r e v b r a s o r t o p . 2016;51(3):333–336
SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Original
Article
Postoperative
comparison
of
the
results
from
use
of
antibiotic
prophylaxis
for
one
and
five
days
among
patients
undergoing
lumbar
arthrodesis
夽
Charbel
Jacob
Júnior
∗,
André
Camatta
de
Assis,
Romulo
Guerra
Guimarães,
Igor
Machado
Barbosa,
José
Lucas
Batista
Júnior
HospitalSantaCasadeMisericórdiadeVitória,Vitória,ES,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received25March2015 Accepted18August2015 Availableonline2May2016
Keywords:
Antibioticprophylaxis Spinalsurgery Cephalosporins
a
b
s
t
r
a
c
t
Objective:Tocomparethepostoperativeresultsfromuseofantibioticprophylaxisforone andfivedaysamongpatientsundergoinglumbararthrodesisatuptothreelevels.
Methods:Forty-threepatientswhoallunderwentlumbararthrodesisduetodegenerative discdiseaseatone,twoorthreelevelswereevaluated.Theyweredividedrandomlyinto twogroups:onereceivedantibioticprophylaxiswithcefalotin(1g)andtheotherreceived thesameantibioticforfivedays.Afterthesurgicalintervention,thepatientswereevaluated atthetimeofhospitaldischarge,atthefirstreturntotheclinic(twoweekslater)and90 daysafterthedateofthesurgerywiththesurgicalwound,withclinicalexaminationofthe surgicalwoundandlaboratorytestsonbothgroups.
Results:Itwasobservedthatamongthepatientsinthegroupwithonedayofantibiotic prophylaxis,28.6%presentedcomplicationsinthesurgicalwound,whileinthegroupwith fivedays,27.9%presentedcomplications.
Conclusion: Thisstudydemonstratesthatasingledoseofantibioticprophylaxisisas effec-tiveasaregimenofmultipledosesinlumbararthrodesissurgeryatuptothreelevels.Thus, thecostsandrisksofsubjectingpatientstohospitalizationunderaprolongeddrugregimen areunjustifiable.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
夽
StudyconductedattheSpineGroup,HospitalSantaCasadeMisericórdiadeVitória,Vitória,ES,Brazil.
∗ Correspondingauthor.
E-mail:[email protected](C.JacobJúnior).
http://dx.doi.org/10.1016/j.rboe.2016.04.006
334
rev bras ortop.2016;51(3):333–336Comparac¸ão
pós-operatória
dos
resultados
do
uso
de
antibioticoprofilaxia
por
um
e
cinco
dias
em
pacientes
submetidos
à
artrodese
lombar
Palavras-chave:
Antibioticoprofilaxia Cirurgiacolunavertebral Cefalosporinas
r
e
s
u
m
o
Objetivo: Compararosresultadospós-operatóriosdousodaantibioticoprofilaxiaporume cincodiasnospacientessubmetidosàartrodeselombardeatétrêsníveis.
Métodos: Foramavaliados43 pacientes,todossubmetidos àartrodeselombar devidoà doenc¸adegenerativadiscalcomum,doisoutrêsníveis.Divididosdeformarandomizada emdoisgrupos,umgruporecebeuantibioticoprofilaxiacomcefalotina1geooutrogrupo recebeuomesmoantibióticoporcincodias.Apósaintervenc¸ãocirúrgica,fez-seaavaliac¸ão dospacientesnadatadaalta,noprimeiroretornoaoambulatório,apósduassemanas,e após90diasdadatadoprocedimentocirúrgico,comexameclínicodaferidaoperatóriae exameslaboratoriaisdeambososgrupos.
Resultados: Observou-sequeospacientesdogrupocomumdiadeantibioticoplofilaxia, 28,6%apresentaramcomplicac¸õesnaferidaoperatóriaeogrupodecincodias,27,9%.
Conclusão: Esteestudodemonstraqueumaúnicadosedeantibioticoprofilaxiaétãoeficaz quantooregimedemúltiplasdosesemcirurgiasdeartrodeselombaratétrêsníveis.Não justificaoscustoseriscosdesubmeteropacienteainternac¸ãosobregimemedicamentoso prolongado.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Lowbackpainwithorwithoutsciaticaaffectsapproximately 80%oftheworldpopulation.Spinalinstability,withorwithout discdisease,isanimportantetiologyofthisdisease.
In cases of low back pain refractory to conservative treatment,andaftercarefulandaccuratediagnosisof verte-bralinstability,lumbararthrodesis(whichconsistsofspinal fusion)isindicated.
Althoughlumbararthrodesisisagood methodforpain relief,italsopresentscomplications;oneofthemost impor-tantissurgicalsiteinfection(SSI).Althoughitsincidenceis low,itseffectsaredevastating.SSIcanleadtoeconomicloss and injurytopatients duetoseveralfactors,including the needforprolongeduseofantimicrobialdrugsandsecondary surgery,amongothers.SSIisalsohighlydisadvantageousfor physiciansfromthecost-effectivenessstandpoint.1
Theriskfactorsassociatedwithinfectioncanbedivided intothoseintrinsictothepatient,suchassmoking,diabetes, malnutrition,obesity,rheumatoidarthritis,chronicuseof cor-ticosteroids,andneoplasms,andextrinsic,suchasincreased surgicaltimeandhighnumberofprofessionalsinthesurgical field.2
Somemeasuresadoptedintheintraoperativeand imme-diatepostoperativeperiodmayhelptodecreasetherateof postoperativeinfections.Amongthem,themaintenanceof theasepticfield,attentiontohemostasis,devitalizedtissue minimization,properuseofdrains,andantibioticprophylaxis arehighlighted.2
Antibioticprophylaxisisthemainmethodtopreventthis complication.Itsimportanceandefficiencyduringsurgeryare known:asignificantreductioninthenumberofinfectionsis observedinpatientswhoreceiveit.3
Somestudieshaveshownthatasingledoseofantibiotic isaseffectiveasmultiple-doseprophylaxis.However,thisis notuniversallyaccepted. Thisstudyaimedtocompare the postoperativeresultsofpatientsonantibioticprophylaxisfor oneand fivedaysthatunderwentup tothree-levellumbar arthrodesis.
Material
and
methods
Forty-threepatientswereassessedthroughaprospective, ran-domizedstudyafterapprovalfromtheinstitution’sResearch EthicsCommittee(#12039513.9.0000.5065).Allpatients under-wentlumbarfusionduetodegenerativediscdiseaseforone, two,orthreelevels.Aftersurgery,patientswereassessedon the dayofdischarge,atthefirstoutpatientfollow-up,after twoweeks,and90daysaftersurgicalprocedure,whereclinical evaluationofthewoundandlaboratorytestsforbothgroups werecarriedout.
Inclusioncriteriacomprisedpatientswhounderwent lum-bar arthrodesis in up to three levels due to degenerative diseasesandwhowerefollowed-upattheorthopedicclinicof thisinstitution.Patientswhounderwentlumbararthrodesis forreasonsotherthandegenerativedisease,suchastumors orfractures,andthosewhounderwentlumbararthrodesisfor morethanthreelevelswereexcluded.
Afterinclusioninthestudy,patientswereassigneda num-ber (one or two)by drawinglots, whichdefined the group theybelongedto.Group1receivedantibioticprophylaxiswith first-generationcephalosporinforonedayandGroup2,same antibioticbutforfivedays.
rev bras ortop.2016;51(3):333–336
335
Table1–Percentageofgeneralcomplications.
Totalpatients Infection Dehiscence Hyperemia Cerebrospinalfluidleaks Seroma Total
43 1 1 1 1 8 12
sedimentationrate,C-reactiveprotein)wereusedforthe anal-ysis.Theassessmentofthesurgicalwoundindicatedthetrue importanceofsignssuchasheat,redness,wounddehiscence, andpurulentexudation.
Thechi-squaredtest(2)and binomial testswere used,
consideringp<0.05andn=1.
Results
Thestudycomprised43patientsfromNovember2012until April2014;22werefemale,withmeanageof49.9years(range 16–76years). Theobserved complications were SSI, suture dehiscence,cerebrospinalfluidleaks,andexacerbated hyper-emia.
Inthepresentstudy,SSIratesof2.3%andgeneral compli-cationratesof27.8%wereobserved,asdescribedinTable1.
Thefollowinganalysisassessedtherelationshipbetween postoperativeadministrationofantibiotics intwodifferent periods:Group1(24h)andGroup2(fivedays),asshownin
Table2.In thisanalysis, “normal” and“altered”conditions wereconsidered.“Normal”representsthegroupthatwasin perfectconditionaftertheantibioticadministrationperiod, and“altered,”thosewhohadsometypeofabnormality,such asone-pointdehiscence,infection,cerebrospinalfluid rhinor-rhea,hyperemia,andseroma.
Thechi-squaredtest,asshowninTable3,indicatesthat thehypothesisofassociationbetweenantibiotic administra-tionperiodandconditionofthepatientafterthisperiodwas rejected(p=0.924).Thus,therewasnoassociation between thefactthatthe antibioticwasgivenforeither24horfive daysandpatientfinalstatus.
However,onequestioncanberaised:wasthereadifference betweentheproportionsofnormalandalteredwithineach antibioticadministrationperiod?
Table2–Percentageofcomplicationsbygroup.
Normal Altered
Group
24h
Absolute 15 6 21
Relative 71.4% 28.6% 100.0%
Fivedays
Absolute 16 6 22
Relative 72.7% 27.3% 100.0%
Total
Absolute 31 12 43
Relative 72.1% 27.9% 100.0%
Table3–Chi-squaredtest.
Value Significancep
Chi-squaredtest 0.009 0.924
Binomialtestsfortheseproportions,asshowinTable4, indicate that in the 24-h group, there was no difference betweenthepostoperativeconditions,withasignificanceof 0.078(>0.05).
Forthe24-hgroup,thedifferencebetweentheproportions ofnormalandalteredconditionswasalsonotsignificant,with asignificanceof0.052(>0.05),asshowninTable5.
Theseresultscorroboratetheassociationtestcarriedouta prioriandindicatethatlongerperiodsofantibioticusedonot contributetoincreasedratesof“normal”outcome.
However,itmustbehighlightedthatsuchtestsaremore reliablewhenthereisalargernumberofoccurrencesforthe analyzedcategories.
Discussion
AsdiscussedbyMeyeretal.,2certainriskfactorshavebeen
proventoincreasetheriskofSSIinpatientsoperatedfor lum-barstenosis.Diabetesmellitusisthemostimportantfactor, inadditiontoadvancedage,immunosuppression,smoking, chronic use of corticosteroids, multilevel surgery, obesity, hypertension,andlivercirrhosis.Consideringthatthe over-allrateofSSIinspinalsurgeryislow(<2%),3theonlypatient
inthestudywhopresentedSSIhadtworiskfactorsfor infec-tion(elderly,hypertensive),correspondingto1/44or2.28%of thesample.Despitetheemphasisondrugtherapy,prevention ofsurgicalinfectionsgoeswellbeyondantibioticprophylaxis. Nosurgeonshouldunderestimatetheimportanceof appro-priatepreoperativecare,followingthe1999CenterforDisease ControlandPrevention(CDC)SSIpreventionguidelines,which recommends areductionto<24hofpreoperative hospital-ization,shavingwithtrimmerorscissorsat<2h,antibiotic
Table4–Binomialtest.
Conditions n Observedproportions Significancep
Groups
Group1 Normal 15 0.71 0.078
Group2 Altered 6 0.29
Total 21 1.00
Group=24h.
Table5–Differencebetweentheproportionsof conditions.
Conditions n Observedproportions Significancep
Groups
Group1 Normal 6 0.27 0.052
Group2 Altered 16 0.73
Total 22 1.00
336
rev bras ortop.2016;51(3):333–336prophylaxisinitiatedatupto1h,antisepsisoftheoperative field,anddurationofantibioticprophylaxis<24h.3,4
Althoughpreoperativeantibiotic prophylaxisiseffective to preventbacterial infection, prolonged use of antibiotics isnotjustified.Ameta-analysisbyBarker5didnotidentify
anyadditionalbenefitfrommultiple-doseregimens.The pro-longeduseofantibioticsincreasestheriskofresistanceof bacterialstrainswithoutbenefits.6–8Furthermore,thecurrent
orientationforclean spinalsurgeryisasingleprophylactic dose9,10; if anew dose isadded, it should notexceed24h
postoperative.11–13
Inthepresentstudy,a24-hantibioticprotocolversus120-h wasproposed;theindividualhealthvariablesofeachsubject weredisregarded,andtheincidenceofinfectionwasassessed separately. The results presenteddemonstrated that there wasnodifferenceintheincidenceofinfectionwithingroups, whichdoesnotjustifytheprolongeduseofantibiotics.
Other minor complications were observed in the study. Eight injuries had seroma, one had lush hyperemia, one evolvedintocerebrospinal fluidfistula,andonehad dehis-cenceofasuturecaused bysuperficialinfection. All these minorcomplicationswerenotincludedasSSIbecausethey werenotdeep,i.e.,belowthelimitofmuscularfascia.13
Conclusion
Thisstudydemonstratedthatasingledoseofantibiotic pro-phylaxis with first-generation cephalosporin is aseffective asapre-andpostoperativemultiple-doseregimeninlumbar arthrodesissurgeryinuptothreelevels.Thecostsandrisks ofsubjectingthepatienttohospitalizationundermedication regimenarenotjustified.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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1. TakahashiH,WadaA,IidaY,YokoyamaY,KatoriS,Hasegawa K,etal.Antimicrobialprophylaxisforspinalsurgery.JOrthop Sci.2009;14(1):40–4.
2.MeyerGPC,GomesFCP,LimaALLM,CristanteAF,MarconRM, etal.Estudoretrospectivodasinfecc¸õespós-operatóriasem cirurgiadecoluna:correlac¸ãocomonúmerodelimpezas cirúrgicasrealizadas.Coluna/Columna.2011;10(2): 127–31.
3.KimB,MoonSH,MoonES,KimHK,ParkJO,ChoIJ,etal. Antibioticmicrobialprophylaxisforspinalsurgery: comparisonbetween48and72-hourampprotocols.Asian SpineJ.2010;4(2):71–6.
4.HellbuschLC,Helzer-JulinM,DoranSE,LeibrockLG,LongDJ, PuccioniMJ,etal.Single-dosevsmultiple-doseantibiotic prophylaxisininstrumentedlumbarfusion–aprospective study.SurgNeurol.2008;70(6):622–7.
5.BarkerFG2nd.Efficacyofprophylacticantibiotictherapyin spinalsurgery:ameta-analysis.Neurosurgery.
2002;51(2):391–400.
6.WattersWC3rd,BaisdenJ,BonoCM,HeggenessMH,Resnick DK.Antibioticprophylaxisinspinesurgery:an
evidence-basedclinicalguidelinefortheuseofprophylactic antibioticsinspinesurgery.SpineJ.2009;9(2):142–6.
7.PetignatC,FrancioliP,HarbarthS,RegliL,PorchetF,Reverdin A,etal.Cefuroximeprophylaxisiseffectivein
noninstrumentedspinesurgery:adouble-blind, placebo-controlledstudy.Spine(PhilaPa1976). 2008;33(18):1919–24.
8.MastronardiL,TattaC.Intraoperativeantibioticprophylaxis incleanspinalsurgery:aretrospectiveanalysisina consecutiveseriesof973cases.SurgNeurol. 2004;61(2):129–35.
9.BowaterRJ,StirlingSA,LilfordRJ.Isantibioticprophylaxisin surgeryagenerallyeffectiveintervention?Testingageneric hypothesisoverasetofmeta-analyses.AnnSurg.
2009;249(4):551–6.
10.KatoD,MaezawaK,YonezawaI,IwaseY,IkedaH,NozawaM, etal.Randomizedprospectivestudyonprophylactic antibioticsincleanorthopedicsurgeryinonewardfor1year. JOrthopSci.2006;11(1):20–7.
11.DobzyniakMA,FischgrundJS,HankinsS,HerkowitzHN. Singleversusmultipledoseantibioticprophylaxisinlumbar discsurgery.Spine(PhilaPa1976).2003;28(21):
E453–5.
12.KhanIU,JanjuaMB,HasanS,ShahS.Surgicalsiteinfectionin lumbarsurgeries,preandpostoperativeantibioticsand lengthofstay:acasestudy.JAyubMedCollAbbottabad. 2009;21(3):135–8.
