Infection Control Today

APR 2019

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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33 April 2019 ICT Factors that defne the pathogenesis of SSI are the virulence, host-site immunity, and dosage. 15 The virulence is the microorganism's ability to infect the host. Although many bacterial species have been identifed to cause SSI, the most common ones, Staphylococcus epidermidis and Staphylococcus aureus, are always present at the vicinity as part of a patient's own fora. In addition, they have the potential to form bioflms, secluding itself from macrophages or other immune responses at the host site. The host sites in spine surgery are the pedicles of the vertebrae. This in combination with availability of metal surface (pedicle screws) provides a conducive environment for the bacteria to grow. Lastly, the dose dictates how much bacterial bioburden the "sterile" implant carries, after handing and at implantation. Among these, the only factor that we can really control at the screw-bone interface is the bacterial dosage, which essentially is at the core of aseptic surgical philosophy. Therefore, shouldn't some form of intraop- erative-implant-guard be a standard in spinal fusion surgery, to fght the one of the key pathogenesis of SSI? Clinicians are further encouraged to refect on the questions below in sequence: 1. What does it mean for a practicing surgeon? 2. What would your patient choose considering this information? 3. Should "lower" infection rates be an excuse or a reason to knowingly put bacteria in patients? 4. Is the surgical site infection rate low? McClelland, et al. (2016) says 12.7 percent SSI rate in a PCT. 5. Think about the spinal deformity surgery. Why is the SSI rate higher in them? Is it more implants or longer exposure time? May be both! 6. Do you know that bacteria at screw-bone interface causes screw loosening? Leitner by et al 2018 7. Could this help reduce antibiotic administration long-term, therefore combating the bigger war against antibiotic resistance? Aakash Agarwal, PhD, is from the Engineering Center for Orthopedic Research Excellence (ECORE) in the Department of Bioengineering and Orthopedics Surgery, Colleges of Engineering and Medicine, at the University of Toledo. References: 1. McClelland S, Takemoto RC, Lonner BS, et al. Analysis of postoperative thoracolumbar spine infections in a prospective randomized controlled trial using the centers for disease control surgical site infection criteria. Intern J Spine Surgery 10 (2016):14. 2. Grabel ZJ, Boden A, Segal DN, Boden S, Milby AH and Heller JG. The impact of prophylactic intraoperative vancomycin powder on microbial profle, antibiotic regimen, length of stay, and reoperation rate in elective spine surgery. Spine J. 2018. 3. Hedequist D, Haugen A, Hresko T and Emans J. Failure of attempted implant retention in spinal deformity delayed surgical site infections. Spine. 34, No. 1 (2009): 60-64. 4. Leitner L, Malaj I, Sadoghi P, et al. Pedicle screw loosening is correlated to chronic subclinical deep implant infection: a retrospective database analysis. Euro Spine J. (2018):1-7. 5. Callanan TC, Lebl DR, Cammisa FP, et al. Occult infection in patients who have undergone spinal surgery with instrumentation. Spine J. 16, No. 10 (2016): S132-S133. 6. Lieberman IH. and Hu X. Revision Spine Surgery in Patients without Clinical Signs of Infection: How Often are There Occult Infections in Removed Hardware? Spine J. 17, No. 10 (2017): S187. 7. Hu X and Lieberman IH. Revision spine surgery in patients without clinical signs of infection: How often are there occult infections in removed hardware? Euro Spine J. (2018): 1-5. 8. Agarwal A, Schultz C, Goel VK, et al. (2018). Implant Prophylaxis: The Next Best Practice Toward Asepsis in Spine Surgery. Global Spine J. 2018. 9. Agarwal A, Schultz C, Agarwal AK, Wang JC, Garfn SR, and Anand N. Harboring Contaminants in Repeatedly Reprocessed Pedicle Screws. Global Spine J. 2018. 10. Agarwal A, Lin B, Wang JC, et al. Effcacy of Intraoperative Implant Prophylaxis in Reducing Intraoperative Microbial Contamination. Global Spine J. 2018. 11. Agarwal A, et al. Reducing Bacterial Dose During Instrumented Spine Surgery: A Clinical Study on a Novel and Effortless Method, NASS, Los Angeles. Sept. 26-29, 2018. 12. Agarwal A, et al. Avoiding Unnecessary Contamination of Implant-Bone Interface: A multi- center study, SMISS, Las Vegas. Sept. 6-8, 2018. 13. Agarwal A, MacMillan A, Goel V, Agarwal AK, and Karas C. A Paradigm Shift Toward Terminally Sterilized Devices. Clin Spine Surgery. 31, No. 7 (2018): 308-311. 14. Rehman A, Rehman Atig-ur, Rehman Tausif-ur, and Freeman C. Removing outer gloves as a method to reduce spinal surgery infection. Clin Spine Surgery. 28, No. 6 (2015): E343-E346. 15. Anderson DJ. Surgical site infections. Infect Dis Clin North America. 25, No. 1 (2011): 135-153 Figure 2: Schematic showing the pathogenesis of SSI, highlighting that the only preventive measure in our control is dosage

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