Elsevier

Surgical Neurology

Volume 50, Issue 3, September 1998, Pages 208-212
Surgical Neurology

Original Articles
Topical irrigation with polymyxin and bacitracin for spinal surgery

https://doi.org/10.1016/S0090-3019(97)00499-0Get rights and content

Abstract

BACKGROUND The purpose of the present study was to evaluate constant irrigation with saline containing 50,000 units each of polymyxin and bacitracin in a regimen of antimicrobial prophylaxis for clean spinal surgery at two community hospitals with a zero infection rate.

METHODS The focus was on the bactericidal effects of prophylactic topical antibiotics by assessing random contamination in neurosurgical wounds from: 1) the flora of the integument and nares of the operating team, 2) the surgical apparel, 3) the patient’s skin, 4) air-borne organisms in the operating theater, and 5) the surgeon’s gloves.

RESULTS Based on individual biotyping of bacteria and antimicrobial sensitivity testing, no consistent source or pattern could be uncovered for the organisms recovered from the operative site. Relying on longitudinal data, the incidence of intraoperative bacterial growth with continuous saline lavage was reduced from 64 to 4% when the combination of topical polymyxin and bacitracin was added.

CONCLUSIONS Although the virtual elimination of bacterial growth in the surgical site was accomplished, the efficacy of topical antibiotics in the prevention of wound infection remains unproven.

Section snippets

Clinical materials and methods

Nyack Hospital and Community Hospital at Dobbs Ferry are located in suburban counties approximately 20 miles from New York City. Our series included 50 consecutive spinal operations from June 1995 through September 1996. There were 27 men and 23 women with ages ranging from 16 to 65. The cases included 22 arthroscopic microdiscectomies, 18 lumbar laminotomies for excision of a herniated nucleus pulposus, and 10 anterior cervical discectomies. None of the patients had any known infection before

Results

No wound infections were documented in the 50 consecutive patients who underwent spinal surgery during the 16 months of our study. Table 1 summarizes the isolates and sources of the various potential pathogens identified. Staphylococci were cultured from 48 out of 50 patients’ skin cultures and from 40 out of 50 cultures of the operating room environment. Coagulase-negative Staphylococcus species was the most common bacterial isolate, and 21% were resistant to cefazolin at both hospitals. Of

Discussion

Because of the limitation of longitudinal clinical studies, which cannot follow the parameters of animal laboratory research, the authors have tried to assess systemic and topical prophylactic antibiotics by focusing on sources of contamination, the antibiotic sensitivity of organisms cultured during neurosurgical procedures, and the occurrence of intraoperative growth of potential pathogens. Given the methodology and the unwillingness to consider placebos which would place patients at

Conclusions

Five separate studies of the bacteriologic factors in neurosurgical operations have now been completed at one university medical center and three community hospitals where the rate of wound infection in clean neurosurgical cases has remained close to zero. The methodology has been carefully planned and consistently applied. Sampling techniques were established in the first study at Nyack Hospital [17], and bacteriologic testing for all of the projects was conducted at the same microbiology

Acknowledgements

The authors wish to thank the other members of the Microbiology Laboratory of Nyack Hospital for their excellent technical assistance.

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    It should be noted that some of these variables are hard to compare directly to the original Malis study as it did not include a demographic or case breakdown.9 Three more recent studies identified branched off from direct SSI evaluation to include surgical site microorganism investigations in comparison with SSI development and the analysis of factors that influence the risk of SSI development.3,17,18 These branching studies allow for a broader understanding of the extent to which contributory factors influence the efficacy of antibiotic irrigation in preventing SSI development.

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    In vitro and animal studies using bone or metal surfaces failed to show better performance for neomycin and bacitracin solutions in comparison with normal saline for removing bacteria from bone, titanium, and stainless steel [190–192]. Despite evidence that topical antibiotics decrease bacterial inoculum in clean surgical wounds [210], it has not been shown that they offer any advantage over intravenous antibiotic prophylaxis, nor that they have been proven to decrease the incidence of SSI [184,186]. A study of a canine model for TJA reported a reduction in the SSI rate with neomycin containing irrigation solution [211].

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