DOI: 10.1016/j.jocn.2020.07.066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/21/2020] [Accepted: 07/27/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Postoperative fever (POF), associated with posterior cranial fossa (PCF) surgery, occurs commonly and is a potential intracranial infection indicator of perioperative antibiotics prolongation and advancement. The existing prophylactic approaches to balancing the risk between intracranial infection and antibiotics abuse are debatable. METHODS We retrospectively assessed 100 patients subjected to PCF tumor resection between December 2015 and December 2018 at a single institution. Forty febrile patients were selected for further analysis. Of them, 16 received basic and 24 advanced antibiotics and were subjected to prophylactic antibiotic assessment. RESULTS The total POF rate of PCF tumor resection was 49.4%. POF occurred from day 1 to day 5, along with the abnormalities of cerebrospinal fluid (CSF) profiles and the mild meningeal irritation symptom. CSF cultures of all selected patients were negative. In the comparison between the basic and advanced antibiotic therapy, we found no statistically significant differences in the results of the average and dynamic analysis of the body temperature and CSF profiles. Negative results of outcome studies were also obtained in the duration of fever, duration of hospitalization, and total hospitalization expenses. However, the expenses were substantially increased in the advanced antibiotic treatment. CONCLUSIONS Although POF is a common symptom after PCF tumor resection, definite intracranial infection is rare. A high body temperature and significant abnormal CSF profiles at an early stage may not be a specific and sufficient indicator of intracranial infection to upgrade antibiotics therapy when standard prophylactic protocols have been accurately achieved.
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Affiliation(s)
- Yida Wang
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Zhen Li
- Department of Neurosurgery, Jingjiang People's Hospital, Jingjiang, Jiangsu 214500, China
| | - Xiangyuan Cao
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Chengcheng Zhou
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Yi Jin
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China.
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27
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Erken HY, Nusran G, Karagüven D, Yilmaz O, Kuru T. No Decrease in Infection Rate with the Use of Local Vancomycin Powder After Partial Hip Replacement in Elderly Patients with Comorbidities. Cureus 2020; 12:e10296. [PMID: 33047086 PMCID: PMC7540078 DOI: 10.7759/cureus.10296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Introduction The goal of this study was to evaluate the effects of local intra-wound vancomycin powder (VP) administration to decrease surgical site infections (SSIs), particularly in elderly patients with comorbidities, after having undergone partial hip replacement in the treatment of intertrochanteric (ITF) or femoral neck fractures (FNF). Methods We retrospectively reviewed patients who underwent partial hip replacement in the treatment of ITF or FNF in one year. We divided the patients into two groups. The non vancomycin-treated group received standard systemic prophylaxis only (1 gr cefazolin IV), while the vancomycin-treated group received 1 gr of VP in the surgical wound just before surgical closure in addition to the systemic prophylaxis. We included patients of 64 years or older who also had one or more comorbidities. We compared the post-operative SSI rates between the non vancomycin-treated group and the vancomycin-treated group. Results A total of 93 patients were included in the study. We detected post-operative wound infection in six patients (6.4%). The rate of SSI was found to be 5.7% in the vancomycin-treated group and 6.9% in the non vancomycin-treated group respectively, which showed no statistically significant difference (p:0.498). The incidence of SSI was statistically higher in the patients who had a follow-up in the post-operative intensive care unit than the patients who had not any follow-up in the intensive care unit. Conclusion Local application of VP in the surgical wound was found to be ineffective in reducing the incidence of SSI after partial hip replacement in elderly patients with comorbidities.
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Affiliation(s)
- H Yener Erken
- Orthopaedics and Traumatology, Canakkale Onsekiz Mart University, Canakkale, TUR
| | - Gurdal Nusran
- Orthopaedics and Traumatology, Canakkale Onsekiz Mart University, Canakkale, TUR
| | | | - Onur Yilmaz
- Orthopaedics and Traumatology, Canakkale Onsekiz Mart University, Canakkale, TUR
| | - Tolgahan Kuru
- Orthopaedics and Traumatology, Canakkale Onsekiz Mart University, Canakkale, TUR
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Yavuz IA, Oken OF, Yildirim AO, Inci F, Ceyhan E, Gurhan U. No effect of vancomycin powder to prevent infection in primary total knee arthroplasty: a retrospective review of 976 cases. Knee Surg Sports Traumatol Arthrosc 2020; 28:3055-3060. [PMID: 31728604 DOI: 10.1007/s00167-019-05778-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 10/28/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Vancomycin powder (VP) has been used to prevent periprosthetic joint infection (PJI). However, studies investigating the efficacy of VP to prevent infection in primary total knee arthroplasty (TKA) are very rare. The purpose of this study was to investigate the efficacy of VP application to prevent PJI in TKA. METHODS Between 2012 and 2016, 976 consecutive patients who underwent primary TKA were included in the present study. Patients were divided into two groups. There were 474 patients (48.6%) in the VP group and 502 patients in the control group (51.4%). Except for VP, all procedures were the same in both groups. In the VP group, 2 g of VP was poured into the joint just before the fascia was closed. Average follow-up was 53.2 months (24-84 months). RESULTS Infection was found in 4 (0.84%) of 474 patients in the VP group and 5 (0.99%) of 502 patients in the control group. There was no statistically significant difference between groups in terms of infection rates (p = 0.535). Staphylococcus aureus was found in 2 patients in the VP group. Two patients had S. aureus and 1 patient had Pseudomonas aeruginosa in the control group. There was no statistically significant difference between groups in terms of demographic parameters (p > 0.05). CONCLUSION Intrawound VP administration doesn't change the infection rates in primary TKA. The VP administration for preventing PJI is not recommended in primary TKA. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Ibrahim Alper Yavuz
- Department of Orthopaedics and Traumatology, University of Health Science, Ankara Numune Training and Research Hospital, Ankara, Turkey.
| | - Ozdamar Fuad Oken
- Department of Orthopaedics and Traumatology, University of Health Science, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Ahmet Ozgur Yildirim
- Department of Orthopaedics and Traumatology, University of Health Science, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Fatih Inci
- Department of Orthopaedics and Traumatology, University of Health Science, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Erman Ceyhan
- Department of Orthopaedics and Traumatology, University of Health Science, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Utku Gurhan
- Department of Orthopaedics and Traumatology, University of Health Science, Ankara Numune Training and Research Hospital, Ankara, Turkey
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Yu L, Fei Q, Lin J, Yang Y, Xu Y. The Osteogenic Effect of Local Delivery of Vancomycin and Tobramycin on Bone Marrow Stromal Cells. Infect Drug Resist 2020; 13:2083-2091. [PMID: 32753906 PMCID: PMC7351982 DOI: 10.2147/idr.s261767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/18/2020] [Indexed: 01/12/2023] Open
Abstract
Purpose Bone tissue infections are a difficult problem in orthopedic surgery. Topical application of vancomycin and tobramycin powder has been proved to significantly reduce infection rates. However, the osteogenic effect of the topical application of these two antibiotics is unclear. In this study, the osteogenic effect of local delivery antibiotics on bone regeneration was investigated in vitro. Methods Bone marrow stromal cells (BMSCs) were incubated in the presence of vancomycin (14.28μg/mL), tobramycin (28.57μg/mL), or vancomycin combined with tobramycin (vancomycin 14.28μg/mL and tobramycin 28.57μg/mL). Cell viability, proliferation, and migration were analyzed. The alizarin red staining as well as the alkaline phosphatase staining was investigated. Then, the quantitative real-time (qRT)-PCR of osteogenic mRNA expression levels were also evaluated. Results The results showed that vancomycin combined with tobramycin has no adverse effect on the viability and proliferation of BMSCs. The topical application of vancomycin alone may interfere with the bone regenerative processes. However, the tobramycin can promote the osteogenic differentiation of BMSCs and also rescue the osteogenic potential of BMSCs inhibited by vancomycin both in vitro. Conclusion From this in vitro study, local application of vancomycin combined with tobramycin does not affect the osteogenic potential of BMSCs.
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Affiliation(s)
- Lingjia Yu
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, People's Republic of China
| | - Qi Fei
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, People's Republic of China
| | - Jisheng Lin
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, People's Republic of China
| | - Yong Yang
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, People's Republic of China
| | - Yisheng Xu
- Orthopedics Department, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, Guangdong 510120, People's Republic of China
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Highly efficient imidazolium-containing oligomers for preventing MRSA biofilm and postoperative spinal infection. Eur Polym J 2020. [DOI: 10.1016/j.eurpolymj.2020.109910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Dodson V, Majmundar N, Swantic V, Assina R. The effect of prophylactic vancomycin powder on infections following spinal surgeries: a systematic review. Neurosurg Focus 2020; 46:E11. [PMID: 30611167 DOI: 10.3171/2018.10.focus18470] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 10/29/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe use of vancomycin powder in spine surgery for prophylaxis against surgical site infections (SSIs) is well debated in the literature, with the majority of studies demonstrating improvement and some studies demonstrating no significant reduction in infection rate. It is well known in certain populations that vancomycin powder reduces the general rate of infection, but its effects on reducing the rate of infection due to gram-negative pathogens are not well reviewed. The goal of this paper was to review studies that investigated the efficacy of vancomycin powder as a prophylactic agent against SSI and demonstrate whether the rate of infections by gram-negative pathogens is impacted.METHODSAn electronic search of the published literature was performed using PubMed and Google Scholar in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A variety of combinations of the search terms "vancomycin powder," "infection," "spine," "gram-negative," "prophylaxis," and "surgical site" was used. Inclusion criteria were studies that 1) described an experimental group that received intraoperative intrawound vancomycin powder; 2) included adequately controlled groups that did not receive intraoperative intrawound vancomycin powder; 3) included the number of patients in both the experimental and control groups who developed infection after their spine surgery; and 4) identified the pathogen-causing infection. Studies not directly related to this review's investigation were excluded from the initial screen. Among the studies that met the criteria of the initial screen, additional reasons for exclusion from the systematic review included lack of a control group, unspecified size of control groups, and inconsistent use of vancomycin powder in the experimental group.RESULTSThis systematic review includes 21 studies with control groups. Vancomycin powder significantly reduced the relative risk of developing an SSI (RR 0.55, 95% CI 0.45-0.67, p < 0.0001). In addition, the use of vancomycin powder did not significantly increase the risk of infection by gram-negative pathogens (RR 1.11, 95% CI 0.66-1.86, p = 0.701).CONCLUSIONSThe results of this systematic review suggest that intrawound vancomycin powder is protective against SSI. It is less clear if this treatment increases the risk of gram-negative infection. Further studies are required to investigate whether rates of infection due to gram-negative pathogens are affected by the use of vancomycin powder.
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Abstract
In July of 2018, the Second International Consensus Meeting (ICM) on Musculoskeletal Infection convened in Philadelphia, PA was held to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 17 focused on the use of antibiotics in spine surgery, for which this article provides the recommendations, voting results, and rationales.
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Li Y, Li L, Ma Y, Zhang K, Li G, Lu B, Lu C, Chen C, Wang L, Wang H, Cui X. 3D-Printed Titanium Cage with PVA-Vancomycin Coating Prevents Surgical Site Infections (SSIs). Macromol Biosci 2020; 20:e1900394. [PMID: 32065462 DOI: 10.1002/mabi.201900394] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/20/2020] [Indexed: 01/14/2023]
Abstract
Many coating materials have been studied to prevent surgical site infections (SSIs). However, antibacterial coating on surfaces show weak adhesion using the traditional titanium (Ti) cage, resulting in low efficacy for preventing SSIs after spinal surgery. Herein, a 3D-printed Ti cage combined with a drug-releasing system is developed for in situ drug release and bacteria killing, leading to prevention of SSIs in vitro and in vivo. First, a 3D-printed Ti cage is designed and prepared by the Electron Beam Melting (EBM) method. Second, polyvinyl alcohol (PVA) containing hydrophilic vancomycin hydrochloride (VH) is scattered across the surface of 3D-printed porous Ti (Ti-VH@PVA) cages. Ti-VH@PVA cages show an efficient drug-releasing profile and excellent bactericidal effect for three common bacteria after more than seven days in vitro. In addition, Ti-VH@PVA cages exhibit reliable inhibition of inflammation associated with Staphylococcus aureus and effective bone regeneration capacity in a rabbit model of SSIs. The results indicate that Ti-VH@PVA cages have potential advantages for preventing SSIs after spinal surgery.
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Affiliation(s)
- Yuan Li
- Department of Orthopaedics, The 8th Medical Center of Chinese PLA General Hospital, Beijing, 100091, China.,CAS Center for Excellence in Nanoscience, CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety, National Center for Nanoscience and Technology (NCNST), No. 11 Beiyitiao, Zhongguancun, Beijing, 100190, China.,College of Medicine, Southwest Jiaotong University, Chengdu, 610031, China
| | - Litao Li
- Department of Orthopaedics, The 8th Medical Center of Chinese PLA General Hospital, Beijing, 100091, China
| | - Yiguang Ma
- Department of Orthopaedics, The 8th Medical Center of Chinese PLA General Hospital, Beijing, 100091, China.,CAS Center for Excellence in Nanoscience, CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety, National Center for Nanoscience and Technology (NCNST), No. 11 Beiyitiao, Zhongguancun, Beijing, 100190, China
| | - Kuo Zhang
- CAS Center for Excellence in Nanoscience, CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety, National Center for Nanoscience and Technology (NCNST), No. 11 Beiyitiao, Zhongguancun, Beijing, 100190, China
| | - Guang Li
- Department of Orthopaedics, The 8th Medical Center of Chinese PLA General Hospital, Beijing, 100091, China.,CAS Center for Excellence in Nanoscience, CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety, National Center for Nanoscience and Technology (NCNST), No. 11 Beiyitiao, Zhongguancun, Beijing, 100190, China
| | - Bin Lu
- Department of Orthopaedics, The 8th Medical Center of Chinese PLA General Hospital, Beijing, 100091, China
| | - Chenglin Lu
- Shandong Weigao Orthopedic Device Co., Ltd., No. 26 Xiangjiang Street, Tourist Resorts, Weihai, 264200, Shandong Province, China
| | - Cheng Chen
- Shandong Weigao Orthopedic Device Co., Ltd., No. 26 Xiangjiang Street, Tourist Resorts, Weihai, 264200, Shandong Province, China
| | - Lei Wang
- CAS Center for Excellence in Nanoscience, CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety, National Center for Nanoscience and Technology (NCNST), No. 11 Beiyitiao, Zhongguancun, Beijing, 100190, China
| | - Hao Wang
- CAS Center for Excellence in Nanoscience, CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety, National Center for Nanoscience and Technology (NCNST), No. 11 Beiyitiao, Zhongguancun, Beijing, 100190, China
| | - Xu Cui
- Department of Orthopaedics, The 8th Medical Center of Chinese PLA General Hospital, Beijing, 100091, China
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Abstract
Fracture-related infection (FRI) remains a challenging complication that imposes a heavy burden on orthopaedic trauma patients. The surgical management eradicates the local infectious focus and if necessary facilitates bone healing. Treatment success is associated with debridement of all dead and poorly vascularized tissue. However, debridement is often associated with the formation of a dead space, which provides an ideal environment for bacteria and is a potential site for recurrent infection. Dead space management is therefore of critical importance. For this reason, the use of locally delivered antimicrobials has gained attention not only for local antimicrobial activity but also for dead space management. Local antimicrobial therapy has been widely studied in periprosthetic joint infection, without addressing the specific problems of FRI. Furthermore, the literature presents a wide array of methods and guidelines with respect to the use of local antimicrobials. The present review describes the scientific evidence related to dead space management with a focus on the currently available local antimicrobial strategies in the management of FRI. LEVEL OF EVIDENCE:: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
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Delgado-López PD, Martín-Alonso J, Martín-Velasco V, Castilla-Díez JM, Galacho-Harriero A, Ortega-Cubero S, Herrero-Gutiérrez AI, Rodríguez-Salazar A. Vancomycin powder for the prevention of surgical site infection in posterior elective spinal surgery. Neurocirugia (Astur) 2019; 31:64-75. [PMID: 31611139 DOI: 10.1016/j.neucir.2019.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/05/2019] [Accepted: 07/25/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To assess the effectiveness and safety of vancomycin powder as surgical site infection (SSI) prophylaxis in posterior bilateral elective spinal surgery. MATERIALS AND METHODS Single-center quasi-experimental pre and postintervention comparative cohort study. The post-intervention group received standard intravenous antibiotic prophylaxis plus 1g of vancomycin powder into the surgical field before wound closure, and the pre-intervention group only the intravenous prophylaxis. RESULTS 150 patients were included in each group. Twelve SSI (7 superficial and 5 deep) occurred in the post-intervention group and 16 SSI (7 superficial and 9 deep) in the pre-intervention group. The risk of deep SSI decreased from 6.0% to 3.3% (OR 0,54, 95%CI 0.17-1.65, p=0.411) with vancomycin powder. The percentage of deep SSI due to gram negative-positive germs were 80%-20% and 33%-67% for the post- and pre-intervention groups, respectively (p=0.265). No local or systemic adverse effects occurred attributable to vancomycin powder. CONCLUSION In posterior elective spinal surgery, prophylaxis with vancomycin powder did not result in a significantly reduced incidence of superficial and deep SSI. There was a trend towards a higher incidence of deep SSI caused by gram negative microorganisms among those treated with vancomycin.
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Affiliation(s)
| | | | | | | | | | - Sara Ortega-Cubero
- Servicio de Neurocirugía, Hospital Universitario de Burgos, Burgos, España
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Ishida W, Perdomo-Pantoja A, Elder BD, Locke J, Holmes C, Witham TF, Lo SFL. Effects of Intraoperative Intrawound Antibiotic Administration on Spinal Fusion: A Comparison of Vancomycin and Tobramycin in a Rat Model. J Bone Joint Surg Am 2019; 101:1741-1749. [PMID: 31577679 DOI: 10.2106/jbjs.18.00988] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Local, intrawound use of antibiotic powder, such as vancomycin and tobramycin, in spinal fusion surgery has become an increasingly common prophylactic measure in an attempt to reduce rates of postsurgical infection. However, the effects of localized antibiotic delivery on fusion remain unclear. The objective of this study was to examine the in vivo effects of intraoperative local delivery of 2 antibiotics commonly used in bone-grafting surgery on spinal fusion outcomes in a rat model. METHODS Single-level (L4-L5), bilateral posterolateral intertransverse process lumbar fusion surgery was performed on 60 female Lewis rats (6 to 8 weeks of age) using syngeneic iliac crest allograft mixed with clinical bone-graft substitute and varying concentrations of antibiotics (n = 12 each): (1) control without any antibiotics, (2) low-dose vancomycin (14.3 mg/kg), (3) high-dose vancomycin (71.5 mg/kg), (4) low-dose tobramycin (28.6 mg/kg), and (5) high-dose tobramycin (143 mg/kg). Eight weeks postoperatively, fusion was evaluated via micro-computed tomography (µCT), manual palpation, and histological analysis, with blinding to treatment group. In the µCT analysis, fusion-mass volumes were measured for each rat. Each spine specimen (L4-L5) was rated (manual palpation score) on a scale of 2 to 0 (2 = fused, 1 = partially fused, and 0 = non-fused). RESULTS The mean fusion-mass volume on µCT (mm) was as follows: control, 29.3 ± 6.2; low-dose vancomycin, 26.3 ± 8.9; high-dose vancomycin, 18.8 ± 7.9; low-dose tobramycin, 32.7 ± 9.0; and high-dose tobramycin, 43.8 ± 11.9 (control versus high-dose vancomycin, p < 0.05; and control versus high-dose tobramycin, p < 0.05). The mean manual palpation score for each group was as follows: control, 1.46 ± 0.58; low-dose vancomycin, 0.86 ± 0.87; high-dose vancomycin, 0.68 ± 0.62; low-dose tobramycin, 1.25 ± 0.71; and high-dose tobramycin, 1.32 ± 0.72 (control versus high-dose vancomycin, p < 0.05). The histological analyses demonstrated a similar trend with regard to spinal fusion volume. CONCLUSIONS Intraoperative local application of vancomycin, particularly at a supraphysiological dosage, may have detrimental effects on fusion-mass formation. No inhibitory effect of tobramycin on fusion-mass formation was observed. CLINICAL RELEVANCE When spine surgeons decide to use intraoperative intrawound antibiotics in spinal fusion surgery, they should weigh the reduction in surgical site infection against a possible inhibitory effect on fusion.
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Affiliation(s)
- Wataru Ishida
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - John Locke
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christina Holmes
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sheng-Fu L Lo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Li S, Rong H, Zhang X, Zhang Z, Wang C, Tan R, Wang Y, Zheng T, Zhu T. Meta-analysis of topical vancomycin powder for microbial profile in spinal surgical site infections. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:2972-2980. [PMID: 31522274 DOI: 10.1007/s00586-019-06143-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 09/05/2019] [Accepted: 09/07/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To systematically evaluate the impact of topical vancomycin powder for microbial profile in spinal surgical site infections. METHODS All available literature regarding the topical use of vancomycin powder to prevent postoperative spinal infections was retrieved from the MEDLINE, EMBASE, and Cochrane databases starting from the creation date and up until September 30, 2018. RESULTS A total of 21 studies involving 15,548 patients were reviewed. The combined odds ratio showed that topical use of vancomycin powder was effective for reducing the incidence of gram-positive bacterial infections in spinal surgical sites (OR 0.41, P < 0.00001) without affecting its efficacy in the prevention of polymicrobial infections (OR 0.30, P = 0.03). Additionally, it could significantly reduce the infection rate of methicillin-resistant staphylococcus (OR 0.34, P < 0.0001). However, topical vancomycin powder showed no advantage for preventing gram-negative bacterial infections (OR 0.94, P = 0.75). CONCLUSIONS Topical administration of vancomycin powder may not increase the rates of gram-negative bacterial or polymicrobial infections in spinal surgical sites. On the contrary, it can significantly reduce the infection rates of gram-positive bacteria, methicillin-resistant staphylococcus (MRS) and microorganism. Of course, the topical vancomycin powder cannot change the rates of gram-negative bacterial infections, which may be related to the antimicrobial spectrum of vancomycin. Due to the limited number of articles included in this study, additional large-scale and high-quality studies are needed to provide more reliable clinical evidence.
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Affiliation(s)
- Sipeng Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, 300052, China
| | - Hongtao Rong
- Department of Neurosurgery, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, 300052, China
| | - Xueqin Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, 300052, China
| | - Zhengshan Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, 300052, China
| | - Chao Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, 300052, China
| | - Rui Tan
- Department of Neurosurgery, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, 300052, China
| | - Yi Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, 300052, China
| | - Ting Zheng
- Tianjin Medical University General Hospital, Tianjin, China
| | - Tao Zhu
- Department of Neurosurgery, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin, 300052, China.
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Ludwig do Nascimento T, Finger G, Sfreddo E, Martins de Lima Cecchini A, Martins de Lima Cecchini F, Stefani MA. Double-blind randomized clinical trial of vancomycin in spinal arthrodesis: no effects on surgical site infection. J Neurosurg Spine 2019; 32:473-480. [PMID: 31491758 DOI: 10.3171/2019.6.spine19120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 06/17/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical site infection (SSI) results in high morbidity and mortality in patients undergoing spinal fusion. Using intravenous antibiotics in anesthesia induction reduces the rate of postoperative infection, but it is not common practice to use them topically, despite recent reports that this procedure helps reduce infection. The objective of this study was to determine whether the topical use of vancomycin reduces the rate of postoperative SSI in patients undergoing thoracolumbar fusion. METHODS A randomized, double-blind clinical trial in a single hospital was performed comparing vancomycin and placebo in thoracolumbar fusion patients. RESULTS A total of 96 patients were randomized to placebo or vancomycin treatment. The mean patient age was 43 ± 14.88 years, 74% were male, and the most common etiology was fall from height (46.9%). The overall rate of postoperative SSI was 8.3%, and no difference was found between the groups: postoperative infection rates in the vancomycin and placebo groups were 8.2% and 8.5% (relative risk [RR] of SSI not using vancomycin 1.04, 95% confidence interval [CI] 0.28-3.93, p = 0.951), respectively. Patients with diabetes mellitus had higher SSI rates (RR 8.98, 95% CI 1.81-44.61, p = 0.007). CONCLUSIONS This is the first double-blind randomized clinical trial to evaluate the effects of topical vancomycin on postoperative infection rates in thoracolumbar fusion patients, and the results did not differ significantly from placebo.Clinical trial registration no.: RBR-57wppt (ReBEC; http://www.ensaiosclinicos.gov.br/).
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Affiliation(s)
- Tobias Ludwig do Nascimento
- 1Department of Neurosurgery, Hospital Cristo Redentor, Grupo Hospitalar Conceição, Porto Alegre; and
- 2Graduate School of Medicine, Surgical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Guilherme Finger
- 1Department of Neurosurgery, Hospital Cristo Redentor, Grupo Hospitalar Conceição, Porto Alegre; and
- 2Graduate School of Medicine, Surgical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Ericson Sfreddo
- 1Department of Neurosurgery, Hospital Cristo Redentor, Grupo Hospitalar Conceição, Porto Alegre; and
| | | | | | - Marco Antônio Stefani
- 2Graduate School of Medicine, Surgical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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Grabel ZJ, Boden A, Segal DN, Boden S, Milby AH, Heller JG. The impact of prophylactic intraoperative vancomycin powder on microbial profile, antibiotic regimen, length of stay, and reoperation rate in elective spine surgery. Spine J 2019; 19:261-266. [PMID: 29859351 DOI: 10.1016/j.spinee.2018.05.036] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/08/2018] [Accepted: 05/24/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT There is growing concern that the microbial profile of surgical site infection (SSI) in the setting of prophylactic vancomycin powder may favor more resistant and uncommon organisms. PURPOSE To demonstrate the impact of prophylactic intraoperative vancomycin powder on microbial profile, antibiotic regimen, length of stay (LOS), and reoperation rate in spine surgical site infection. STUDY DESIGN AND/OR SETTING Retrospective cohort study. PATIENT SAMPLE the study included 115 postoperative spine patients who were required to return to the operating room for SSI. OUTCOME MEASURES The outcome measures were microbial profile, reoperation rate, antibiotic regimen, and LOS for patients with postoperative spine infection who either did (treated) or did not (untreated) receive prophylactic vancomycin powder during their index procedure. METHODS A retrospective review of patients who underwent posterior thoracic and/or lumbar spine surgery between 2010 and 2017 was conducted. Those undergoing surgical treatment of SSI were identified, and patients were divided into two groups - those who were treated with intraoperative vancomycin (treated) and those who were not (untreated). The organism profile for each group was compared. The average LOS, reoperation rate, and number of patients requiring more than 1 antibiotic were calculated for each patient in both groups. RESULTS There were 5,909 procedures performed. One hundred and fifteen SSIs were identified, resulting in a 1.9% infection rate. Prophylactic vancomycin powder was used in the index procedure for 42 of those cases. 23.8% of cultures in the vancomycin group were polymicrobial and 16.7% were gram-negative compared with 9.6% (p=0.039) and 4.1% (p=0.021) in the untreated group, respectively. In the vancomycin-treated group, 26.1% of patients underwent repeat irrigation and debridement compared with 38.4% in the untreated group (p=0.184). The percentage of patients in the treatment and untreated group who required more than 1 antibiotic was 26.0% and 26.1%, respectively (p=0.984). Mean LOS in the treatment group was 8.0 versus 7.9 for the untreated group (p=0.945) CONCLUSIONS: In this series, vancomycin powder was associated with a higher prevalence of gram-negative and polymicrobial organisms in patients that ultimately developed postoperative SSI. However, this did not adversely affect the need for multiple reoperations, antibiotic regimen, or LOS for these patients.
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Affiliation(s)
- Zachary J Grabel
- Department of Orthopaedic Surgery, Emory University School of Medicine, 59 Executive Park South, Atlanta, GA 30329, USA.
| | - Allison Boden
- Department of Orthopaedic Surgery, Emory University School of Medicine, 59 Executive Park South, Atlanta, GA 30329, USA
| | - Dale N Segal
- Department of Orthopaedic Surgery, Emory University School of Medicine, 59 Executive Park South, Atlanta, GA 30329, USA
| | - Stephanie Boden
- Department of Orthopaedic Surgery, Emory University School of Medicine, 59 Executive Park South, Atlanta, GA 30329, USA
| | - Andrew H Milby
- Department of Orthopaedic Surgery, University of Pennsylvania, 426 B Stemmler Hall, 36th Street and Hamilton Walk, Philadelphia, PA 19104-6081 USA
| | - John G Heller
- Department of Orthopaedic Surgery, Emory University School of Medicine, 59 Executive Park South, Atlanta, GA 30329, USA
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Alverdy JC. The wound environment, microbial virulence and postoperative infection: Practical lessons for the surgeon. Cir Esp 2018; 96:612-619. [PMID: 30502224 DOI: 10.1016/j.ciresp.2018.09.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 09/23/2018] [Accepted: 09/27/2018] [Indexed: 01/10/2023]
Abstract
For the practicing surgeon, the development of a postoperative wound infection represents a major complication that can be both costly and disabling. As a result, surgeons apply multiple methods of prevention including skin decontamination, use of antibiotics, irrigation with or without antiseptics and meticulous use of technique. In elective surgery, however, most wound infections cannot be predicted. In this review we discuss emerging concepts in wound infection pathogenesis and include a discussion on how the wound environment may directly activate bacteria to express a more harmful or virulent phenotype. Based on these emerging concepts, we provide the practicing surgeon with molecular level evidence to explain why some methods of wound infection protection may be useful while others are not.
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Affiliation(s)
- John C Alverdy
- Profesor de Cirugía, Departamento de Cirugía, Universidad de Chicago, Chicago, Illinois, Estados Unidos de América.
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41
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Patel NN, Guild GN, Kumar AR. Intrawound vancomycin in primary hip and knee arthroplasty: a safe and cost-effective means to decrease early periprosthetic joint infection. Arthroplast Today 2018; 4:479-483. [PMID: 30560180 PMCID: PMC6287227 DOI: 10.1016/j.artd.2018.07.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 07/27/2018] [Accepted: 07/30/2018] [Indexed: 12/17/2022] Open
Abstract
Background Periprosthetic joint infection (PJI) is a devastating complication after hip and knee arthroplasty. Intrawound vancomycin has been described extensively in the spine literature; however, information regarding use in arthroplasty is limited. We investigate the efficacy and safety of intrawound vancomycin in arthroplasty surgery. Methods All primary total hip and knee arthroplasty cases (n = 460) performed by a single surgeon from April 2016 to October 2017 were reviewed. Starting in October 2016, intrawound vancomycin was used in all total joints. Baseline characteristics, infection rates, 90-day readmission, and other complications were compared between untreated subjects and those who received intrawound vancomycin. In addition, cost data were considered. Mean follow-up durations for the control and vancomycin groups were 11.3 and 7.7 months, respectively. Results Baseline characteristics and comorbidities were similar for the control (n = 112) and vancomycin groups (n = 348). The vancomycin cohort demonstrated decreased both overall infection rate (0.57% vs 2.7%; P = .031) and PJI rate (0.29% vs 2.7%; P = .009) compared with the untreated group. There was no statistical difference in incidence of ototoxicity or acute kidney injury. Although there was no difference in overall 90-day readmission rate, the vancomycin subset demonstrated lower readmission rate due to infection (0.57% vs 2.7%; P = .031). Based on the cost of vancomycin powder and calculated number needed to treat (NNT = 47.5), the cost to prevent 1 infection with the addition of intrawound vancomycin was $816. Conclusions These findings suggest that intrawound vancomycin may be a safe, cost-effective means that shows promise in reducing PJI in early follow-up. Future prospective studies are warranted.
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Affiliation(s)
- Nick N Patel
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - George N Guild
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Arun R Kumar
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Affiliation(s)
- Alex McLaren
- College of Medicine-Phoenix, University of Arizona, Phoenix, Arizona
| | | | - Antonia F Chen
- Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sandra B Nelson
- Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Boston, Massachusetts
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Postoperative Infection in Patients Undergoing Posterior Lumbosacral Spinal Surgery: A Pictorial Guide for Diagnosis and Early Treatment. Clin Spine Surg 2018; 31:225-238. [PMID: 29595747 DOI: 10.1097/bsd.0000000000000633] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Surgical site infections after posterior spinal surgery may lead to spondylodiscitis, pseudarthrosis, correction loss, adverse neurological sequelae, sepsis, and poor outcomes if not treated immediately. Infection rates vary depending on the type and extent of operative procedures, use of instrumentation, and patients' risk factors. Image evaluation is crucial for early diagnosis and should be complementary to clinical routes, laboratory survey, and treatment timing. Magnetic resonance imaging detects early inflammatory infiltration into the vertebrae and soft tissues, including hyperemic changes of edematous marrow, vertebral endplate, and abscess or phlegmon accumulation around the intervertebral disk, epidural, and paravertebral spaces. Aggressive surgical treatment can eradicate infection sources, obtain a stable wound closure, decrease morbidity, and restore spinal integrity. Organ/space infection is defined as any body parts opened to manipulate other than superficial/deep incision. Advanced magnetic resonance imaging evaluating abnormal fluid accumulation, heterogenous contrast enhancement of the endplate erosion due to cage/screw infection is categorized to inform a presumptive diagnosis for early implant salvage. However, patients' defense response, infection severity, bacteriology, treatment timing, spinal stability, and available medical and surgical options must be fully considered. Revision surgery is indicated for pseudarthrosis, implant loosening with correction loss, recalcitrant spondylodiscitis, and adjacent segment diseases for infection control.
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44
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Moon AS, Manoharan SR. Letter to the Editor. Use of intraoperative vancomycin powder and postoperative infection. J Neurosurg Spine 2018; 29:229-230. [PMID: 29799336 DOI: 10.3171/2018.1.spine1867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Andrew S Moon
- 1Tufts University School of Medicine, Boston, MA; and.,2University of Alabama at Birmingham, Birmingham, AL
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Alverdy JC. Microbiome Medicine: This Changes Everything. J Am Coll Surg 2018; 226:719-729. [PMID: 29505823 DOI: 10.1016/j.jamcollsurg.2018.02.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 02/08/2018] [Indexed: 12/13/2022]
Affiliation(s)
- John C Alverdy
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL.
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Xu X, Zhu H, Lv H. Safety of Staphylococcus aureus four-antigen and three-antigen vaccines in healthy adults: A meta-analysis of randomized controlled trials. Hum Vaccin Immunother 2017; 14:314-321. [PMID: 29064736 DOI: 10.1080/21645515.2017.1395540] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Two new Staphylococcus aureus vaccines, S. aureus four-antigen (SA4Ag) and three-antigen (SA3Ag) vaccines, have good immunogenicity and tolerance. However, the safety of these vaccines is worth exploring. Here, we performed a meta-analysis to investigate the safety of SA3Ag and SA4Ag by evaluating systemic and local adverse events. METHODS The Medline, EMBASE, and Cochrane databases were searched for randomized clinical trials confirming the safety of SA4Ag and SA3Ag. Two investigators independently selected suitable trials, assessed trial quality, and extracted data. RESULTS Three studies comprising a total of 1,148 participants were included in this review. The two S. aureus vaccines did not increase systemic adverse events (relative ratio 1.1 [95% confidence interval 0.98, 1.24]), but increased the incidence of local adverse events (2.89 [2.15, 3.90]). However, the incidence of severe local adverse events (4.06 [0.78, 21.24]) did not rise significantly. CONCLUSIONS SA4Ag and SA3Ag have acceptable safety in adults.
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Affiliation(s)
- Xiaoqun Xu
- a Department of Clinical Laboratory, Centre of Laboratory Medicine , Zhejiang Provincial People's Hospital, The Affiliated People's Hospital of Hangzhou Medical College , Hangzhou , Zhejiang , China.,b Zhejiang Chinese Medical University , Hangzhou , Zhejiang , China
| | - Houyong Zhu
- c Department of Cardiology , Hangzhou Hospital of Traditional Chinese Medicine; Hangzhou Dingqiao Hospital , Hangzhou , Zhejiang , China
| | - Huoyang Lv
- a Department of Clinical Laboratory, Centre of Laboratory Medicine , Zhejiang Provincial People's Hospital, The Affiliated People's Hospital of Hangzhou Medical College , Hangzhou , Zhejiang , China
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