Infections in the operated spine: Update on risk management and therapeutic strategies

Abstract

Level V.

Variables associated with remission in spinal surgical site infections

“…We think that none knows the ideal duration of intravenous or total antibiotic therapy, which moreover might be patient or pathogen-dependent. Most author groups report a minimum length of parenteral antibiotic courses of 4-6 weeks and a total duration up to three months (3,(6)(7)(8)(9)15,17,21), although some authors only recommend 2 weeks of parental therapy (9,29) or even only 2-3 days (16), without further compromising the success when compared to the literature. To cite examples, Clark and Shufflebarger treated delayed infections with surgery and 48-72 hours of parenteral antibiotics followed by ten days of targeted oral antibiotics.…”

“…We personally think that, as long as oral antibiotics are used with good bioavailability and bone tissue diffusion (9,32), the antimicrobial treatment can theoretically be oral from the start in absence of bacteraemia or hemodynamically significant sepsis, and should not last more than 6 weeks for infected bone or disc. Glassman et al successfully treated two patients with spinal SSI with oral ciprofloxacin from the start, an antibiotic with excellent oral bioavailability and bone penetration (17).…”

“…Most publications or experts recommend a minimum length of intravenous antibiotic courses of 4-6 weeks, often followed by prolonged oral antimicrobial regimens (3,(6)(7)(8)(9), or they do not pronounce on detailed antibiotic modalities at all (10)(11)(12). Most of these recommendations are reviews and lack own data (6)(7)(8)(9). Any benefits of long-term antibiotic use remain to be determined (3).…”

Use of PET/CT in the early diagnosis of implant related wound infection and avoidance of wound debridement

“…Establishment of diagnosis thus is typically delayed until the infection has spread along the instrumentation with apparent clinical manifestations such as a fluctuant mass, spontaneous drainage, or radiological loosening of the instrumentation [7]. Traditionally, late infections are treated aggressively with extensive wound debridement and prolonged courses of antibiotics [7][8][9], and ultimately implant removal. This is devastating, particularly when a solid spine fusion has not yet been achieved.…”

“…Conventional imaging modalities, such as plain radiographs and computed tomography (CT), have limited value for an early diagnosis of late infection when structural changes of bone or soft tissues have yet to occur [11]. Magnetic resonance (MR) imaging may be another choice but its accuracy is substantially influenced by the metallic artifacts [8].…”