Abstract：
Surgical site infection (SSI) following spine surgery causes major morbidity and greatly impedes functional recovery. In the modern era of advanced operative techniques and improved perioperative care, SSI remains a problematic complication that may be reduced with institutional practices. The objectives of this study were to 1) characterize the SSI rate and microbial etiology following spine surgery for various thoracolumbar diseases, and 2) identify risk factors that were associated with SSI despite current perioperative management.
All patients treated with thoracic or lumbar spine operations on the neurosurgery service at the University of California, San Francisco from April 2012 to April 2016 were formally reviewed for SSI using the National Healthcare Safety Network (NHSN) guidelines. Preoperative risk variables included age, sex, BMI, smoking, diabetes mellitus (DM), coronary artery disease (CAD), ambulatory status, history of malignancy, use of preoperative chlorhexidine gluconate (CHG) showers, and the American Society of Anesthesiologists (ASA) classification. Operative variables included surgical pathology, resident involvement, spine level and surgical technique, instrumentation, antibiotic and steroid use, estimated blood loss (EBL), and operative time. Multivariable logistic regression was used to evaluate predictors for SSI. Odds ratios and 95% confidence intervals were reported.
In total, 2252 consecutive patients underwent thoracolumbar spine surgery. The mean patient age was 58.6 ± 13.8 years and 49.6% were male. The mean hospital length of stay was 6.6 ± 7.4 days. Sixty percent of patients had degenerative conditions, and 51.9% underwent fusions. Sixty percent of patients utilized presurgery CHG showers. The mean operative duration was 3.7 ± 2 hours, and the mean EBL was 467 ± 829 ml. Compared to nonfusion patients, fusion patients were older (mean 60.1 ± 12.7 vs 57.1 ± 14.7 years, p < 0.001), were more likely to have an ASA classification > II (48.0% vs 36.0%, p < 0.001), and experienced longer operative times (252.3 ± 120.9 minutes vs 191.1 ± 110.2 minutes, p < 0.001). Eleven patients had deep SSI (0.49%), and the most common causative organisms were methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus. Patients with CAD (p = 0.003) or DM (p = 0.050), and those who were male (p = 0.006), were predictors of increased odds of SSI, and presurgery CHG showers (p = 0.001) were associated with decreased odds of SSI.
This institutional experience over a 4-year period revealed that the overall rate of SSI by the NHSN criteria was low at 0.49% following thoracolumbar surgery. This was attributable to the implementation of presurgery optimization, and intraoperative and postoperative measures to prevent SSI across the authors’ institution. Despite prevention measures, having a history of CAD or DM, and being male, were risk factors associated with increased SSI, and presurgery CHG shower utilization decreased SSI risk in patients.
ASA = American Society of Anesthesiologists; CAD = coronary artery disease; CHG = chlorhexidine gluconate; CI = confidence interval; DM = diabetes mellitus; EBL = estimated blood loss; LOS = length of stay; MIS = minimally invasive surgery; MRSA = methicillin-resistant Staphylococcus aureus; MRSE = methicillin-resistant Staphylococcus epidermidis; MSSA = methicillin-sensitive S. aureus; MSSE = methicillin-sensitive S. epidermidis; NHSN = National Healthcare Safety Network; OR = odds ratio; SSI = surgical site infection.
All patients treated with thoracic or lumbar spine operations on the neurosurgery service at the University of California, San Francisco from April 2012 to April 2016 were formally reviewed for SSI using the National Healthcare Safety Network (NHSN) guidelines. Preoperative risk variables included age, sex, BMI, smoking, diabetes mellitus (DM), coronary artery disease (CAD), ambulatory status, history of malignancy, use of preoperative chlorhexidine gluconate (CHG) showers, and the American Society of Anesthesiologists (ASA) classification. Operative variables included surgical pathology, resident involvement, spine level and surgical technique, instrumentation, antibiotic and steroid use, estimated blood loss (EBL), and operative time. Multivariable logistic regression was used to evaluate predictors for SSI. Odds ratios and 95% confidence intervals were reported.
In total, 2252 consecutive patients underwent thoracolumbar spine surgery. The mean patient age was 58.6 ± 13.8 years and 49.6% were male. The mean hospital length of stay was 6.6 ± 7.4 days. Sixty percent of patients had degenerative conditions, and 51.9% underwent fusions. Sixty percent of patients utilized presurgery CHG showers. The mean operative duration was 3.7 ± 2 hours, and the mean EBL was 467 ± 829 ml. Compared to nonfusion patients, fusion patients were older (mean 60.1 ± 12.7 vs 57.1 ± 14.7 years, p < 0.001), were more likely to have an ASA classification > II (48.0% vs 36.0%, p < 0.001), and experienced longer operative times (252.3 ± 120.9 minutes vs 191.1 ± 110.2 minutes, p < 0.001). Eleven patients had deep SSI (0.49%), and the most common causative organisms were methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus. Patients with CAD (p = 0.003) or DM (p = 0.050), and those who were male (p = 0.006), were predictors of increased odds of SSI, and presurgery CHG showers (p = 0.001) were associated with decreased odds of SSI.
This institutional experience over a 4-year period revealed that the overall rate of SSI by the NHSN criteria was low at 0.49% following thoracolumbar surgery. This was attributable to the implementation of presurgery optimization, and intraoperative and postoperative measures to prevent SSI across the authors’ institution. Despite prevention measures, having a history of CAD or DM, and being male, were risk factors associated with increased SSI, and presurgery CHG shower utilization decreased SSI risk in patients.
ASA = American Society of Anesthesiologists; CAD = coronary artery disease; CHG = chlorhexidine gluconate; CI = confidence interval; DM = diabetes mellitus; EBL = estimated blood loss; LOS = length of stay; MIS = minimally invasive surgery; MRSA = methicillin-resistant Staphylococcus aureus; MRSE = methicillin-resistant Staphylococcus epidermidis; MSSA = methicillin-sensitive S. aureus; MSSE = methicillin-sensitive S. epidermidis; NHSN = National Healthcare Safety Network; OR = odds ratio; SSI = surgical site infection.
摘要：
脊柱手术后的手术部位感染（SSI）会导致严重的发病率，并极大地阻碍功能恢复。在先进的手术技术和改进的围手术期护理的现代，SSI仍然是一个有问题的并发症，可以通过机构实践减少。这项研究的目的是1）表征各种胸腰椎疾病的脊柱手术后的SSI率和微生物病因，和2)确定与SSI相关的危险因素,尽管目前的围手术期管理.
所有接受过胸椎或腰椎手术的患者在加州大学神经外科服务，从2012年4月至2016年4月，旧金山使用国家医疗保健安全网络（NHSN）指南对SSI进行了正式审查。术前风险变量包括年龄，性别,BMI,吸烟,糖尿病（DM），冠状动脉疾病（CAD），卧床状态,恶性肿瘤病史，术前使用葡萄糖酸氯己定（CHG）淋浴，和美国麻醉医师协会（ASA）分类。手术变量包括手术病理学，居民参与,脊柱水平和手术技术，仪器仪表,抗生素和类固醇的使用，估计失血量（EBL），和手术时间。多变量逻辑回归用于评估SSI的预测因子。报告了赔率比和95%置信区间。
总共，2252例连续患者接受了胸腰椎脊柱手术。患者平均年龄为58.6±13.8岁，男性占49.6%。平均住院时间为6.6±7.4天。60%的患者有退行性疾病，51.9%接受了融合。60％的患者使用了手术前CHG淋浴。平均手术时间为3.7±2小时，平均EBL为467±829ml。与非融合患者相比，融合患者年龄较大（平均60.1±12.7vs57.1±14.7岁，p<0.001)，更有可能有ASA分类>II(48.0%对36.0%，p<0.001)，并且经历了更长的手术时间（252.3±120.9分钟vs191.1±110.2分钟，p<0.001)。11例患者有深度SSI（0.49%），最常见的致病菌是甲氧西林敏感金黄色葡萄球菌和耐甲氧西林金黄色葡萄球菌。CAD（p=0.003）或DM（p=0.050）患者，和那些男性（p=0.006），是SSI几率增加的预测因子，术前CHG淋浴(p=0.001)与SSI几率降低相关。
这项机构在4年期间的经验表明，根据NHSN标准，胸腰椎手术后的SSI总体发生率较低，为0.49％。这是由于实施了预处理优化，术中和术后的措施，以防止在作者所在机构的SSI。尽管采取了预防措施，有CAD或DM的历史，作为男性，是与SSI增加相关的危险因素，术前CHG淋浴的使用降低了患者的SSI风险。
ASA=美国麻醉医师协会；CAD=冠状动脉疾病；CHG=葡萄糖酸氯己定；CI=置信区间；DM=糖尿病；EBL=估计失血量；LOS=住院时间；MIS=微创手术；MRSA=耐甲氧西林金黄色葡萄球菌；MRSE=耐甲氧西林表皮葡萄球菌；MSSA几率=耐甲氧西林表皮葡萄球菌；SSE=国家耐甲氧西林/耐量比
所有接受过胸椎或腰椎手术的患者在加州大学神经外科服务，从2012年4月至2016年4月，旧金山使用国家医疗保健安全网络（NHSN）指南对SSI进行了正式审查。术前风险变量包括年龄，性别,BMI,吸烟,糖尿病（DM），冠状动脉疾病（CAD），卧床状态,恶性肿瘤病史，术前使用葡萄糖酸氯己定（CHG）淋浴，和美国麻醉医师协会（ASA）分类。手术变量包括手术病理学，居民参与,脊柱水平和手术技术，仪器仪表,抗生素和类固醇的使用，估计失血量（EBL），和手术时间。多变量逻辑回归用于评估SSI的预测因子。报告了赔率比和95%置信区间。
总共，2252例连续患者接受了胸腰椎脊柱手术。患者平均年龄为58.6±13.8岁，男性占49.6%。平均住院时间为6.6±7.4天。60%的患者有退行性疾病，51.9%接受了融合。60％的患者使用了手术前CHG淋浴。平均手术时间为3.7±2小时，平均EBL为467±829ml。与非融合患者相比，融合患者年龄较大（平均60.1±12.7vs57.1±14.7岁，p<0.001)，更有可能有ASA分类>II(48.0%对36.0%，p<0.001)，并且经历了更长的手术时间（252.3±120.9分钟vs191.1±110.2分钟，p<0.001)。11例患者有深度SSI（0.49%），最常见的致病菌是甲氧西林敏感金黄色葡萄球菌和耐甲氧西林金黄色葡萄球菌。CAD（p=0.003）或DM（p=0.050）患者，和那些男性（p=0.006），是SSI几率增加的预测因子，术前CHG淋浴(p=0.001)与SSI几率降低相关。
这项机构在4年期间的经验表明，根据NHSN标准，胸腰椎手术后的SSI总体发生率较低，为0.49％。这是由于实施了预处理优化，术中和术后的措施，以防止在作者所在机构的SSI。尽管采取了预防措施，有CAD或DM的历史，作为男性，是与SSI增加相关的危险因素，术前CHG淋浴的使用降低了患者的SSI风险。
ASA=美国麻醉医师协会；CAD=冠状动脉疾病；CHG=葡萄糖酸氯己定；CI=置信区间；DM=糖尿病；EBL=估计失血量；LOS=住院时间；MIS=微创手术；MRSA=耐甲氧西林金黄色葡萄球菌；MRSE=耐甲氧西林表皮葡萄球菌；MSSA几率=耐甲氧西林表皮葡萄球菌；SSE=国家耐甲氧西林/耐量比
