title: What's the evidence? Systematic literature review of risk factors and preventive strategies for surgical site infection following pediatric spine surgery.
abstract: BACKGROUND
  Despite relatively high rates of surgical site infections (SSIs) after pediatric spine surgery, practice guidelines are absent. We performed a systematic review of the literature, determining the level of evidence for risk factors for SSIs and prevention practices to reduce SSIs following pediatric spine surgery.
  
  
  METHODS
  The search utilized the root search words "spine," "scoliosis," and "infection" resulting in 9594 abstracts. Following removal of duplicate abstracts, those that assessed only SSI rates, SSI treatment, nonoperative spine infections, or adult populations, 57 relevant studies were rated for level of evidence and graded using previously validated scales.
  
  
  RESULTS
  Very few studies lead to grade A (good evidence) or grade B (fair evidence) recommendations. Ceramic bone substitute did not increase the risk of SSIs when compared with autograft (grade A). Comorbid medical conditions, particularly cerebral palsy or myelodysplasia; urinary or bowel incontinence; nonadherence to antibiotic prophylaxis protocols; and increased implant prominence increase the risk of SSIs (grade B). SSIs caused by gram-negative bacilli were more frequent in neuromuscular populations and first-generation stainless steel implants increased the risk of delayed infection compared to newer generation titanium implants (grade B). Evaluations of other risk factors for SSIs yielded conflicting or poor-quality evidence (grade C); these included malnutrition or obesity; number of levels fused or fusion extended to the sacrum/pelvis; blood loss; and use of allograft. Insufficient evidence (0 to 1 published studies) was available to recommend numerous practices shown to reduce SSI risk in other populations such as chlorhexidine skin wash the night before surgery, preoperative nasal swabs for Staphylococcus aureus, chlorhexidine skin disinfection, perioperative prophylaxis with intravenous vancomycin, vancomycin, or gentamicin powder in the surgical site or graft.
  
  
  CONCLUSIONS
  Few studies have evaluated risk factors and preventive strategies for SSIs following pediatric spine surgery. This systematic review documents the relative lack of evidence supporting SSI prevention practices and highlights priorities for research.
  
  
  METHODS
  Level III therapeutic study.
authors.affiliation: Department of Orthopaedic Surgery, Harvard Medical School, Children's Hospital Boston, Boston, MA 02115, USA. michael.glotzbecker@childrens.harvard.edu
authors.forename: Michael P
authors.initials: MP
authors.lastname: Glotzbecker
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Riedel
authors.forename: Michael G
authors.initials: MG
authors.lastname: Vitale
authors.forename: Hiroko
authors.initials: H
authors.lastname: Matsumoto
authors.forename: David P
authors.initials: DP
authors.lastname: Roye
authors.forename: Mark
authors.initials: M
authors.lastname: Erickson
authors.forename: John M
authors.initials: JM
authors.lastname: Flynn
authors.forename: Lisa
authors.initials: L
authors.lastname: Saiman
mesh_terms: D002648:Child; D006801:Humans; D017410:Practice Guidelines as Topic; D012307:Risk Factors; D012600:Scoliosis / Q000601:surgery*; D013123:Spinal Fusion / Q000379:methods*; D013530:Surgical Wound Infection / Q000517:prevention & control*