Strategies to prevent post-operative surgical site infection in spinal surgery: a narrative review

Background Post-operative surgical site infections (SSIs) remain a major source of morbidity following spinal surgery, contributing to prolonged hospitalisations, re-operation, implant failure and increased healthcare costs. Despite advances in surgical technique and peri-operative care, SSI prevention in spine surgery remains challenging.

Objective To provide a narrative synthesis of contemporary evidence relating to the prevention of SSIs in spinal surgery across the pre-operative, intra-operative, and post-operative phases, with additional emphasis on emerging and translational technologies.

Methods A structured literature review of MEDLINE/PubMed (1990–2024) was performed. Systematic reviews, randomized controlled trials, high-quality cohort studies, and major international guideline statements were selectively included to synthesise current preventive strategies in spinal surgery.

Results SSI prevention in spinal surgery requires a multimodal peri-operative strategy. Pre-operative optimisation includes smoking cessation, glycaemic control, nutritional assessment, anaemia correction, and targeted Staphylococcus aureus screening and decolonisation. Intra-operative measures supported by moderate-to-high-quality evidence include chlorhexidine–alcohol skin preparation, weight-adjusted antibiotic prophylaxis with appropriate re-dosing, dilute povidone–iodine irrigation, meticulous tissue handling, and intrawound vancomycin powder in selected high-risk posterior instrumented cases. Post-operative interventions such as extended occlusive dressings, silver-impregnated dressings, and prophylactic negative-pressure wound therapy may reduce SSI risk in high-risk populations. Prolonged post-operative antibiotic administration beyond 24 h has not demonstrated additional benefit and may increase antimicrobial resistance. Emerging technologies targeting biofilm formation and antimicrobial resistance represent promising future directions.

Conclusions Preventing SSIs in spinal surgery requires an integrated peri-operative approach informed by evolving evidence. While several strategies are supported by consistent data, significant gaps remain, particularly regarding emerging technologies. Ongoing high-quality clinical studies are needed to refine SSI prevention frameworks in spine surgery.

Keywords: Postoperative spine infections · Prevention of postoperative spine infections · Multidisciplinary approach · Risk factors of post-operative spine infections

Post-operative spinal infections remain among the most challenging complications in spine surgery, with reported rates ranging from 0 to 17% depending on patient risk factors, surgical complexity, and anatomical location. Even a single deep surgical site infection (SSI) can result in prolonged antibiotic therapy, repeated surgical debridement, hardware failure, and increased long-term morbidity. As surgical volumes increase and patient comorbidities become more complex, the importance of evidence-based preventive strategies has never been greater.

Efforts to prevent post-operative infections are still a struggle that healthcare professionals cannot eradicate but minimize. Postoperative spinal infections are an increasing burden on health care, as the incidence is rising as the number of spinal surgeries increases. The post-spinal surgery infection rate ranges from 0 to 17% [1]. In the cervical spine, the post-operative spinal infection rate is 3.4%. Among them, anterior cervical spine surgeries are 0.1–1.6% [2].

Postoperative spinal infections are classified into superficial infections, deep infections, and organ space infections. Superficial infections present within 1 month of surgery with the discharge, which grows causative organisms. Superficial infections involving the skin and the subcutaneous tissues. Deep infections present with discharge or abscess formation and involve fascia and underneath muscles. Infections deep into the muscle layer are organ space infections [Ex: Epidural infections/abscess, spondylitis, discitis & psoas abscess].

Post-operative spine infections are increasing hospital stays, re-operation rates, the financial burden on health care, morbidity, and mortality, and worsening the long-term outcome of the patients [3].

Postoperative spinal infections encompass a heterogeneous group of entities ranging from superficial wound infections to deep organ-space infections and implant-associated infections. Earlier reviews highlighted the substantial morbidity, prolonged antibiotic use, and need for reoperation associated with these complications [4, 5] More recent literature has emphasised that variability in definitions and diagnostic thresholds has contributed to inconsistent reporting of incidence and outcomes across studies [6].

In response, contemporary efforts have focused on refining classification systems and standardising terminology, particularly for implant-associated infections, which are increasingly recognised as biologically distinct entities driven by biofilm formation [7].

This manuscript was designed as a narrative review to synthesise contemporary evidence on SSI prevention in spinal surgery. A structured but non-systematic literature review search was performed using MEDLINE/PubMed covering publications from January 1990 to December 2024. Search terms included: ‘spine’, ‘spinal surgery’, ‘surgical site infection’, ‘infection prevention’, ‘MRSA decolonisation’, ‘chlorhexidine’, ‘vancomycin powder’, ‘povidone-iodine irrigation’, ‘biofilm’, ‘implant infection’, ‘bacteriophage therapy’, and ‘antimicrobial peptides’. Boolean operators were used to refine results.

Priority was given to high-quality systematic reviews, meta-analyses, randomized controlled trials, large cohort studies, and major international guideline statements relevant to spinal SSI prevention. Evidence was synthesised descriptively, with emphasis on peri-operative risk mitigation, implant-associated infection, and emerging technologies. As a narrative synthesis, no formal quantitative pooling or risk of bias scoring was performed.

Understanding risk factors for SSIs allows identification of patients with a higher risk and supports targeted peri-operative mitigation strategies. These factors can be broadly categorized into patient-related and surgery-related outcomes (Table 1).

Pre-operative optimization represents the most effective opportunity to reduce SSI risk. Consistent evidence supports modification of key risk factors prior to elective spinal surgery.

Smoking cessation, glycaemic optimisation, nutritional assessment, correction of anaemia, and targeted Staphylococcus aureus decolonisation are all associated with lower SSI rates in spine surgery cohorts. While the optimal thresholds and timing of intervention vary across studies, these measures collectively reduce microbial burden and improve wound healing capacity.

Prevention strategies for post-operative surgical site infections are divided into pre-operative strategies, surgical preparation, intraoperative strategies, and postoperative strategies.

Pre-operative assessment and optimization

Effective prevention of postoperative spinal infections begins well before the patient enters the operating theatre. The pre-operative period offers the greatest opportunity to modify risk factors and reduce the microbial burden that contributes to postoperative surgical site infections (SSIs). Pre-operative strategies include optimisation of patient comorbidities, decolonisation protocols, lifestyle modifications, and enhanced prehabilitation approaches. Each strategy is supported by varying levels of evidence, with strong, consistent data supporting smoking cessation, glycaemic optimisation, and MRSA screening.

Cessation of smoking

Smoking adversely affects tissue perfusion, oxygenation, and immune cell function. Nicotine induces vasoconstriction, reducing subcutaneous oxygen delivery and impairing neutrophil-mediated oxidative killing. Meta-analyses demonstrate significantly increased SSI rates in smokers undergoing cervical [8] and lumbar spine surgery. A minimum of four weeks of abstinence prior to elective spinal procedures is recommended to meaningfully reduce infection risk. Smoking is a proven modifiable risk factor for postoperative spinal infections. Cessation of smoking at least for four weeks prior to surgery, has demonstrated reduction in the risk of surgical site infection [9].

Glycaemic optimisation

Hyperglycaemia impairs leukocyte chemotaxis, angiogenesis, and collagen synthesis, increasing susceptibility to infection. The study by Hikata et al. demonstrated that patients with a pre-operative HbA1c above 7.0% had a more than two-fold increase in deep SSI following thoracolumbar fusion [10]. Tight glycaemic control remains a cornerstone of pre-operative optimisation, and elective surgery may be deferred in patients with poorly controlled diabetes when feasible given the association with increased SSI risk [11–13].

Methicillin-resistant staphylococcus aureus (MRSA) screening and decolonisation

Staphylococcus aureus, including methicillin-resistant strains (MRSA), accounts for a substantial proportion of postoperative spinal infections [14]. Pre-operative nasal swabs screening followed by decolonization using 2% Mupirocin ointment and Chlorhexidine gluconate wash has shown evidence of reduced SSI rates in orthopaedic and spine populations [15]. However, emerging resistance to mupirocin underscores the need for judicious use of decolonization protocols [16].

Nutritional optimization and anemia correction

Malnutrition, reflected by serum albumin levels below 35 g/L, is associated with increased infection risk due to impaired wound healing and diminished immune response. Pre-operative nutritional assessment and correction of hypo-albuminaemia improve postoperative outcomes. Similarly, correction of anaemia (haematocrit below 35%) enhances oxygen-carrying capacity and reduces SSI risk [17].

Obesity and weight management

Obesity poses technical challenges during spine surgery and contributes to increased wound tension, longer operative times, and impaired perfusion. A meta-analysis by Abdallah et al. demonstrated that each 5-unit increase in BMI correlates with a 13% increased risk of postoperative SSI. Targeted weight reduction may reduce risk, although evidence on optimal pre-surgical BMI thresholds remains evolving [18].

Immunosuppression and steroid use

Patients on chronic corticosteroid therapy or immunosuppressive medications are at increased risk for infection due to impaired cell-mediated immunity [19]. Temporary dose reduction or cessation may be beneficial when clinically appropriate, although the decision must balance surgical infection risk with underlying disease control.

Pre-operative urinary tract assessment

Routine screening for asymptomatic bacteriuria prior to elective spinal surgery remains controversial. While urinary tract infections (UTIs) are recognized risk factors for post-operative complications, current evidence does not support routine treatment of asymptomatic bacteriuria in non-urological surgery. Over-treatment may contribute to antimicrobial resistance without reducing SSI rates. Targeted urine testing may be considered in symptomatic patients or those with recurrent UTIs, particularly in high-risk populations such as elderly women. However, antimicrobial stewardship principles favour selective rather than universal screening strategies.

Surgical preparation

Bathing before the surgery
Taking a bath before surgery has been studied in many general surgical studies and has been proven to reduce surgical site infections [20]. There are no proven benefits to using topical antiseptic solutions before surgery to prevent surgical site infections. Chlorhexidine is used by several centres for pre-operative antiseptic showers. Chlorhexidine is bactericidal as it binds with the bacterial cell wall. The binding has been mediated by cationic chlorhexidine molecules and negatively charged bacterial cell walls. However, a meta-analysis of randomized control trials does not show any superiority of antiseptic bathing before surgery [21].

Hair removal before the surgery
Pre-operative hair removal via non-abrasive techniques is associated with lower SSI rates compared with shaving. Shaving causes minor abrasions around the surgical site, and it allows skin commensals to grow on it. This leads to an increased rate of surgical site infections. Post-operative hair removal suggests benefit when it is necessary and with clippers rather than the blades [22].

Pre-operative prophylactic antibiotics administration
The use of prophylactic antibiotics has proven to be effective in preventing postoperative spinal infections. Nunez-Pereira et al. have studied the use of individualized antibiotic choices on patients with the risk of being colonized with microorganisms (ex: patients with incontinence, and urinary tract colonization) and found there is a significant reduction in the incidence of postoperative spinal infection among patients who had an individualized antibiotic regime [23].

The duration of antibiotics is also yet to be proven. The common practice is to continue the antibiotics for the next 24 h. In a few centres, the continuation of antibiotics will be until the drains are removed. However, Takimoto and colleagues found that there is no difference in the incidence of postoperative spinal infections among patients who had antibiotics until the drains were out, compared to the early cessation of antibiotics [24].

Intra-operative contamination represents a critical determinant of SSI risk. Evidence consistently supports the use of chlorhexidine–alcohol skin preparation, weight-based antibiotic prophylaxis with timely re-dosing, and meticulous soft-tissue handling.

Adjunctive measures such as dilute povidone-iodine irrigation and intrawound vancomycin powder have demonstrated reduced deep SSI rates, particularly in posterior instrumented procedures. These interventions should be interpreted within the context of evolving antimicrobial stewardship principles.

Theatre protocols, surgical scrubbing, sterile surgical dressing, and drapes

The intra-operative environment represents a critical phase in the prevention of postoperative spinal infections. The majority of contaminating organisms are introduced during the surgical procedure, emphasising the importance of strict aseptic technique, minimisation of bacterial bioburden, and protection of implants. Evidence-based intra-operative interventions significantly reduce SSI risk. There are many theatre etiquette guidelines to reduce the intraoperative contamination of microorganisms during surgery. Changing into sterilized clothing and shoes, using protective caps and masks, proper scrubbing before each surgery, keeping nails shorter, and avoiding nail polish reduce the translocation of operating suit personnel microbial flora to the surgical site [25]. Furthermore, reducing staff movements during surgery also reduces the risk of contaminating the surgical instruments and the field.

The standard handwashing technique has been proven to reduce post-operative surgical site infection. It should be methodical and should be practiced stringently before donning the sterile gown and sterile gloves. According to the WHO surgical site infection prevention guidelines, surgical teams should practice proper handwashing using a proper antiseptic solution for 2–5 min. Further, it states that wearing sterile gloves only prevents contamination and blood-borne pathogen transmission to the surgeon.

According to the 2008 NICE guidelines suggests that the surgical team scrub with an aqueous antiseptic solution for the first case of the day and an alcoholic hand rub for the subsequent cases. Further, the guideline mentions avoiding the routine use of iodine-impregnated incisive drapes as it increases the risk of surgical site infections. It also reinforced the use of sterile gowns during the surgery.

There is no consensus on disposable vs. reusable drapes. Many institutions in the Western world are using disposable drapes. But there is no hard evidence to suggest the superiority of one over the other [26]. Additionally, special drapes are necessary when a microscope, fluoroscopy, and intraoperative computed tomography are used during the surgery.

Skin preparation

Skin antisepsis is one of the most effective intra-operative strategies for SSI reduction. A landmark randomised controlled trial by Darouiche et al. 15 (NEJM 2010) demonstrated the clear superiority of chlorhexidine gluconate (CHG) in an alcohol base compared with povidone–iodine alone. CHG–alcohol rapidly disrupts bacterial membranes and provides persistent antimicrobial activity. Sequential application of povidone - iodine followed by CHG alcohol further reduces bacterial colonisation in spinal procedures [27].

Antibiotics prophylaxis

The optimal duration of prophylactic antibiotic administration following spinal surgery remains debated. Contemporary evidence and guideline statements support discontinuation within 24 h of surgery, even in instrumented procedures. Randomised studies have demonstrated no significant reduction in SSI when antibiotics are continued until drain removal compared to cessation at 24 h. Prolonged antibiotic administration is associated with increased risk of Clostridioides difficile infection, antimicrobial resistance, nephrotoxicity, and additional healthcare cost. Extended prophylaxis may be justified only in exceptional circumstances where active infection is suspected, rather than as routine practice. Antibiotic duration should therefore be guided by antimicrobial stewardship principles and patient-specific risk factors [28].

Dilute povidone-Iodine (0.35%) Irrigation

Irrigation of the surgical wound with dilute 0.35% povidone–iodine (PI) solution reduces bacterial load and significantly lowers deep SSI rates. However PI irrigation does not delay wound healing and provides broad-spectrum antimicrobial activity [29]. PI is effective against gram-positive and gram-negative organisms and penetrates biofilms at low concentrations.

Local intrawound vancomycin powder

Intrawound vancomycin powder has gained widespread adoption in posterior instrumented spinal procedures due to its targeted activity against gram-positive organisms, particularly Staphylococcus aureus and MRSA. The rationale involves achieving high local antibiotic concentrations at the surgical site while minimising systemic exposure. Multiple retrospective studies and meta-analyses have demonstrated reductions in deep SSI rates, particularly in high-risk multilevel or revision procedures. However, heterogeneity in dosing (typically 1–2 g), application technique, and patient selection remains. Concerns persist regarding potential selection pressure for resistant organisms and the risk of sterile seroma formation. Current evidence suggests benefit in selected high-risk cases, but routine universal application requires continued evaluation within antimicrobial stewardship frameworks [30].

Temperature regulation and oxygenation

Intra-operative hypothermia impairs coagulation, reduces tissue oxygenation, and increases SSI risk [31]. Active warming devices, such as forced-air warming blankets, maintain normothermia and reduce complications. Maintaining an inspired oxygen fraction (FiO₂) of at least 50% improves tissue oxygen delivery and may reduce infection rates [32].

Hemostasis, tissue handling and minimisation of dead space

Meticulous surgical technique including minimal soft tissue trauma, precise electrocautery use, and adequate hemostasis reduces the accumulation of hematoma and seroma, both of which predispose to infection. Frequent release of retractors suggest benefit in the prevention of tissue devascularisation.

No-touch handling and implant exposure time

Implants should remain in sterile packaging until the moment of implantation. Exposure of implants for more than one hour increases contamination risk. The use of single-packed, pre-sterilised implants reduces risk associated with repeated reprocessing. A strict no-touch technique further is associated with reduced bacterial transfer.

Drains

The use of postoperative drains in spine surgery remains controversial. While drains may prevent hematoma formation, they also introduce a potential pathway for bacterial entry. (13).Large studies in adolescent scoliosis and adult populations show no significant difference in SSI rates between drain and no-drain cohorts, though drain use is associated with higher transfusion rates [33]. Drain placement should, therefore, be individualised based on intra-operative findings.

Post-operative wound management plays an essential role in preventing progression from contamination to established infection. Strategies such as prolonged occlusive dressings, silver-impregnated dressings, and closed-incision negative-pressure wound therapy have shown benefit in selected high-risk populations, although high-quality randomised data remain limited.

Silver impregnated dressing

Silver dressings exhibit broad-spectrum antimicrobial activity through the sustained release of ionic silver, which disrupts bacterial cell membranes, DNA replication, and metabolic processes. Although high-level evidence is still limited, several prospective and retrospective studies suggest that silver-impregnated dressings reduce SSI rates in high-risk spinal procedures, particularly long posterior instrumentation cases. Their use suggests benefit in patients with diabetes, obesity, or prolonged operative times [34].

Timing of dressing changes

Traditionally, wound dressings were changed 24–48 h post-operatively; however, data increasingly support leaving occlusive dressings in place for longer periods. A large retrospective study demonstrated reduced infection rates when dressings were left undisturbed for at least five days following surgery. Minimising wound exposure decreases external contamination and avoids disruption of early wound healing [35].

Negative pressure wound therapy (NPWT)

NPWT applies sub-atmospheric pressure to the closed incision, reducing edema, enhancing perfusion, and removing fluids that may harbour bacteria. Several spine-focused studies demonstrate reductions in dehiscence and deep SSI rates when NPWT is applied prophylactically, especially in long-segment fusions, revisions, and obese patients. Despite promising results, large randomised controlled trials remain limited, and NPWT is typically reserved for high-risk populations.

Post-operative antibiotic duration

Although some centres extend prophylactic antibiotics until drain removal, multiple high-quality studies have shown no reduction in SSI when antibiotics are continued beyond 24 h. Prolonged antibiotic use increases the risk of Clostridioides difficile infection, antibiotic resistance, and drug toxicity.

Emerging strategies targeting biofilm disruption, antimicrobial resistance, and host immune modulation including antimicrobial peptides, nanoparticle-based antibiotic carriers, bacteriophage therapy, and vaccine development represent promising avenues for SSI prevention in spinal surgery. These technologies remain largely investigational but may redefine infection prevention paradigms as translational evidence matures.

Implants

Single-packed implants & the no-touch technique
Introduction of single-packed implants and using the no-touch technique until insertion of the screws. It has been proven that the exposure time of the implant is directly proportional to the level of contamination [36]. In addition, more than 01 h of exposure time is a risk factor for post-operative spinal infection. The washing and reprocessing of implants lead to corrosion and potential contamination. This increases the risk of deep infections and reduces the longevity of the implants. Adherence to the strict no-touch technique during the surgery until it is inserted into the bone will reduce the risk of contamination and increase longevity [37].

Drug eluting implants
Implants coated with antibiotics, antiseptics, and silver to prevent post-operative spine infections have been studied. None of these have proven their benefits until now due to several disadvantages. Those coatings release antibiotics for a limited period and increase the risk of developing drug resistance. Antiseptic agents (e.g., Chlorhexidine/ or chloro-xylenol) have lower antimicrobial properties [38].

Advances in antibiotics

Introduction of new antibiotics
The invention of newer antibiotic agents which penetrate the biofilm should be encouraged. This property has been shown in rifampicin against staphylococcus implant-associated infections. Identification or invention of newer antibiotics with this property will reduce the incidence of antibiotic resistance against rifampicin [39].

Antibiotic carriers
Antibiotic carriers are organic or inorganic particles that mediate the penetration of biofilms and increase the availability of antibiotics in the biofilms. These carriers are nanoparticles linked to the antibiotic agents that allow penetration into the biofilm. There are liposome molecules used as carriers. The antibiotic-liposome conjugation increases the intracellular availability of antibiotics to eradicate intracellular microorganisms [40].

Antimicrobial peptide (AMPs)
AMPs are naturally occurring molecules that disrupt bacterial cell membranes and offer broad-spectrum activity with a low risk of resistance development. Synthetic AMPs are being engineered for controlled release from implant surfaces and suture materials [41]. Their ability to penetrate biofilms positions them as promising alternatives or adjuncts to traditional antibiotics.

Biofilm-disrupting technologies
Since biofilm formation on hardware surfaces is a primary mechanism of chronic spinal infection, strategies aimed at disrupting or preventing biofilms are under active investigation. These include enzymatic biofilm degraders, quorum-sensing inhibitors, and electrical microcurrents applied to titanium implants. Early pilot studies shows evidence of cathodic voltage-controlled electrical stimulation may impair biofilm formation and promote bacterial [42].

Vaccination against microorganisms
Staphylococcus aureus is the leading cause of postoperative spine infections, yet no vaccine is currently approved. Multiple vaccine candidates, such as SA4Ag, NDV-3 A, and 4 C-Staph, have completed early-phase clinical trials, demonstrated strong immunogenicity but limited protective efficacy to date [43]. Advances in adjuvant technology, multi-antigen targeting, and host immune profiling may improve future vaccine effectiveness (Table 2).

This narrative review synthesises established and emerging evidence on SSI prevention in spinal surgery within the context of evolving definitions and growing recognition of implant-associated infection. Foundational reviews and contemporary analyses consistently demonstrate that post-operative spinal infections arise from a complex interaction between host susceptibility, surgical exposure, and microbial biofilm formation.

Recent international efforts to standardise terminology and diagnostic criteria further underscore the need for coherent peri-operative prevention frameworks that extend beyond isolated interventions [44].

As spinal procedures become more complex and antimicrobial resistance continues to rise, innovative technologies such as antimicrobial peptides, nanoparticle drug carriers, bacteriophage therapy, biofilm-disrupting modalities, and Staphylococcus aureus vaccines represent promising avenues for the future. These developments, combined with predictive analytics and personalised medicine approaches, may help redefine infection prevention in spine surgery. Continued research, including rigorous multicentre trials, is essential to evaluate the safety, efficacy, and cost-effectiveness of emerging infection-prevention strategies. By integrating established best practices with innovative technologies, the spine community can significantly reduce postoperative infections, improve patient outcomes, and enhance the overall quality of care in spinal surgery.

Author contributions K.P and A.S wrote the manuscript O.K edited the manuscript A.D and A.G supplied oversight and guidance.

Funding Open Access funding enabled and organized by CAUL and its Member Institutions. No funding received.

Data availability No datasets were generated or analysed during the current study.

Declarations

Conflict of interest The authors declare no competing interests.

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