title: The influence of perioperative risk factors and therapeutic interventions on infection rates after spine surgery: a systematic review.
abstract: METHODS
  Systematic review.
  
  
  OBJECTIVE
  The objectives of this systematic review were to determine the patient and perioperative risk factors that contribute to infections after spine surgery and to examine the level of evidence to support the use of therapeutic interventions to reduce infection rates.
  
  
  BACKGROUND
  Infection continues to be one of the most common and feared complications after spine surgery. As such, it is used as a sentinel event for quality assurance processes. It is clear that the causes of infections after spine surgery are multifactorial and numerous patient- and procedure-related factors have been proposed as contributory elements. In addition, numerous perioperative adjuncts have been suggested to reduce infection rates.
  
  
  METHODS
  A systematic review of the English-language literature (published between January 1990 and June 2009) was undertaken to identify articles examining risk factors associated with and adjunct treatment measures for preventing surgical-site infections. Two independent reviewers assessed the level of evidence quality using the Grading of Recommendations Assessment, Development, and Evaluation criteria, and disagreements were resolved by consensus.
  
  
  RESULTS
  Of the 127 articles identified, 32 met the criteria to undergo full-text review. Individual patient, operative, and perioperative variables have been identified that are associated with increased infection rates (i.e., older age, obesity, diabetes, malnutrition, higher American Society of Anesthesiologists score, posterior approaches, and blood transfusions) but these variables have not been combined to provide individual patient risks based on a composite of factors (e.g., risk stratification). Of the surgical adjuncts investigated, only irrigation with dilute betadine solution showed moderate support for reducing infection rates.
  
  
  CONCLUSIONS
  It is clear that the causes of postoperative spinal site infections are multifactorial and related to a complex interplay of patient and procedural influences. Because of these complexities, for any individual and surgical procedure, predictable infection rates likely exist that do not extrapolate to 0. Although we have identified factors associated with increased infection rates, further studies will be required to allow multifactorial risk stratification for individual patients and to further investigate the use of therapeutic adjuncts.
authors.affiliation: Department of Neurosurgery, University of Pennsylvania, 3400 Spruce Street, 3rd FloorSilverstein, Philadelphia, PA 19104, USA. schustej@uphs.upenn.edu
authors.forename: James M
authors.initials: JM
authors.lastname: Schuster
authors.forename: Glenn
authors.initials: G
authors.lastname: Rechtine
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Norvell
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Dettori
mesh_terms: D000891:Anti-Infective Agents, Local / Q000627:therapeutic use; D015984:Causality; D004866:Equipment Contamination / Q000517:prevention & control / Q000706:statistics & numerical data; D006801:Humans; D019635:Neurosurgical Procedures / Q000009:adverse effects*; D011206:Povidone-Iodine / Q000627:therapeutic use; D012307:Risk Factors; D040242:Risk Reduction Behavior; D013122:Spinal Diseases / Q000601:surgery*; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000517:prevention & control / Q000628:therapy*; D007507:Therapeutic Irrigation / Q000592:standards / Q000706:statistics & numerical data
chemical_list: D000891:Anti-Infective Agents, Local; D011206:Povidone-Iodine