Perioperative Care and Operating Room Management 30 (2023) 100308

Contents lists available at ScienceDirect

Perioperative Care and Operating Room Management

journal homepage: www.elsevier.com/locate/pcorm

Surgical site infection in pediatric spinal fusion surgery revisited: Outcome

and risk factors after preventive bundle implementation
Wiriya Maisat a, b, c, *, Koichi Yuki a, b, *
a
Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, USA
b
Department of Anaesthesia, Harvard Medical School, Boston, USA
c
Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Surgical site infections (SSI) contribute to significant morbidity, mortality, length of stay, and
Antibiotic prophylaxis financial burden. We sought to evaluate the incidence and risk factors of surgical site infection following pe­
Risk factors diatric spinal fusion surgery in patients for whom standard perioperative antibiotic prophylaxis and preventive
Scoliosis
strategies have been implemented.
Spinal fusion
Surgical wound infection
Methods: We conducted a retrospective study of children aged <18 years who underwent spinal fusion surgery
from January 2017 to November 2021 at a quaternary academic pediatric medical center. Univariable analysis
was used to evaluate associations between potential risk factors and SSI.
Results: Of 1111 patients, 752 (67.6%) were female; median age was 14.2 years. SSI occurred in 14 patients
(1.3%). Infections were superficial incisional (n = 2; 14.3%), deep incisional (n = 9; 64.3%), and organ/space (n
= 3; 21.4%). Median time to SSI was 14 days (range, 8 to 45 days). Staphylococcus aureus and Escherichia coli were
the most frequently-isolated bacteria. Potential risk factors for SSIs included low body weight (Odds ratio (OR)
0.96, 95% confidence interval (CI) 0.93–0.99, p = 0.026), ASA classification of ≥3 (OR 24.53, 95%CI
3.20–188.22, p = 0.002), neuromuscular scoliosis (OR 3.83, 95%CI 3.82–78.32, p<0.001), prolonged operative
time (OR 1.56, 95%CI 1.28–1.92, p<0.001), prolonged anesthetic time (OR 1.65, 95%CI 1.35–2.00, p<0.001),
administration of prophylactic antibiotic ≥60 min before skin incision (OR 11.52, 95%CI 2.34–56.60, p = 0.003),
and use of povidone-iodine alone for skin preparation (OR 5.97, 95%CI 1.27–28.06, p = 0.024).
Conclusion: In the context of a robust bundle for SSI prevention; low body weight, ASA classification of ≥3,
neuromuscular scoliosis, prolonged operative and anesthetic times, administration of prophylactic antibiotic
>60 min before skin incision, and use of povidone-iodine alone for skin preparation increased the risk of SSI.
Administration of prophylactic antibiotic within 60 min of skin incision, strict adherence to high-risk preventive
protocol, and use of CHG-alcohol could potentially reduce the rate of SSI.

1. Introduction complexity.11
Evidence-based practice guidelines have been developed to address
Surgical site infection (SSI) is one of the major healthcare-associated modifiable risk factors to minimize the risk of SSI or the severity of the
infections that contributes to significant morbidity, mortality, length of infection.16–20 Adherence to a protocol using several strategies to pre­
stay, and financial burden for hospitalized patients in the United vent infection resulted in a lower SSI rate.21 This study aims to evaluate
States.1,2 Overall SSI incidence in pediatric orthopedic operations is the incidence and risk factors of SSIs following pediatric spinal fusion
2.5–2.8%,3,4 and the number is remarkably higher in spinal fusion sur­ surgery in the context of a standardized perioperative antibiotic pro­
gery at 3.6–10.3%.5-10 Over the past decade, several studies have re­ phylaxis and implementation of routine preventive strategies into clin­
ported risk factors for SSI in pediatric spinal fusion surgery, including ical practice.
underlying etiology of scoliosis,11-13 patient comorbidities7,14 such as
obesity, suboptimal antibiotic prophylaxis,7,13,15 and surgical

* Corresponding authors at: Cardiac Anesthesia Division, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, 300
Longwood Avenue, Boston, MA 02115, USA.
E-mail addresses: wiriya.maisat@childrens.harvard.edu (W. Maisat), koichi.yuki@childrens.harvard.edu (K. Yuki).

https://doi.org/10.1016/j.pcorm.2023.100308
Received 26 September 2022; Received in revised form 3 January 2023; Accepted 30 January 2023
Available online 1 February 2023
2405-6030/© 2023 Elsevier Inc. All rights reserved.

Downloaded for Institut Latihan KKM (ilkkm@moh.gov.my) at Training Management Division Ministry of Health Malaysia from
ClinicalKey.com/nursing by Elsevier on June 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All
rights reserved.
W. Maisat and K. Yuki Perioperative Care and Operating Room Management 30 (2023) 100308

2. Materials and methods 3. Results

2.1. Patient cohort and data collection A total of 1544 patients underwent spine surgery between January
2017 and November 2021 at our institution. Among these, we enrolled
This retrospective cohort study was approved by the Institutional 1111 patients younger than 18 years of age who underwent spinal fusion
Review Board at Boston Children’s Hospital, and informed consent was surgeries regardless of surgical approaches.
exempted. We included patients younger than 18 years of age at the time In our cohort, the majority of patients were female (n = 752, 67.6%)
of surgery who underwent spinal fusion surgery from January 2017 to with a median age of 14.2 years (IQR 12.5–15.8), the youngest patient
November 2021 at our institution. was 8 months old. Demographic data and patient characteristics were
Patient demographic data were collected including gender, age, race, presented in Table 1. Adolescent idiopathic scoliosis was the most
body weight, height, American Society of Anesthesiologists (ASA) common indication for surgery (n = 430, 38.7%), followed by neuro­
physical status classification, and primary etiology of scoliosis present­ muscular scoliosis (n = 187, 16.8%). Approximately one-third of pa­
ing for surgery. Intraoperative data included surgical and anesthesia tients had ASA classification of at least 3 (n = 369, 35%). The most
attendings, operative time (duration from skin incision to skin closure), common primary surgical antibiotic prophylaxis was cefazolin (n = 969,
anesthetic time (duration from the start to the end of anesthesia), type 87.2%), gentamicin was administered in 192 (17.3%) patients. Most of
and timing of intravenous antibiotic, skin preparation agent, medica­ the patients (n = 1068, 96.4%) received prophylactic antibiotic within
tions, temperature, and blood transfusion. All data were retrieved from 60 min before skin incision, whereas, 20 (1.8%) and 19 (1.7%) patients
electronic medical records and Anesthesia Information Management received antibiotic longer than 60 min before skin incision and after skin
System™ (AIMS; Cerner, MO, USA). incision, respectively. Four patients had already received preoperative
antibiotic, we did not include these patients in the analysis related to
antibiotic timing.
2.2. SSI definition and prevention bundles
The overall incidence of SSIs following spinal fusion surgery was
1.3% (14 out of 1111 patients) with an annual infection varying from 0.0
SSI was diagnosed based on the National Healthcare Safety Network
to 2.6%. Table 2 summarized the detailed characteristics of all patients
(NHSN) definitions from the US Centers for Disease Control and Pre­
who developed postoperative SSIs. All of the patients underwent pos­
vention and occurred within 90 days after the index procedure.22 Pa­
terior spinal fusion surgery with the age ranging from 10.6 to 17.5 years
tients who developed SSI after spinal fusion surgery were identified
through continuous prospective surveillance by the Infection Prevention
and Control department. Table 1
At our institution, the general SSI prevention bundle includes 1) Patient characteristics.
preoperative bath with soap or an antiseptic agent; 2) skin preparation Total (n = 1111)
with chlorhexidine gluconate (CHG)-alcohol (ChloraPrep™), povidone- Gender; female 752 (67.7)
iodine (Betadine®) alone, povidone-iodine plus CHG-alcohol, povidone- Age (yr) 14.2 (12.5,15.8)
iodine plus alcohol, or all three antiseptics combined; 3) using clippers Race
for hair removal; and 4) perioperative antibiotic prophylaxis. Cefazolin White 690 (62.1)
Black/African American 58 (5.2)
was the first-line prophylactic antibiotic for standard-risk spinal fusion
Asian 34 (3.1)
(i.e., idiopathic scoliosis in otherwise healthy patients) and adminis­ American Indian/Alaska native 4 (0.4)
tered within 60 min prior to surgical incision and re-dosed every 4 h Other 124 (11.2)
intraoperatively. An alternative antibiotic (clindamycin or vancomycin) Declined/unable to answer 201 (18.0)
Body weight (kg) 52.8 (42.8,64.1)
would be administered if a patient had a history of penicillin or ceph­
Height (cm) 160.0 (149.8,167.5)
alosporin allergy. The choice of antibiotic in those cases was made based ASA classification
on the institutional guideline. 1 157 (14.2)
Patients with high-risk spinal fusion (i.e., complex surgery, associ­ 2 560 (50.4)
ated significant comorbidities such as cerebral palsy, neuromuscular 3 360 (32.4)
4 33 (3.0)
scoliosis, etc.) also received cefazolin as a first-line agent with additional
Diagnosis
gentamicin. Vancomycin would be administered if the patients were Idiopathic scoliosis 596 (53.6)
labeled with penicillin or cephalosporin allergy or colonized with Neuromuscular scoliosis 187 (16.8)
Methicillin-resistant Staphylococcus aureus (MRSA). Additional measures Congenital scoliosis 97 (8.7)
were exercised including 1) chlorhexidine bath the night before surgery, Unspecified or unknown 231 (20.8)
Type of prophylactic antibiotic
2) preoperative patient education sheet, 3) intraoperative wound irri­ Cefazolin 969 (87.2)
gation, 4) maintaining normothermia, 5) vancomycin powder added to Clindamycin 128 (11.5)
bone graft, and 6) use of impervious dressings. Vancomycin 12 (1.1)
Ceftriaxone 1 (0.1)
Linezolid 1 (0.1)
2.3. Statistical analysis Adjunct Gentamicin 192 (17.3)
Adjunct Gentamicin with
Cefazolin 167 (87.0)
We presented number and percentage for categorical variables, mean Clindamycin 16 (8.3)
and standard deviation (SD) for continuous variables with normal dis­ Vancomycin 7 (3.6)
tribution, or median and interquartile range (IQR) for variables with Cefazolin and Vancomycin 2 (1.0)
skewed distribution. Shapiro-Wilk test was used to assess normality. Antibiotic-to-incision time (min) 15.0 (11.0,21.0)
Antibiotic timing
Potential risk factors for SSI were assessed with univariable logistic
Before skin incision
regression analysis. The results were reported as odds ratio (OR) and 0–30 min 989 (89.3)
95% confidence interval (CI). P-value of <0.05 was considered statisti­ 31–60 min 79 (7.1)
cally significant. Pearson pairwise correlation coefficient (r) between >60 min 19 (1.7)
variables was examined to address the potential collinearity of two After skin incision 20 (1.8)

variables. The statistical analysis was performed using PASW Statistics Data are presented as number (%), median (IQR).
for Windows, Version 18.0 (SPSS Inc., Chicago, IL, USA). ASA, American Society of Anesthesiologists.

2
Downloaded for Institut Latihan KKM (ilkkm@moh.gov.my) at Training Management Division Ministry of Health Malaysia from
ClinicalKey.com/nursing by Elsevier on June 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All
rights reserved.
 W. Maisat and K. Yuki
ClinicalKey.com/nursing by Elsevier on June 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All
Downloaded for Institut Latihan KKM (ilkkm@moh.gov.my) at Training Management Division Ministry of Health Malaysia from

Table 2
Detailed characteristics of patients who developed SSIs following spinal fusion surgery.
No Age Gender Type of Levels of spinal SSI onset SSI type Operative time Organism(s) Prophylactic Gentamycin Antibiotic-to- Skin prep
(yr) scoliosis fusion (POD) (min) antibiotic incision time (min) solution

1 14.9 F Neuromuscular T7 to pelvis 14 Deep incisional 301 1) Klebsiella oxytoca Cefazolin Y 13 Chloraprep™
2) Raoultella ornitholytica
2 17.0 M Neuromuscular T2 to S1 12 Deep incisional 664 1) Escherichia sp. Cefazolin N 18 Chloraprep™
2) Proteus
3 13.4 M Neuromuscular T3 to pelvis 40 Organ/Space 532 1) Staphylococcus aureus Cefazolin N 28 Betadine®
4 16.5 F Neuromuscular thoracic to lumbar 45 Deep incisional 666 1) E. coli Cefazolin Y 118 Betadine®
(unspecified) 2) Klebsiella pneumoniae
3) Bacteroides fragilis
5 15.8 M Neuromuscular T2 to L2 8 Deep incisional 428 1) Cutibacterium granulosum Clindamycin N 14 Chloraprep™
2) Cutibacterium acnes
3) Enterobacter cloacae complex
rights reserved.

sp. SCP12–74
6 14.6 F Neuromuscular T2 to pelvis 14 Superficial 523 1) Proteus mirabilis Cefazolin Y 20 Chloraprep™
3

incisional
7 16.8 F Idiopathic T3 to iliac 22 Deep incisional 566 1) Staphylococcus aureus Cefazolin Y 17 Chloraprep™
8 11.3 F Neuromuscular T2 to S1 12 Organ/Space 592 1) Staphylococcus aureus Vancomycin Y 73 Chloraprep™
2) Klebsiella pneumoniae
9 12.0 F Neuromuscular T4 to pelvis 9 Superficial 649 1) Bacteroides caccae Cefazolin N 25 Chloraprep™
incisional
10 17.5 F Idiopathic T11 to L4 23 Deep incisional 222 1) Streptococcus pyogenes Cefazolin N 0 Chloraprep™
2) Staphylococcus aureus

Perioperative Care and Operating Room Management 30 (2023) 100308

3) Serratia marcescens
11 10.6 M Neuromuscular T3 to pelvis 9 Deep incisional 575 1) Bacteroides caccae Cefazolin Y 43 Chloraprep™
2) Veillonella parvula
3) E. coli
12 12.3 M Neuromuscular T3 to pelvis 12 Deep incisional 402 1) E. coli Cefazolin Y 2 Chloraprep™
13 16.4 M Neuromuscular T2 to S5 15 Organ/Space 721 1) Pseudomonas aeruginosa Cefazolin Y − 55 Chloraprep™
2) Propionibacterium sp.
14 11.8 F Neuromuscular T1 to pelvis 21 Deep incisional 322 1) E. coli Cefazolin Y 30 Chloraprep™

POD, postoperative day number; SSI, surgical site incision.

W. Maisat and K. Yuki Perioperative Care and Operating Room Management 30 (2023) 100308

old. Most of the infected patients had neuromuscular scoliosis (n = 12, 4. Discussion
85.7%). The median onset of SSIs was 14 days after the surgery (range of
8 to 45 days). Deep incisional SSIs were the most frequent which In the context of an implementation of SSI prevention bundles and
accounted for 64.3% (n = 9) of the infections; followed by organ/space standardized perioperative antibiotic prophylaxis, the incidence of SSIs
and superficial incisional infections at 21.4% (n = 3) and 14.3% (n = 2), following pediatric spinal fusion surgery in our study was 1.3%. We
respectively. Polymicrobial infection was common, with the majority of identified lower body weight, ASA classification of ≥3, neuromuscular
organisms isolated being Gram-negative bacteria (18 out of 26). Staph­ scoliosis, prolonged operative and anesthesia times, administration of
ylococcus aureus (n = 4, 15.4%) and Escherichia coli (n = 4, 15.4%) were prophylactic antibiotic >60 min before skin incision, and use of
the most common organisms isolated from cultured specimens. Over povidone-iodine alone for skin preparation as potential risk factors for
80% of patients who developed SSI received cefazolin as the primary postoperative SSIs. Although there was no statistical significance, one
prophylactic antibiotic (n = 12, 85.6%), the others received clindamycin surgeon, with the least number of cases performed, demonstrated a
(n = 1, 7.2%) and vancomycin (n = 1, 7.2%). Gentamicin was admin­ distinctly high proportion of SSI incidence suggesting surgeon experi­
istered to 9 infected patients. Regarding the antibiotic timing, most of ence might affect the rate of SSI. To test variability, we need to have a
the patients received prophylactic antibiotic within 60 min prior to skin much higher case number in a future study.
incision (n = 11, 78.6%) except 2 patients and 1 patient whose antibi­ Although we did not compare the incidence of SSI before and after
otics were given longer than 60 min before skin incision and after skin the implementation of SSI prevention bundles at our institution, the SSI
incision, respectively. The distribution of the timing of antibiotic rate for pediatric spine fusion is remarkably lower than previously re­
administration relative to surgical incision between patients with and ported by others.5-10 Nevertheless, considering the potential risk factors
without SSI is presented in Fig. 1. All patients received intraoperative re- we have identified, there are still rooms for improvement to maintain as
dosing of antibiotic per institutional protocol. There was a total of 8 low SSI rate as possible.
surgical attendings and 63 anesthesia attendings involved in our cohort. Most current guidelines recommend the administration of prophy­
We did not include anesthesia attendings in the statistical analysis. lactic antibiotic within 60 min prior to the surgical incision for most
In the univariable analysis (Table 3), potential risk factors for SSIs antibiotic classes, and within 120 min for vancomycin and fluo­
included low body weight (OR 0.96, 95%CI 0.93–0.99, p = 0.026), ASA roquinolones.17-20 Our institutional guideline mandates the adminis­
classification of ≥3 (OR 24.53, 95%CI 3.20–188.22, p = 0.002), tration of prophylactic antibiotics (other than vancomycin and
neuromuscular scoliosis (OR 3.83, 95%CI 3.82–78.32, p<0.001), pro­ fluoroquinolones) within 60 min of the skin incision. However, the
longed operative time (OR 1.56, 95%CI 1.28–1.92, p<0.001), prolonged protocol of 60-minute interval was violated in some patients (n = 39,
anesthetic time (OR 1.65, 95%CI 1.35–2.00, p<0.001), administration 3.5%), and three of them belonged to the SSI group. Among the patients
of prophylactic antibiotic >60 min before skin incision (OR 11.52, 95% with SSI, three patients received prophylactic antibiotics inappropri­
CI 2.34–56.60, p = 0.003), and use of povidone-iodine alone for skin ately, either greater than 60 min (two patients) or after skin incision
preparation (OR 5.97, 95%CI 1.27–28.06, p = 0.024). There was a very (one patient). Additionally, the antibiotic was presumably administered
high correlation between operative time and anesthetic time (r = 0.96, at the time of skin incision (time zero) in one SSI patient. This finding
p<0.001). strongly emphasized the importance of appropriate antibiotic timing to
prevent SSI.
Positioning for spine surgery is one of the factors that likely hinders
the proper antibiotic timing. We generally administer prophylactic
antibiotic after general anesthetic induction is completed. When anti­
biotic was given >60 min before skin incision, the patient was still in a
supine position. As it usually takes some time to position the patient to
prone, it is reasonable to give the antibiotic after the patient is in a prone
position to minimize the antibiotic-to-skin incision window.
Cefazolin has a short half-life and exhibits time-dependent killing, in
which efficacy is optimized when drug concentration remains above the
minimum inhibitory concentration (MIC) of a bacterium for at least
40–50% of the dosing interval.23 Previous studies demonstrated
approximately 30% reduction of plasma cefazolin concentration by 60
min after the administration.24,25 These pharmacokinetics studies are
consistent with a clinical study of antimicrobial prophylaxis and SSI risk;
the authors reported that SSI risk was elevated as the interval between
antibiotic infusion and skin incision increased.26 Given a large reduction
in plasma cefazolin levels over time, the effective tissue drug concen­
tration may fall below a target level for common Gram-positive, and
particularly, Gram-negative pathogens that were prevalent among our
infected patients.27
Our study showed a higher proportion of polymicrobial and Gram-
negative infections compared with previously published literature.5,28
This finding likely represents the patient population of our cohort, with
the majority of the infected patients having neuromuscular scoliosis, a
group in whom polymicrobial and Gram-negative infections are more
frequent.8,29,30 The higher incidence of isolated Gram-negative bacteria
in these patients is the reason behind the recommendation for additional
antibiotic prophylaxis in high-risk pediatric populations. Although we
Fig. 1. The distribution of timing interval of antibiotic administration relative
to skin incision between the SSI and non-SSI groups. The horizontal lines were unable to extract high-risk cases due to the inconsistency of
indicate skin incision time (0-minute) and 60-minute before skin incision, the high-risk case database collection during the pandemic, patients with
recommended interval for prophylactic antibiotic administration and surgi­ ASA classification of ≥3 and/or neuromuscular scoliosis presumably
cal incision. represented high-risk candidates. Given that ASA classification of ≥3

4
Downloaded for Institut Latihan KKM (ilkkm@moh.gov.my) at Training Management Division Ministry of Health Malaysia from
ClinicalKey.com/nursing by Elsevier on June 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All
rights reserved.
W. Maisat and K. Yuki Perioperative Care and Operating Room Management 30 (2023) 100308

Table 3
Univariable analysis of risk factors for SSIs following spine fusion surgery.
Total (n = 1111) SSI Unadjusted OR (95%CI) p-value

Yes (n = 14) No (n = 1097)

Gender; female 752 (67.7) 7 (50.0) 745 (67.9) 0.47 (0.16,1.36) 0.16
Age (yr) 14.2 (12.5,15.8) 12.3 (11.5,16.7) 14.1 (12.5,15.6) 1.09 (0.88,1.35) 0.45
Body weight (kg) 52.8 (42.8,64.1) 38.1 (34.9,41.3) 53.1 (44.5,64.3) 0.96 (0.93,0.99) 0.026*
ASA ≥3 393 (35.4) 13 (92.9) 380 (34.6) 24.53 (3.20,188.22) 0.002*
Diagnosis
Idiopathic scoliosis 628 (56.5) 2 (14.3) 626 (57.1) 1.00 (reference)
Neuromuscular scoliosis 228 (20.5) 12 (85.7) 216 (19.7) 17.39 (3.86,78.32) <0.001*
Congenital scoliosis 105 (9.5) 0 (0.0) 105 (9.6) n/a n/a
Revision surgery 30 (2.7) 0 (0.0) 30 (2.7) n/a n/a
Surgeon n/a 0.72
1 126 (11.4) 1 (7.1) 125 (11.4)
2 189 (17.0) 2 (14.3) 187 (17.1)
3 54 (4.9) 5 (35.7) 49 (4.5)
4 92 (8.3) 1 (7.1) 91 (8.3)
5 347 (31.3) 1 (7.1) 346 (34.6)
6 150 (13.5) 1 (7.1) 149 (13.6)
7 65 (5.9) 1 (7.1) 64 (5.8)
8 86 (7.8) 2 (14.3) 84 (7.7)
Operative time (hr) 4.9 (3.6,6.7) 8.89 (5.9,10.7) 4.5 (3.4,6.3) 1.56 (1.28,1.92) <0.001*
Anesthetic time (hr) 6.1 (4.7,8.2) 12.0 (8.3,12.9) 6.1 (4.7,8.2) 1.65 (1.35,2.00) <0.001*
Type of antibiotic
Cefazolin 969 (87.2) 12 (85.8) 957 (87.2) 1.00 (reference)
Clindamycin 128 (11.5) 1 (7.1) 127 (11.6) 0.63 (0.08,4.89) 0.66
Vancomycin 12 (1.1) 1 (7.1) 11 (1.0) 7.25 (0.87,60.7) 0.07
Ceftriaxone 1 (0.1) 0 (0.0) 1 (0.1) n/a n/a
Linezolid 1 (0.1) 0 (0.0) 1 (0.1) n/a n/a
Non-cefazolin antibiotic 142 (12.8) 2 (14.3) 140 (12.8) 1.14 (0.25,5.14) 0.87
Antibiotic timing
After skin incision 20 (1.8) 1 (7.1) 19 (1.7) 5.15 (0.63,42.30) 0.13
0–30 min 989 (89.3) 10 (71.4) 979 (89.6) 1.00 (reference)
31–60 min 79 (7.1) 1 (7.1) 78 (7.1) 1.26 (0.16,9.93) 0.83
>60 min 19 (1.7) 2 (14.3) 17 (1.6) 11.52 (2.34,56.60) 0.003*
Skin preparation agent
ChloraPrep™ 944 (95.9) 12 (85.7) 932 (96.1) 1.00 (reference)
Betadine® 28 (2.8) 2 (14.3) 26 (2.7) 5.97 (1.27,28.06) 0.024*
Others 12 (1.2) 0 (0.0) 12 (1.2) n/a n/a
Average temperature ( ◦ C) 36.2 (35.8,36.6) 36.4 (35.7,36.6) 36.2 (35.8,36.6) 1.53 (0.62,3.80) 0.36
Dexamethasone use 725 (65.3) 10 (71.4) 715 (65.2) 1.34 (0.42,4.29) 0.63
Inotrope/vasopressor infusion 577 (81.4) 8 (80.6) 569 (81.4) 0.91 (0.19,4.35) 0.91
PRBC transfusion 144 (13.0) 2 (14.3) 142 (12.9) 1.12 (0.25,5.06) 0.88
Cell saver transfusion 659 (59.3) 8 (57.1) 651 (59.3) 0.91 (0.32,2.65) 0.87

Data are presented as number (%), median (IQR).

ASA, American Society of Anesthesiologists; PRBC, packed red blood cell.

and neuromuscular scoliosis are risk factors for SSI, it is noticeable that preparation, line access, positioning from supine to prone, and radio­
the rate of gentamicin administration was lower than the number of graphic imaging. The prolonged duration of anesthesia indicates longer
these presumed high-risk patients. Additionally, gentamicin was not anesthetics exposure; most of our patients were maintained with volatile
administered in some of the infected patients who had neuromuscular anesthetics that may predispose them to infections due to the immu­
scoliosis. This possibly highlights the necessity of Gram-negative bac­ nosuppressive effects of volatile anesthetics as previously described.36,37
terial coverage in high-risk populations. Decontamination of the skin with antiseptic prior to skin incision is
Prolonged operative time usually involves surgical complexity and one of the standard measures to prevent SSI. We found that the use of
significant blood loss. The longer the skin is exposed, the higher the risk povidone-iodine alone was a potential risk for SSI. Povidone-iodine may
of developing wound infection as skin flora gain access during surgery not be suitable for spine surgery as it has only two-hour duration of
while the incision is open.31,32 Even a small number of bacteria can action, in contrary to chlorhexidine-based solutions that could be
cause infection in the presence of a prosthesis.33 Appropriate choice, effective for as long as 48 h.38 Another disadvantage for povidone-iodine
timing, and re-dosing of prophylactic antibiotic is essential to prevent is that transcutaneous iodine absorption may result in iatrogenic hy­
SSI in this context. However, a standard re-dosing interval may not be perthyroid or hypothyroidism in pediatric population.39 Our hospital
effective in the presence of excessive blood loss. In adults, it is recom­ policy has recently changed to omit the use of povidone-iodine alone
mended that an additional dose of cefazolin should be administered and require an alcohol-based skin preparation agent unless the patient is
when the blood loss is greater than 1500 mL,19,34 despite that, the allergic to alcohol or has abundant hair.
threshold for pediatric patients has not yet been established. Significant Overweight or obesity, not low body weight, is more likely a risk
intraoperative blood loss and fluid replacement also result in plasma and factor for SSI according to the previous study.7 The caveats are possibly
tissue gentamicin concentrations lower than MIC for Gram-negative owing to that we enrolled all pediatric patients regardless of age, and
bacteria.35 We also identified prolonged anesthetic time as another that we did not standardize body weight with age-related percentile
risk factor for SSI. Given that the duration of anesthesia is substantially which might interfere with the validity of the result interpretation.
correlated with the duration of surgery, it is difficult to determine sta­ Nevertheless, low body weight may indicate poor nutritional status
tistically which factors are more likely to be associated with SSI risk. and/or significant comorbidities, suggesting preoperative nutritional
Besides operative time, anesthetic time typically involves patient supplementation should be important.

5
Downloaded for Institut Latihan KKM (ilkkm@moh.gov.my) at Training Management Division Ministry of Health Malaysia from
ClinicalKey.com/nursing by Elsevier on June 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All
rights reserved.
W. Maisat and K. Yuki Perioperative Care and Operating Room Management 30 (2023) 100308

Despite our institution being a large referral center for pediatric spine deformity. Pediatr Infect Dis J. 2016;35(1):66–70. https://doi.org/10.1097/
inf.0000000000000925.
spine surgery with a large number of high-risk cases, the SSI rate is still
9 Piantoni L, Tello CA, Remondino RG, et al. Antibiotic prophylaxis in high-risk
relatively low, likely demonstrating the effectiveness of our SSI pre­ pediatric spine surgery: is cefazolin enough? Spine Deform. 2020;8(4):669–676.
vention bundle in place during the study period. The small number of https://doi.org/10.1007/s43390-020-00092-7.
SSI in our study limits the power to perform a multivariable analysis. 10 Warner SJ, Uppstrom TJ, Miller AO, et al. Epidemiology of deep surgical site
infections after pediatric spinal fusion surgery. Spine (Phila Pa 1976). 2017;42(3):
Additionally, our patient cohort may not be representative of other in­ E163–e168. https://doi.org/10.1097/brs.0000000000001735.
stitutions. Another potential limitation is overall SSI bundle reliability 11 Mackenzie WG, Matsumoto H, Williams BA, et al. Surgical site infection following
for each surgery. During this time overall bundle reliability (that is, spinal instrumentation for scoliosis: a multicenter analysis of rates, risk factors, and
pathogens. J Bone Joint Surg Am. 2013;95(9):800–806. https://doi.org/10.2106/jbjs.
compliance with all elements of the bundle) has ranged from 64% to L.00010. s1-2.
87%. Gaps in compliance with other elements of the bundle (such as lack 12 Murphy NA, Firth S, Jorgensen T, Young PC. Spinal surgery in children with
of preoperative bathing or utilizing povidone-iodine alone as a skin idiopathic and neuromuscular scoliosis. What’s the difference? J Pediatr Orthop.
2006;26(2):216–220. https://doi.org/10.1097/01.bpo.0000206516.61706.6e.
preparation prior to incision) could have increased the risk of SSI for 13 Subramanyam R, Schaffzin J, Cudilo EM, Rao MB, Varughese AM. Systematic review
individual patients, and we did not account for these factors in the of risk factors for surgical site infection in pediatric scoliosis surgery. Spine J. 2015;
analysis. This study is also limited by its retrospective nature. 15(6):1422–1431. https://doi.org/10.1016/j.spinee.2015.03.005.
14 Master DL, Poe-Kochert C, Son-Hing J, Armstrong DG, Thompson GH. Wound
infections after surgery for neuromuscular scoliosis: risk factors and treatment
5. Conclusions outcomes. Spine (Phila Pa 1976). 2011;36(3):E179–E185. https://doi.org/10.1097/
BRS.0b013e3181db7afe.
15 Milstone AM, Maragakis LL, Townsend T, et al. Timing of preoperative antibiotic
In the context of a standard SSI prevention bundle including anti­
prophylaxis: a modifiable risk factor for deep surgical site infections after pediatric
biotic prophylaxis, we demonstrated a relatively low incidence of SSI spinal fusion. Pediatr Infect Dis J. 2008;27(8):704–708. https://doi.org/10.1097/
following pediatric spinal fusion surgery. Administration of prophylactic INF.0b013e31816fca72.
antibiotic within 60 min of skin incision, strict adherence to high-risk 16 Vitale MG, Riedel MD, Glotzbecker MP, et al. Building consensus: development of a
Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk
protocol, and use of CHG-alcohol could potentially reduce the rate of pediatric spine surgery. J Pediatr Orthop. 2013;33(5):471–478. https://doi.org/
SSI. However, larger prospective studies are needed to validate this 10.1097/BPO.0b013e3182840de2.
finding before existing SSI prevention guidelines are modified. 17 Allegranzi B, Bischoff P, de Jonge S, et al. New WHO recommendations on
preoperative measures for surgical site infection prevention: an evidence-based
global perspective. Lancet Infect Dis. 2016;16(12):e276–e287. https://doi.org/
Funding 10.1016/s1473-3099(16)30398-x.
18 WHO Guidelines Approved by the Guidelines Review Committee. Global Guidelines
for the Prevention of Surgical Site Infection. World Health Organization; 2018.
This study was in part supported by Data Engineering Quality & 19 Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for
Outcomes Research Award (W.M.) and NIH R01GM127600 (K.Y.) antimicrobial prophylaxis in surgery. Surg Infect (Larchmt). 2013;14(1):73–156.
https://doi.org/10.1089/sur.2013.9999.
20 Anderson DJ, Podgorny K, Berríos-Torres SI, et al. Strategies to prevent surgical site
CRediT authorship contribution statement infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35
(2):S66–S88. https://doi.org/10.1017/s0899823x00193869. Suppl.
Wiriya Maisat: Methodology, Formal analysis, Investigation, 21 Glotzbecker M, Troy M, Miller P, et al. Implementing a multidisciplinary clinical
pathway can reduce the deep surgical site infection rate after posterior spinal fusion
Writing – original draft. Koichi Yuki: Conceptualization, Methodology,
in high-risk patients. Spine Deform. 2019;7(1):33–39. https://doi.org/10.1016/j.
Writing – review & editing, Supervision. jspd.2018.06.010.
22 Centers for Disease Control and Prevention. Surgical Site Infection Event (SSI); 2019.
Accessed January 2022 https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.
Declaration of Competing Interest
pdf.
23 DeRyke CA, Lee SY, Kuti JL, Nicolau DP. Optimising dosing strategies of
None. antibacterials utilising pharmacodynamic principles: impact on the development of
resistance. Drugs. 2006;66(1):1–14. https://doi.org/10.2165/00003495-200666010-
00001.
Acknowledgments 24 Lapmahapaisan S, Maisat W, Tantiwongkosri K, Jutasompakorn P, Sisan W. Plasma
concentrations of cefazolin in pediatric patients undergoing cardiac surgery. Ann
Drs. Gregory Priebe and Thomas Sandra (Boston Children’s Hospital) Card Anaesth. 2021;24(2):149–154. https://doi.org/10.4103/aca.ACA_106_19.
25 Haessler D, Reverdy ME, Neidecker J, Brûlé P, Ninet J, Lehot JJ. Antibiotic
for valuable discussion and comments. prophylaxis with cefazolin and gentamicin in cardiac surgery for children less than
ten kilograms. J Cardiothorac Vasc Anesth. 2003;17(2):221–225. https://doi.org/
References 10.1053/jcan.2003.51.
26 Steinberg JP, Braun BI, Hellinger WC, et al. Timing of antimicrobial prophylaxis and
the risk of surgical site infections: results from the trial to reduce antimicrobial
1 Shepard J, Frederick J, Wong F, Madison S, Tompkins L, Hadhazy E. Could the
prophylaxis errors. Ann Surg. 2009;250(1):10–16. https://doi.org/10.1097/
prevention of health care-associated infections increase hospital cost? The financial
SLA.0b013e3181ad5fca.
impact of health care-associated infections from a hospital management perspective.
27 Himebauch AS, Sankar WN, Flynn JM, et al. Skeletal muscle and plasma
Am J Infect Control. 2020;48(3):255–260. https://doi.org/10.1016/j.
concentrations of cefazolin during complex paediatric spinal surgery. Br J Anaesth.
ajic.2019.08.035.
2016;117(1):87–94. https://doi.org/10.1093/bja/aew032.
2 Shepard J, Ward W, Milstone A, et al. Financial impact of surgical site infections on
28 Fang A, Hu SS, Endres N, Bradford DS. Risk factors for infection after spinal surgery.
hospitals: the hospital management perspective. JAMA Surg. 2013;148(10):907–914.
Spine (Phila Pa 1976). 2005;30(12):1460–1465. https://doi.org/10.1097/01.
https://doi.org/10.1001/jamasurg.2013.2246.
brs.0000166532.58227.4f.
3 Bruny JL, Hall BL, Barnhart DC, et al. American college of surgeons national surgical
29 Sponseller PD, LaPorte DM, Hungerford MW, Eck K, Bridwell KH, Lenke LG. Deep
quality improvement program pediatric: a beta phase report. J Pediatr Surg. 2013;48
wound infections after neuromuscular scoliosis surgery: a multicenter study of risk
(1):74–80. https://doi.org/10.1016/j.jpedsurg.2012.10.019.
factors and treatment outcomes. Spine (Phila Pa 1976). 2000;25(19):2461–2466.
4 Viqueira AQ, Caravaca GR, Quesada Rubio JA, Francés VS. Surgical site infection
https://doi.org/10.1097/00007632-200010010-00007.
rates and risk factors in orthopedic pediatric patients in Madrid, Spain. Pediatr Infect
30 Szöke G, Lipton G, Miller F, Dabney K. Wound infection after spinal fusion in
Dis J. 2014;33(7):693–696. https://doi.org/10.1097/inf.0000000000000232.
children with cerebral palsy. J Pediatr Orthop. 1998;18(6):727–733.
5 Cahill PJ, Warnick DE, Lee MJ, et al. Infection after spinal fusion for pediatric spinal
31 McLeod LM, Keren R, Gerber J, et al. Perioperative antibiotic use for spinal surgery
deformity: thirty years of experience at a single institution. Spine (Phila Pa 1976).
procedures in US children’s hospitals. Spine (Phila Pa 1976). 2013;38(7):609–616.
2010;35(12):1211–1217. https://doi.org/10.1097/BRS.0b013e3181c212d1.
https://doi.org/10.1097/BRS.0b013e318289b690.
6 Labbé AC, Demers AM, Rodrigues R, Arlet V, Tanguay K, Moore DL. Surgical-site
32 Rihn JA, Lee JY, Ward WT. Infection after the surgical treatment of adolescent
infection following spinal fusion: a case-control study in a children’s hospital. Infect
idiopathic scoliosis: evaluation of the diagnosis, treatment, and impact on clinical
Control Hosp Epidemiol. 2003;24(8):591–595. https://doi.org/10.1086/502259.
outcomes. Spine (Phila Pa 1976). 2008;33(3):289–294. https://doi.org/10.1097/
7 Linam WM, Margolis PA, Staat MA, et al. Risk factors associated with surgical site
BRS.0b013e318162016e.
infection after pediatric posterior spinal fusion procedure. Infect Control Hosp
33 Sartelli M, Coccolini F, Carrieri A, Labricciosa FM, Cicuttin E, Catena F. The
Epidemiol. 2009;30(2):109–116. https://doi.org/10.1086/593952.
"torment" of surgical antibiotic prophylaxis among surgeons. Antibiotics (Basel).
8 Maesani M, Doit C, Lorrot M, et al. Surgical site infections in pediatric spine surgery:
2021;10(11). https://doi.org/10.3390/antibiotics10111357.
comparative microbiology of patients with idiopathic and nonidiopathic etiologies of

6
Downloaded for Institut Latihan KKM (ilkkm@moh.gov.my) at Training Management Division Ministry of Health Malaysia from
ClinicalKey.com/nursing by Elsevier on June 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All
rights reserved.
W. Maisat and K. Yuki Perioperative Care and Operating Room Management 30 (2023) 100308

34 Swoboda SM, Merz C, Kostuik J, Trentler B, Lipsett PA. Does intraoperative blood 37 Stollings LM, Jia LJ, Tang P, Dou H, Lu B, Xu Y. Immune modulation by volatile
loss affect antibiotic serum and tissue concentrations? Arch Surg. 1996;131(11): anesthetics. Anesthesiology. 2016;125(2):399–411. https://doi.org/10.1097/
1165–1171. https://doi.org/10.1001/archsurg.1996.01430230047009. discussion aln.0000000000001195. Aug.
1171-2. 38 Letzelter J, Hill JB, Hacquebord J. An overview of skin antiseptics used in
35 Markantonis SL, Kostopanagiotou G, Panidis D, Smirniotis V, Voros D. Effects of orthopaedic surgery procedures. J Am Acad Orthop Surg. 2019;27(16):599–606.
blood loss and fluid volume replacement on serum and tissue gentamicin https://doi.org/10.5435/jaaos-d-18-00105.
concentrations during colorectal surgery. Clin Ther. 2004;26(2):271–281. https:// 39 Dockery DM, Allu S, Vishwanath N, et al. Review of pre-operative skin preparation
doi.org/10.1016/s0149-2918(04)90025-2. options based on surgical site in orthopedic surgery. Surg Infect (Larchmt). 2021;22
36 Yuki K, Eckenhoff RG. Mechanisms of the immunological effects of volatile (10):1004–1013. https://doi.org/10.1089/sur.2021.085.
anesthetics: a review. Anesth Analg. 2016;123(2):326–335. https://doi.org/10.1213/
ane.0000000000001403. Aug.

7
Downloaded for Institut Latihan KKM (ilkkm@moh.gov.my) at Training Management Division Ministry of Health Malaysia from
ClinicalKey.com/nursing by Elsevier on June 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All
rights reserved.