Introduction

Surgical site infection (SSI) – wound infection that occurs within 30 days post-surgery is a severe complication after spinal surgery. SSI occurs in 1-3% of surgical cases and is preventable. SSIs deleteriously impact healing and the course of treatment. Additionally, SSIs are associated with high morbidity and mortality.

Known risk factors for SSI are tobacco use, the patient’s body mass index (BMI), and diabetes status. Both, Gram positive and Gram negative can cause SSIs; most etiological pathogens are multi-resistant to the commonly prescribed prophylactic antibiotics. Aging, renal disease, osteoporosis, blood transfusions, greater estimated blood loss (EBL), longer operative time (OT), prolonged length of hospital stay (LOS), cerebrospinal fluid leak, history of surgery at the same site, and posterior approach surgery also heighten the risk for SSI after spinal surgeries.^1,2

Case Report

A 57-year-old obese male underwent an elective posterior lumbar spine instrumentation. 

The patient was a chronic diabetic – controlled on medication. He was also on oral atenolol 25 mg for hypertension. The patient had been a chronic smoker, but had quit tobacco use nearly five years prior; his BMI was 32.

As a preventive measure against infection, the surgical site was irrigated with a 10% povidone-iodine (PVP-I) solution during the procedure and before arthrodesis and closure. This intervention successfully prevented the occurrence of SSI in this patient.

Discussion

PVP-I irrigation has been safely used as prophylaxis against SSIs in almost all surgical procedures, such as dermatological, orthopedic, gastrointestinal, as well as those involving traumatic soft tissue wounds.^1,2,3,4 

PVP-I use is also beneficial for burn wounds owing to its excellent antibacterial properties. PVP-I irrigation is efficacious for antisepsis during surgical debridement of superficial and deep burns. It is also used in cases requiring procedures involving the placement of temporary xenograft or definitive autograft. Furthermore, PVP-I is well tolerated and poses a very low risk for allergic reactions or serious adverse effects.³ 

The Centers for Disease Control and Prevention (CDC) guidelines recommend appropriate patient preparation, asepsis, and attention to surgical technique. PVP-I asepsis is highly effective in preventing SSIs and is widely practiced. In certain specific scenarios, antibiotic prophylaxis can also be advised.⁵

Evidence from a recent retrospective observational study suggests that pooling of 1% PVP-I for 90 seconds – at 90-minute intervals, can prevent the occurrence of deep surgical site infection post spinal surgery.⁶

Conclusion

Wound irrigation with PVP-I solution is an effective measure for preventing SSI after elective spinal surgeries. Particularly, in patients with risk factors for SSI, this approach is highly recommended to avoid post-surgical complications and to reduce SSI-associated morbidity and mortality. Furthermore, PVP-I use does not impact bone fusion, and this prophylactic modality can be safely applied in orthopedic procedures. 

References

1. Alkaaki A, Al-Radi OO, Khoja A, et al. Surgical site infection following abdominal surgery: a prospective cohort study. Can J Surg. 2019;62(2):111-117. doi:10.1503/cjs.004818
2. Carballo Cuello CM, Fernández-de Thomas RJ, De Jesus O, De Jesús Espinosa A, Pastrana EA. Prevention of Surgical Site Infection in Lumbar Instrumented Fusion Using a Sterile Povidone-Iodine Solution. World Neurosurg. 2021;151:e700-e706. doi:10.1016/j.wneu.2021.04.094
3. Juhász I. Experiences with the use of povidone-iodine-containing local therapeutics in dermatological surgery and in the treatment of burns: testing for allergic sensitization in postsurgery patients. Dermatology. 2002;204 Suppl 1:52-58. doi:10.1159/000057726
4. Roth B, Neuenschwander R, Brill F, et al. Effect of antiseptic irrigation on infection rates of traumatic soft tissue wounds: a longitudinal cohort study. J Wound Care. 2017;26(3):79-87. doi:10.12968/jowc.2017.26.3.79
5. Owens CD, Stoessel K. Surgical site infections: epidemiology, microbiology and prevention. J Hosp Infect. 2008;70 Suppl 2:3-10. doi:10.1016/S0195-6701(08)60017-1
6. Onishi Y, Masuda K, Tozawa K, Karita T. Outcomes of an Intraoperative Povidone-Iodine Irrigation Protocol in Spinal Surgery for Surgical Site Infection Prevention. Clin Spine Surg. 2019;32(10):E449-E452. doi:10.1097/BSD.0000000000000908