Spinal hardware infection

Background

• Also known as postoperative spinal implant infection

Classification

Classification	Acute Infection	Chronic Infection
Pathogenesis: post-interventional	<6 weeks post-interventionally (early onset)	≥6 weeks post-interventionally (late onset)
Pathogenesis: hematogenous or per continuitatem	<6 weeks of symptoms	≥6 weeks of symptoms
Clinical presentation	acute pain, fever, prolonged wound secretion (>7-10 days), acute neurological deficits	chronic pain, implant migration or loosening, fistula, neurological deficits
Typical pathogens	Staphylococcus aureus, Streptococcus, Gram-negative bacteria	coagulase-negative staphylococci, Cutibacterium acnes

Management

• Empiric therapy should be with vancomycin plus ceftriaxone or vancomycin plus piperacillin-tazobactam
• Antimicrobial management depends on the surgical approach:
  • For removal of all hardware, treat with 6 weeks total (at least 2 weeks IV)
  • For retainment with plan for eradication, treat with 12 weeks total (at least 2 weeks IV)
  • For single-stage replacement, treat with 12 weeks total (at least 2 weeks IV)
  • For retainment with plan for eventual removal, treat with at least 2 weeks IV followed by oral suppression until hardware removal
• Chronic suppressive antibiotics should be considered with difficult-to-treat organisms (Staphylococcus aureus, resistant Gram-negative bacteria, and fungal infections)

Further Reading

• Infection with spinal instrumentation: Review of pathogenesis, diagnosis, prevention, and management. Surg Neurol Int. 2013;4(Suppl 5):S392-403. doi: 10.4103/2152-7806.120783
• Antibiotic treatment of postoperative spinal implant infections. J Spine Surg. 2020;6(4):785–792. doi: 10.21037/jss-20-456