Perioperative Prophylaxis for Surgical Site Infections in Pediatric Spinal Surgery: A Systematic Review and Network Meta-analysis

Introduction: Postoperative surgical site infections in pediatric spinal surgery commonly occur necessitating reoperation(s). Unfortunately, pediatric specific infection prophylaxis guidelines are not available. This network meta-analysis compares perioperative prophylaxis methods including betadine irrigation, saline irrigation, intrawound vancomycin powder, combination therapy (betadine, vancomycin, gentamicin, and cefuroxime), betadine irrigation + vancomycin powder, and no intervention to determine the most effective prophylaxis.

Methods: A systematic review was performed by searching PubMed, EBSCO, Scopus, and Web of Science for peer-reviewed articles published prior to February 2022 comparing two or more infection prophylaxis methods in patients less than 22 years old. Data was extracted for treatment modalities, patient demographics, total number of infections, surgical site infections, deep infections, intraoperative blood loss, operative time, follow up time, and postoperative complications. Quality and risk of bias was assessed using National Institutes of Health tools. A network meta-analysis was performed with reduction of infections as the primary outcome.

Results: Overall, ten studies consisting of 5,164 procedures were included. There was no significant difference between prophylactic treatment options in reduction of infection. However, three treatment options showed significant reduction in total infection compared to no intervention: betadine + vancomycin (odds ratio (OR) 0.23, 95% confidence interval (CI) [0.11; 0.51]), vancomycin (OR 3.13, 95%CI [2.09; 4.70]), and a combination therapy (betadine, vancomycin, gentamicin, and cefuroxime) (OR 0.24, 95%CI [0.10; 0.56]). P-Score hierarchical ranking estimated betadine + vancomycin to be the superior treatment to prevent total infections, deep infections, and surgical site infections (P-Score 0.7876, 0.7175, 0.7291, respectively). No prophylaxis treatment-related complications were reported.

Conclusion : The results of this network meta-analysis show the strongest support for betadine + vancomycin as a method to reduce infections following pediatric spinal surgery. There was heterogeneity among studies and inconsistent outcome reporting; however, three effective treatment options are identified.