Antibiotic Prophylaxis In Spine Surgery
Publication Date: June 20, 2016
Last Updated: March 14, 2022
Recommendations
Efficacy
Preoperative prophylactic antibiotics are suggested to decrease infection rates in patients undergoing spine surgery. (B: Suggested)
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For a typical uncomplicated lumbar laminotomy and discectomy, a single preoperative dose of antibiotics is suggested to decrease the risk of infection and/or discitis. (B: Suggested)
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Prophylactic antibiotics are suggested to decrease the rate of spinal infections after uninstrumented lumbar spinal surgery. (B: Suggested)
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Prophylactic antibiotics may be considered to decrease the rate of infections after instrumented spine fusion. (C: Optional)
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Despite appropriate prophylaxis, the rate of surgical site infections in spine surgery is 0.7% to 10%. The expected rate for patients without comorbidities ranges from 0.7% to 4.3% and for patients with comorbidities ranges from 2.0% to 10%. Current best practice with antibiotic protocols has failed to eliminate (reach an infection rate of 0.0%) surgical site infections.
(Work Group Consensus Statement)
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Despite appropriate prophylaxis, diabetes carries an increased infection rate compared with nondiabetic patients. (, Level III)
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There is insufficient evidence to make a statement regarding the impact of obesity on the rate of surgical site infection in prophylaxed patients. (Insufficient)
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Protocol
Preoperative antibiotic prophylaxis is suggested to decrease infection rates in patients undergoing spine surgery. In typical uncomplicated spinal procedures, the superiority of one agent, dose, or route of administration over any other has not been clearly demonstrated. When determining the appropriate drug choice, the patient’s risk factors, allergies, length and complexity of the procedure, and issues of antibiotic resistance should be considered. (B: Suggested)
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In typical uncomplicated spinal procedures, a single dose of preoperative prophylactic antibiotics with intraoperative redosing as needed is suggested. (B: Suggested)
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In patients with comorbidities or for those undergoing complicated spine surgery, alternative prophylactic regimens, including redosing, gram-negative coverage, or the addition of intrawound application of vancomycin or gentamicin, are suggested to decrease the incidence of surgical site infections compared with standard prophylaxis regimens. (, )
(Work Group Consensus Statement)
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Preoperative antibiotic prophylaxis is suggested to decrease infection rates in patients undergoing spine surgery without spinal implants. In these typical uncomplicated spinal procedures, the superiority of one agent, dose, or route of administration over any other has not been clearly demonstrated. When determining the appropriate drug choice, the patient’s risk factors, allergies, length and complexity of the procedure, and issues of antibiotic resistance should be considered. (B: Suggested)
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In typical uncomplicated open spine surgery without spinal implants, a single dose of preoperative prophylactic antibiotics with intraoperative redosing as needed is suggested. (B: Suggested)
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Preoperative antibiotic prophylaxis is suggested to decrease infection rates in patients undergoing spine surgery with spinal implants. In these complex spinal procedures, the superiority of one agent, dose, or route of administration over any other has not been clearly demonstrated. When determining the appropriate drug choice, the patient’s risk factors, allergies, length and complexity of the procedure, and issues of antibiotic resistance should be considered. (B: Suggested)
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In patients with risk factors for polymicrobial infection, appropriate broad-spectrum antibiotics are suggested to decrease the risk of infection when instrumented fusion is performed. (, )
(Work Group Consensus Statement)
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Simple uncomplicated spine surgery (without instrumentation or comorbidities): one single preoperative dose of antibiotic of choice with intraoperative redosing as needed. (, )
(Work Group Consensus Statement)
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Instrumented spine surgery, prolonged procedures, comorbidities (eg, diabetes, neuromuscular disease, cord injury, or general spine trauma): one single preoperative dose of antibiotic of choice plus consideration of additional gram-negative coverage and/or the application of intrawound vancomycin or gentamicin. (, )
(Work Group Consensus Statement)
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Redosing
Intraoperative redosing within 3 to 4 hours may be considered to maintain therapeutic antibiotic levels throughout the procedure. The superiority of one drug has not been demonstrated in the literature. When determining the appropriate drug choice, the patient’s risk factors, allergies, length and complexity of the procedure, and issues of antibiotic resistance should be considered. (, )
(Work Group Consensus Statement)
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Discontinuation
For typical uncomplicated cases, a single dose of preoperative prophylactic antibiotics with intraoperative redosing as needed is suggested to decrease the risk of surgical site infection. (B: Suggested)
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Prolonged postoperative regimens may be considered in complex situations (ie, trauma, cord injury, neuromuscular disease, diabetes, or other comorbidities). Comorbidities and complex situations reviewed in the literature include obesity, diabetes, neurologic deficits, incontinence, preoperative serum glucose level of O125 mg/dL or a postoperative serum glucose level ofO200 mg/dL, trauma, prolonged multilevel instrumented surgery, and other comorbidities. (C: Optional)
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Wound drains
A comprehensive review of the literature did not yield evidence to address the question related to the effect on postoperative infection rates of the duration of prophylaxis in the presence of a wound drain. There is insufficient evidence to make a recommendation for or against the early discontinuation of antibiotic prophylaxis in patients with wound drains. (Insufficient)
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The use of drains is not recommended as a means to reduce infection rates after single-level surgical procedures. (Insufficient)
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Body habitus
Obese patients are at higher risk for postoperative infection, when given a standardized dose of antibiotic prophylaxis. In spite of this conclusion, there is insufficient evidence to make a recommendation for or against recommending a different protocol for patients based on body habitus. (Insufficient)
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Comorbidities
In patients with comorbidities or for those undergoing complicated spine surgery, alternative prophylactic regimens are suggested to decrease the incidence of surgical site infections compared with standard prophylaxis regimens. (, )
(Work Group Consensus Statement)
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There is insufficient evidence to make a recommendation for or against the specific alternative regimens that are efficacious. However, promising alternative regimens that have been studied include redosing, gram-negative coverage, and the addition of intrawound application of vancomycin or gentamicin. (Insufficient)
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Although no literature was available to address this specific question about patients with a history of Methicillinresistant Staphylococcus aureus (MRSA), the search did identify studies that addressed prophylaxis to reduce infections with MRSA. There is insufficient evidence to make a recommendation for or against the prophylactic use of vancomycin compared with other antimicrobial agents to reduce infections with MRSA. (Insufficient)
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Complications
Reported isolated complications related to prophylactic antibiotics include flushing, hypotension, rashes, intramembranous colitis and, most seriously, Stevens-Johnson Syndrome. (, )
(Work Group Consensus Statement)
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In typical uncomplicated spinal procedures, a single dose of preoperative prophylactic antibiotics with intraoperative redosing as needed is suggested to reduce the risk of complications/adverse events. Reported isolated complications/adverse events related to prophylactic antibiotics are discussed in the previous section and include flushing, hypotension, rashes, intramembranous colitis and, most seriously, Stevens-Johnson Syndrome. (, )
(Work Group Consensus Statement)
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Recommendation Grading
Overview
Title
Antibiotic Prophylaxis In Spine Surgery
Authoring Organization
North American Spine Society
Publication Month/Year
June 20, 2016
Last Updated Month/Year
June 1, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Operating and recovery room
Intended Users
Chiropractor, nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Management, Treatment
Diseases/Conditions (MeSH)
D019072 - Antibiotic Prophylaxis
Keywords
Antibiotic prophylaxis, spine surgery, surgical site infection