Implementing a Multidisciplinary Clinical Pathway Can Reduce the Deep Surgical Site Infection Rate After Posterior Spinal Fusion in High-Risk Patients

Spine Deform. 2019 Jan;7(1):33-39. doi: 10.1016/j.jspd.2018.06.010.


Design: Retrospective comparative study.

Objective: The purpose of this study is to measure SSI outcomes before and after implementation of our center's multidisciplinary clinical pathway protocol for high-risk spinal surgery.

Background: Surgical site infections (SSIs) after spinal fusion harm patients and are associated with significant health care costs. Given the high rate of SSI in neuromuscular populations, there is a rationale to develop infection prevention strategies.

Methods: An institutional clinical pathway was created in 2012 and based on nationally published Best Practice Guidelines as well as hospital practices with a goal of reducing the rate of deep SSI in high-risk patients. Patient and procedure characteristics were compared prior to (2008-2011) and after (2012-2016) implementation of the pathway. Logistic regression using penalized maximum likelihood was used to assess differences in rate of infection before and after implementation.

Results: Cohorts of 132 and 115 high-risk patients were analyzed before and after pathway implementation. Rate of deep infections decreased from 8% to 1% of patients (p = .005). Preoperative antibiotics were dosed within 1 hour in 90% of the postpathway cohort. Redosing was successful in 94% of patients for first redose and 79% for second redose. Betadine irrigation was used in 76% of cases and vancomycin administered in 86%. Multivariable analysis determined that instances of compliant antibiotics dosing had 63% lower odds of infection compared with instances of noncompliance (p = .04).

Conclusions: Implementation of a multidisciplinary pathway aimed to reduce infection in patients at high risk for SSI after spinal fusion led to a significant reduction in deep SSI rate. It is impossible to attribute the drop in the deep SSI rate to any one factor. Our results demonstrate that adherence to a protocol using multiple strategies to reduce infection results in a lower SSI rate, lower care costs, and improved patient-related outcomes.

Level of evidence: Level III.

Keywords: Infection protocol; Neuromuscular scoliosis; Scoliosis; Surgical site infection.

Publication types

  • Comparative Study

MeSH terms

  • Adolescent
  • Antibiotic Prophylaxis / methods*
  • Critical Pathways*
  • Female
  • Humans
  • Logistic Models
  • Male
  • Patient Care Team*
  • Povidone-Iodine / therapeutic use
  • Retrospective Studies
  • Risk Factors
  • Spinal Fusion / adverse effects*
  • Surgical Wound Infection / prevention & control*
  • Vancomycin / therapeutic use


  • Vancomycin
  • Povidone-Iodine