Impact of Prophylactic Use of Irrisept Irrigation System for Spinal Instrumentation

Surgical Site Infection Clinical Trial

Official title:

Impact of Prophylactic Use of Irrisept Irrigation System for Spinal Instrumentation

Clinical Trial Details — Status: Not yet recruiting

Administrative data

• NCT number: NCT06439953
• Other study ID #: Irrimax Trial
• Status: Not yet recruiting
• Phase: N/A
• Start date: June 2024
• Est. completion date: May 2026

Study information

• Verified date: June 2024
• Source: Lifespan
• Contact: Alexander Chernysh
• Phone: 401-444-9868
• Email: AChernysh[@]lifespan.org
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Various spine surgeons perform wound irrigation using saline mixed with vancomycin, relying on mechanical debridement of non-viable tissue, physical disruption of biofilm, and bacteriostatic effect against gram positive flora. When used as a powder, topical application of vancomycin has demonstrated increased risk of symptomatic seroma formation, which is an adverse outcome that often requires bedside or intra-operative aspiration. Broad-spectrum antiseptic agents, such as Irrisept, offer bacteriocidal properties to eliminate hardware inoculation, thereby minimizing the risk of deep space infection, while obviating the risk of seroma development.

Description:

Spinal instrumentation remains the standard of care in the treatment of various traumatic, oncologic, and degenerative spinal pathologies, often requiring the implantation of hardware to stabilize the bony column. In the setting of an aging patient population and expanding indications for instrumentation in younger patients, the number of spinal operations performed has risen substantially within the past decade. Although these procedures have proven to enhance patient quality of life, spinal instrumentation is not without post-operative complication, most notable of which are surgical site infection, seroma formation, and wound breakdown. Such complications can result in notable negative sequelae. Recurrent seroma may compress underlying neurologic structures or increase pressure along the incision, thereby precipitating wound dehiscence and inoculation of the surgical site with pathogenic organisms. Deep space infections often result in prolonged hospitalization, long-term suppressive antibiotic therapy, hardware removal, and permanent disability, which increases cost burden at the patient and hospital level. As such, preventative strategies to reduce the rate of complications following spinal instrumentation remain paramount. Within recent years, attention has turned to various irrigation methods to terminally sterilize prosthetic devices and wound beds, thereby minimizing bacterial colonization and biofilm formation that would otherwise predispose infection. Irrisept (Irrimax Corporation, Gainesville, Florida) is a solution comprised of 0.05% chlorhexidine gluconate in 99.95% sterile water administered through a proprietary, low-pressure lavage mechanism that has demonstrated efficacy as a bacteriocidal agent in orthopedic hip and knee arthroplasty procedures. Whereas other antiseptic irrigation solutions, such as vancomycin-saline lavage, are routinely used to prevent surgical site infection, relative inertness against gram negative organisms and potential predisposition toward seroma formation render them non-ideal for use in spine surgery. Despite the utility of dilute chlorhexidine gluconate as a prophylactic irrigant, there exist gaps in knowledge with regard to the efficacy of Irrisept to prevent post-operative complications following spinal instrumentation. The central hypothesis of this proposal is that prophylactic use of Irrisept irrigation will result in fewer surgical site infections, clinically significant seromas, and gram negative or atypical infections when compared to standard of care irrigation (vancomycin-saline solution with or without topical vancomycin powder). Proposed is a prospective, randomized controlled trial comparing rates of post-operative complications following use of Irrisept irrigation alone versus vancomycin-saline lavage with or without topical vancomycin powder (standard of care) in patients aged 18 years or older who undergo posterior cervical, thoracic, lumbar, and/or sacral spinal instrumentation for various indications (deformity, malignancy, degenerative pathology, and trauma) at Rhode Island Hospital.

Recruitment information / eligibility

• Status: Not yet recruiting
• Enrollment: 200
• Est. completion date: May 2026
• Est. primary completion date: May 2025
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Age: 18+ years old
• Indications: deformity, oncologic, degenerative, trauma
• Standard layer-by-layer closure
• Locoregional flap-based closure

Exclusion Criteria:

• Acute/chronic open wounds (spine or non-spine)
• On-going non-spinal infection within 30 days of index operation
• Concurrent antibiotic use (for spine or non-spine infections)
• History of prior spinal infection
• Allergy to vancomycin or chlorhexidine
• Suspicion for osteomyelitis
• Other surgery within 90 days post-operatively fromm index
• Concurrent enrollment in other trial

Related Conditions & MeSH terms

• Communicable Diseases
• Infections
• Post-Op Complication
• Postoperative Complications
• Site Infection
• Spine Surgery
• Surgical Site Infection
• Surgical Wound Infection

Intervention

Device:
• Chlorhexidine gluconate solution
Evaluating the prophylactic use of Irrisept irrigation alone

Drug:
• Vancomycin
Evaluating the use of versus vancomycin-saline irrigation with or without topical vancomycin

Locations

Country	Name	City	State
United States	Rhode Island Hospital	Providence	Rhode Island

Sponsors (1)

Lead Sponsor	Collaborator
Jared Fridley

Country where clinical trial is conducted

United States, 

References & Publications (18)

Blumberg TJ, Woelber E, Bellabarba C, Bransford R, Spina N. Predictors of increased cost and length of stay in the treatment of postoperative spine surgical site infection. Spine J. 2018 Feb;18(2):300-306. doi: 10.1016/j.spinee.2017.07.173. Epub 2017 Jul 21. — View Citation

Cohen LE, Fullerton N, Mundy LR, Weinstein AL, Fu KM, Ketner JJ, Hartl R, Spector JA. Optimizing Successful Outcomes in Complex Spine Reconstruction Using Local Muscle Flaps. Plast Reconstr Surg. 2016 Jan;137(1):295-301. doi: 10.1097/PRS.0000000000001875. — View Citation

de Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009 Jun;37(5):387-397. doi: 10.1016/j.ajic.2008.12.010. Epub 2009 Apr 23. — View Citation

Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010 Apr 7;303(13):1259-65. doi: 10.1001/jama.2010.338. — View Citation

Ghobrial GM, Cadotte DW, Williams K Jr, Fehlings MG, Harrop JS. Complications from the use of intrawound vancomycin in lumbar spinal surgery: a systematic review. Neurosurg Focus. 2015 Oct;39(4):E11. doi: 10.3171/2015.7.FOCUS15258. — View Citation

Hochberg J, Ardenghy M, Yuen J, Gonzalez-Cruz R, Miura Y, Conrado RM, Pait TG. Muscle and musculocutaneous flap coverage of exposed spinal fusion devices. Plast Reconstr Surg. 1998 Aug;102(2):385-9; discussion 390-2. doi: 10.1097/00006534-199808000-00013. — View Citation

Jain NK, Dao K, Ortiz AO. Radiologic evaluation and management of postoperative spine paraspinal fluid collections. Neuroimaging Clin N Am. 2014 May;24(2):375-89. doi: 10.1016/j.nic.2014.01.001. — View Citation

Johnson AJ, Kapadia BH, Daley JA, Molina CB, Mont MA. Chlorhexidine reduces infections in knee arthroplasty. J Knee Surg. 2013 Jun;26(3):213-8. doi: 10.1055/s-0032-1329232. Epub 2012 Nov 12. — View Citation

Kapadia BH, Zhou PL, Jauregui JJ, Mont MA. Does Preadmission Cutaneous Chlorhexidine Preparation Reduce Surgical Site Infections After Total Knee Arthroplasty? Clin Orthop Relat Res. 2016 Jul;474(7):1592-8. doi: 10.1007/s11999-016-4767-6. — View Citation

Lemans JVC, Oner FC, Wijdicks SPJ, Ekkelenkamp MB, Vogely HC, Kruyt MC. The efficacy of intrawound vancomycin powder and povidone-iodine irrigation to prevent surgical site infections in complex instrumented spine surgery. Spine J. 2019 Oct;19(10):1648-1656. doi: 10.1016/j.spinee.2019.05.592. Epub 2019 May 31. — View Citation

Lung BE, Le R, Callan K, McLellan M, Issagholian L, Yi J, McMaster WC, Yang S, So DH. Chlorhexidine gluconate lavage during total joint arthroplasty may improve wound healing compared to dilute betadine. J Exp Orthop. 2022 Jul 10;9(1):67. doi: 10.1186/s40634-022-00503-w. — View Citation

Mallet C, Meissburger V, Caseris M, Happiette A, Chinnappa J, Bonacorsi S, Simon AL, Ilharreborde B. Does the use of intrawound povidone-iodine irrigation and local vancomycin powder impact surgical site infection rate in adolescent idiopathic scoliosis surgery? Eur Spine J. 2022 Nov;31(11):3020-3028. doi: 10.1007/s00586-022-07340-6. Epub 2022 Aug 1. — View Citation

Martin BI, Mirza SK, Spina N, Spiker WR, Lawrence B, Brodke DS. Trends in Lumbar Fusion Procedure Rates and Associated Hospital Costs for Degenerative Spinal Diseases in the United States, 2004 to 2015. Spine (Phila Pa 1976). 2019 Mar 1;44(5):369-376. doi: 10.1097/BRS.0000000000002822. — View Citation

Rinkinen JR, Weitzman RE, Clain JB, Lans J, Shin JH, Eberlin KR. Locoregional Flap Closure for High-risk Multilevel Spine Surgery. Plast Reconstr Surg Glob Open. 2020 Apr 21;8(4):e2751. doi: 10.1097/GOX.0000000000002751. eCollection 2020 Apr. — View Citation

Schroeder JE, Girardi FP, Sandhu H, Weinstein J, Cammisa FP, Sama A. The use of local vancomycin powder in degenerative spine surgery. Eur Spine J. 2016 Apr;25(4):1029-33. doi: 10.1007/s00586-015-4119-3. Epub 2015 Aug 7. — View Citation

Torres KA, Konrade E, White J, Tavares Junior MCM, Bunch JT, Burton D, Jackson RS, Birlingmair J, Carlson BB. Irrigation techniques used in spine surgery for surgical site infection prophylaxis: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2022 Aug 26;23(1):813. doi: 10.1186/s12891-022-05763-2. — View Citation

Yao R, Tan T, Tee JW, Street J. Prophylaxis of surgical site infection in adult spine surgery: A systematic review. J Clin Neurosci. 2018 Jun;52:5-25. doi: 10.1016/j.jocn.2018.03.023. Epub 2018 Mar 30. — View Citation

Youssef JA, Orndorff DG, Scott MA, Ebner RE, Knewitz AP. Sterile Seroma Resulting from Multilevel XLIF Procedure as Possible Adverse Effect of Prophylactic Vancomycin Powder: A Case Report. Evid Based Spine Care J. 2014 Oct;5(2):127-33. doi: 10.1055/s-0034-1386754. — View Citation

* Note: There are 18 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Occurrence of surgical site infection	Development of infection after index spinal instrumentation	90 days post-operatively
Secondary	Mortality	Capture mortality rates after index spinal instrumentation	12 months post-operatively
Secondary	Duration of index hospitalization	Capture duration of index hospitalization after index spinal instrumentation	12 months post-operatively
Secondary	Occurrence of 30-day readmission	Capture 30-day readmission rates after index spinal instrumentation	30 days post-operatively
Secondary	Occurrence of wound dehiscence	Capture all incidences of wound dehiscence after index spinal instrumentation	12 months post-operatively
Secondary	Time to closed suction drain removal	Capture the time interval to closed suction drain removal after index spinal instrumentation	12 months post-operatively
Secondary	Presence of atypical micro-organisms on wound fluid laboratory culture	Capture the presence of atypical micro-organisms after index spinal instrumentation	12 months post-operatively
Secondary	Cost of spine surgery care from surgery to 12-month post-operative follow up	Consider associated total costs of spinal instrumentation after index spinal instrumentation by comparing total surgical costs and post-surgical outcome expenses of those with and without Irrisept irrigation use	12 months post-operatively