Analysis of a ten step protocol to decrease postoperative spinal wound infections

AIM: To define a ten-step protocol that reduced the incidence of surgical site infection in the spine surgery practice of the senior author and evaluate the support for each step based on current literature. METHODS: In response to unexplained increased infection rates at our institution following spine surgery, a ten-step protocol was implemented: (1) preoperative glycemic management based on hemoglobin A1c (HbA1c); (2) skin site preoperative preparation with 2% chlorhexidine gluconate disposable cloths; (3) limit operating room traffic; (4) cut the number of personnel in the room to the minimum required; (5) absolutely no flash sterilization of equipment; (6) double-gloving with frequent changing of outer gloves; (7) local application of vancomycin powder; (8) re-dosing antibiotic every 4 h for prolonged procedures and extending postoperative coverage to 72 h for high-risk patients; (9) irrigation of subcutaneous tissue with diluted povidone-iodine solution after deep fascial closure; and (10) use of DuraPrep skin preparation at the end of a case before skin closure. Through an extensive literature review, the current data available for each of the ten steps was evaluated. RESULTS: Use of vancomycin powder in surgical wounds, routine irrigation of surgical site, and frequent changing of surgical gloves are strongly supported by the literature. Preoperative skin preparation with chlorhexidine wipes is similarly supported. The majority of current literature supports control of HbA1c preoperatively to reduce risk of infection. Limiting the use of flash sterilization is supported, but has not been evaluated in spine-specific surgery. Limiting OR traffic and number of personnel in the OR are supported although without level 1 evidence. Prolonged use of antibiotics postoperatively is not supported by the literature. Intraoperative use of DuraPrep prior to skin closure is not yet explored. CONCLUSION: The ten-step protocol defined herein has significantly helped in decreasing surgical site infection rate. Several of the steps have already been shown in the literature to have significant effect on infection rates. As several measures are required to prevent infection, instituting a standard protocol for all the described steps appears beneficial.