12 Infection Control

Liong Liem MD¹, Said Shofwan MD2, Grady Janitra MD², and Sholahuddin Rhatomy MD³

¹ Universitair Medische Centra (VUmc), Amsterdam, The Netherlands² Sultan Agung Hospital, Semarang, Indonesia / Sultan Agung University, Semarang, Indonesia³ Dr. Soeradji Tirtonegoro General Hospital, Klaten, Indonesia / Gadjah Mada University, Yogyakarta, Indonesia

Introduction

Overall utilization of interventional procedure for pain management continues to increase. Increased utilization is proportional to the rate of post-procedural infection as a complication and the rate varies by type of procedure and anatomic location [1, 2].

Etiology and Risk Factors

Etiology

The major source of infection is the skin, while bacterial contamination can appear even following strict aseptic guidelines. However, other potential sources of infection categorized into exogenous include surgical personnel, operating room environment, instrument, and materials whereas endogenous sources such as hematogenous spread from outside the spine, direct from distant site where an implant provides nest for the infection [3].

The most commonly found microorganisms in a spinal surgical site of infection are Staphylococcus aureus, Staphylococcus epidermidis and Enterococcus species. Methicillin-resistant S aureus (MRSA), Methicillin-resistant S epidermidis (MRSE) have also been reported. Gram-negative bacteria are also a common cause with Escherichia coli and Pseudomonas aeruginosa are most often found. Fungal infections are reported in several cases especially in immunocompromised patients [4, 5].

Risk Factors

Diabetes Mellitus

Administering steroid injections in a spinal interventional procedure in a patient with diabetes mellitus increases the possibility of infections as patients with diabetes have been described to be at risk for atypical pathogens [6]. There are several cases reporting an incidence of spinal epidural abscess related to the spinal interventional procedure. A case report showed that diabetes mellitus becomes the potential cause of infection in patients with discitis and vertebral osteomyelitis following caudal epidural steroid injection [7]. The increased risk of infection caused by diabetes mellitus leading to meningomyelitis after lumbar steroid injection has been reported [8].

Immunocompromise

Injected steroids compromise immune responses and increase the risk of infection. From several case reports, immunocompromised patients increase the risk factor of spinal epidural abscess related to spinal interventional procedures. All cases reported received epidural and caudal injections [9]. Analysis of 14 case reports of epidural abscess and/or meningitis after epidural steroid injection showed 12 patients had positive cultures for S. aureus and eight were considered immunocompromised [10].

Multiple Injections

Myriad case reports showed evidence of the effects of multiple injections that increased the risk factor of developing infections in spinal interventional procedures. Moreover, the short time between the first to second injection increases the likelihood of developing infection. Four case reports revealed that multiple injections led to meningitis. The range between the injections varied from one week to three months and the infections mostly developed after the second injection [5, 8, 9, 11].

Obesity

Reports pointed to a relationship between obesity associated with infection following spinal interventional procedure. Of those complications of extradural abscesses caused by a steroid injection described in a patient infected by Staphylococcus aureus, one of the co-morbidities that affected the patient’s condition was obesity [12, 13].

Complications of Infections after Spinal Interventional Procedures

Infectious complications include, but are not limited to: abscess confined to epidural, spinal, or subdural, paravertebral, paraspinous, or psoas; meningitis; encephalitis; presence of microorganism in the bloodstream (bacteremia, viremia, fungemia); osteomyelitis; local subcutaneous infection; hardware infections; or discitis (Table 12.1).

Table 12.1 List of case reports related to spinal infection after interventional procedure.

Author, Year	Cause of Previous Procedure	Level of Spine	Treatment
Spinal Epidural Abscess
Waldman et al. [14]	Cervical steroid epidural nerve block	C6	C6 Laminectomy
Clifton et al. [15]	Prolotherapy at lumbar	L5–S1	Radiologic-guided aspiration followed by antibiotics
Knight et al. [16]	Caudal epidural steroid injection	L4–L5	L4–L5 and L5–S1 Foraminal and nerve root canal decompression
Goucke et al. [13]	Lumbar extradural steroid injection	L4–5	T12–L5 Laminectomy
Huang et al. [17]	Cervical epidural steroid injection	C4–5	C5–6 Laminectomy
Hooten et al. [9]	Epidural steroid injection	L2–3	Antibiotics
Kabbara et al. [18]	Transforaminal epidural steroid injection	L4–5	Debridement of the abscess
Noh et al. [19]	Lumbar epidural injection	L4–5	T9–S1 Laminectomy
La Fave et al. [12]	Lumbar steroid injection	C2	C2–C4 Laminectomy
Goris et al. [20]	Cervical epidural steroid injection	C6–7	Cervical laminectomy
Mathew et al. [21]	Interlaminar epidural steroid injection	L3–5	L4–5 Laminectomy
Chan et al. [22]	Lumbar steroid epidural injection	C3–L4	T8–L4 Laminectomy
Mamourian et al. [23]	Epidural steroid injection	L3–S2	L4–S2 Laminectomy
Kaul et al. [24]	Steroid injection at lumbar region	L3–S1	L2–S1 Laminectomy
Bromage PR, et al. [25]	Steroid extradural injection	NR	Laminectomy
Subdural Abscess
Couman et al. [26]	Thoracic epidural injection	T7	L2 Laminectomy
Krauetler et al. [27]	Transforaminal steroid injection	L5–S1	L1–L2 Laminectomy
Chen et al. [28]	Cervical acupuncture	C6–T1	C6–T1 Laminectomy
Lownie et al. [29]	Cervical discography	C5–C6	C5–C6 Laminectomy
Volk et al. [30]	Epidural catheter insertion	L3–L4	L3–L4 Laminectomy
Meningitis
Dougherty JH et al.	Epidural hydrocortisone injection	L4–l5	Antibiotics
Hooten WM.	Epidural steroid injection	L2–3	Antibiotics
Cooper et al. [11]	Epidural steroid injection	L3–4	Antibiotics
Kolbe et al. [5]	Epidural steroid injection	L4–5	Antifungal and antibiotics treatment
Shah et al. [31]	Epidural steroid injection	N/A	Antibiotics
Koo et al. [32]	Interlaminar epidural steroid injection	N/A	Antibiotics
Pharm et al. [33]	Epidural catheterization	N/A	Antibiotics
Shin et al. [34]	Lumbar nerve root block	N/A	Antibiotics
Discitis
Pappy A et al. [35]	Lumbar transforaminal epidural	L2–L5	Antibiotics
Wai-Mun Yue et al. [7]	Epidural injection	L2–3 and L4–5	Antibiotics
Ruofeng Yin et al. [36]	Percutaneous nucleoplasty	C5–7	Antibiotics and cervical decompression
Hooten et al. [37]	Epidural steroid injection	L5–S1	Antibiotics and discectomy
Jun-Soon Park et al. [38]	Intradiscal RF thermocoagulation	L4–5	Antibiotics and laminectomy
Vertebral Osteomyelitis
Mikhael et al. [39]	Discography	L2–S1	Antibiotics
Johnson et al. [40]	Epidural injection	L3–4	Antibiotics
Arun et al. [41]	Epidural catheterization	T12–L4	Antibiotics
Wai-Mun Yue et al. [7]	Epidural injection	L2–3 and L4–5	Antibiotics
Lobaton et al. [42]	Epidural steroid injection	L4–5	L4–5 Corpectomy
Simopoulos et al. [43]	Epidural steroid injection	L4–5	L4–5 Drainage abscess
Copaes et al. [44]	Epidural catheterization	L1–3	Stabilizing T12–L4 and antibiotic treatment
Lynch et al. [45]	Epidural catheterization	L1–2	Antibiotics
Gail et al. [46]	Epidural catheterization	L1	Antibiotics
Torgard et al. [47]	Epidural catheterization	T11–12	Antibiotics
Krishnakumar et al. [48]	Epidural catheterization	L1	Antibiotics
Saigal et al. [49]	Epidural steroid injection	L4–5	Hemilaminectomy and antibiotics treatment
Paraspinal Abscess
Kim et al. [50]	Lumbar medial branch block	L4–5	Antibiotics and percutaneous drainage
Okada et al. [51]	Lumbar medial branch block	L4–5	Antibiotics and surgical debridement
Cook et al. [52]	Lumbar medial branch block	L4–5	Antibiotics and percutaneous drainage
Volk et al. [30]	Epidural catheterization	L3–4	Surgical treatment
Puehler et al. [53]	Paravertebral injections	L4–5 and L5–S1	Antibiotics and surgical treatment
Usta et al. [54]	Percutaneous adhesiolysis	L3–4	Antibiotics

Prevention of Infection

Prevention of infection in patients undergoing interventional procedures involves pre-procedure, intra-procedure, and-post procedure.

Pre-procedure Period

Optimization of Patients’ Conditions

In advance of an elective spine intervention, all modifiable conditions should be optimized. Many studies have shown that the patient’s baseline condition is related to post-procedure complications. Risk factors such as uncontrolled diabetes and altered immune status can significantly increase the risk of infection [6–8]. Studies have shown an increase of infection on day one post-operatively in patients with sugar levels higher than 200 mg/dl. Evaluating patients prior to spine intervention in a multidisciplinary approach is crucial in order to identify co-morbidities and manage them, if required. These assessments significantly reduce post-procedure mortality and pre-admission costs in spinal interventional procedure, including infection [6–8].

Prophylactic Antibiotics

Prophylactic antibiotics have been one of the most important advancements in preventing infection during spinal interventional procedures especially in known or suspected bateremic patients [55]. Prophylactic antibiotics are recommended in disc procedures because of the increased risk of infection due to the avascular structure of the disc. In addition, any procedures related to implantable devices require prophylactic antibiotics. Prophylactic antibiotics are administered within one hour prior to the procedure to reach the minimal inhibitory concentration in the end-organ during the procedure [56]. In addition, routine interventional procedures such as epidurals, facet blocks, medial branch blocks, RFA, and sympathetic blocks do not require antibiotic prophylaxis. Cefazolin is commonly used as antibiotic prophylaxis prior to an interventional procedure while vancomycin is indicated in case of MRSA [57].

Intra-procedure

Routine interventional procedures do not require a standard preparation for surgical procedure while procedures related to provocative disc and implantable devices do require standard preparation for a surgical procedure.