SPINE Volume 40, Number 22, pp 1785–1791 ß 2015 Wolters Kluwer Health, Inc. All rights reserved
SURGERY
Urinary Tract Infection Following Posterior Lumbar Fusion Procedures An American College of Surgeons National Surgical Quality Improvement Program Study Daniel D. Bohl, MPH, Junyoung Ahn, BS,y Ehsan Tabaraee, MD,y Junho Ahn, BS,z Akshay Jain, BS,y Jonathan N. Grauer, MD, and Kern Singh, MD y
Study Design. Retrospective review of prospectively collected data. Objective. To determine the incidence and risk factors for the development of a urinary tract infection (UTI) after a posterior lumbar fusion procedure. Summary of Background Data. UTI after surgery is common and has important clinical consequences for both patients and the health care system. Few studies have examined UTI after spinal fusion procedures. Methods. Patients undergoing posterior lumbar fusion procedures during 2011 to 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Statistical comparisons were made using multivariate regression with adjustment for demographic, comorbidity, and operative characteristics. Results. A total of 10,825 patients met inclusion criteria. The incidence of a UTI was 1.77% (95% confidence interval ¼ 1.52%–2.02%). Independent risk factors for a UTI were greater age (for 50–59 yr, relative risk [RR] ¼ 1.0; 60–69 yr, RR ¼ 2.1; 70 yr, RR ¼ 3.5; P < 0.001), female sex (RR ¼ 2.2, P < 0.001), dependent functional status (RR ¼ 2.1, P ¼ 0.010), malnutrition (RR ¼ 2.3, P ¼ 0.004), diabetic status (for non– insulin-dependent diabetes, RR ¼ 1.5; for insulin-dependent diabetes, RR ¼ 1.9; P ¼ 0.011), and increased operative duration (for 120 – 179 min, RR ¼ 1.4; 180 – 239 min, RR ¼ 2.3; and for 240 min, RR ¼ 2.7; P < 0.001).
From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT; yDepartment of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL; and zNational Institute on Aging/ National Institutes of Health, Biomedical Research Center, Baltimore, MD. Acknowledgment date: February 26, 2015. First revision date: May 20, 2015. Acceptance date: May 20, 2015. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. Relevant financial activities outside the submitted work: board membership, consultancy, expert testimony, grants, royalties. Address correspondence and reprint requests to Kern Singh, MD, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St., Ste 300, Chicago, IL 60612; E-mail: [email protected] DOI: 10.1097/BRS.0000000000001003 Spine
Patients who developed a UTI had a greater risk for systemic sepsis than other patients (11.5% vs. 0.63%; adjusted RR ¼ 14.4, P < 0.001). Patients who developed a UTI had a greater risk for readmission than other patients (36.7% vs. 5.0%; adjusted RR ¼ 6.1, P < 0.001). Conclusion. UTIs occur in nearly 1 in 50 patients undergoing posterior lumbar fusion procedures. Patients who are older, female, dependent, malnourished, or diabetic are at greater risk and should be counseled and monitored accordingly. In addition, morbidity associated with a UTI in this population is substantial, as demonstrated by a 14-fold increase in the risk for systemic sepsis and a 6-fold increase in the risk for readmission. As such, increased preventative measures should be targeted to the patients identified here to be at greatest risk. Key words: age, diabetes mellitus, functional status, malnutrition, National Patient Safety Goal, National Surgical Quality Improvement Program, operative duration., posterior lumbar fusion procedures, preventable adverse event, readmission, sex, systemic sepsis, urinary catheterization, urinary tract infection. Level of Evidence: 3 Spine 2015;40:1785-1791
U
rinary tract infections (UTIs) are the most common nosocomial infections in the United States, accounting for more than one-third of all hospitalacquired infections nationwide.1 The majority of hospitalacquired UTIs are associated with indwelling urinary catheters.2 Indwelling catheters enable the formation of biofilms that facilitate the ascendance of microorganisms into the bladder. Previous studies have demonstrated substantial increases in morbidity3 and mortality4 as a result of UTIs among recently hospitalized patients. Recently, The Joint Commission designated reducing the rates of catheter-associated UTIs a ‘‘National Patient Safety Goal’’ for 2015.5 Similarly, the Centers for Medicare & Medicaid Services recently declared that catheter-associated UTIs are ‘‘preventable adverse events’’ for which reimbursement will be denied.6 In this context, quality improvement programs such as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) have made comparing risk-adjusted rates of UTIs a priority.7,8 www.spinejournal.com
1785
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
SURGERY Posterior lumbar fusion surgery is one of the most commonly performed spine procedures in the United States. Among commonly performed spine procedures, lumbar fusion procedures also have the highest rates of postoperative adverse events.9 Few studies have examined UTI after spine surgery.10,11 Moreover, these studies have been limited by either performance at a single center and small sample size10 or a heterogeneous population of spine procedures.11 The ACS-NSQIP is a nationwide surgical registry that prospectively follows patients for 30 days after major surgical procedures.7,8 The present study used the ACSNSQIP to specifically characterize the incidence, risk factors, and clinical implications of UTIs after posterior lumbar fusion procedures.
MATERIALS AND METHODS
The ACS-NSQIP database was accessed.8 Patients were identified who underwent posterior lumbar fusion surgery during 2011 to 2013. A patient was included if the Current Procedural Terminology code was 22612 (posterolateral lumbar fusion), 22630 (posterior lumbar interbody fusion/transforaminal lumbar interbody fusion), or 22633 (posterolateral lumbar fusion with posterior lumbar interbody fusion/transforaminal lumbar interbody fusion). Additional inclusion criteria were designation of the procedure as elective; fusion of 1, 2, or 3 levels; and complete demographic, comorbidity, and perioperative data. The information provided in the ACS-NSQIP database was used to characterize patients by demographic, comorbidity, and operative characteristics. Demographic characteristics included age (18–49, 50–59, 60–69, or 70 yr), sex (male or female), body mass index (24, 25–29, 30–34, or 35 kg/m2), and functional status (independent or dependent). Comorbidity characteristics included current smoker, malnutrition (preoperative albumin
SURGERY
Urinary Tract Infection Following Posterior Lumbar Fusion Procedures An American College of Surgeons National Surgical Quality Improvement Program Study Daniel D. Bohl, MPH, Junyoung Ahn, BS,y Ehsan Tabaraee, MD,y Junho Ahn, BS,z Akshay Jain, BS,y Jonathan N. Grauer, MD, and Kern Singh, MD y
Study Design. Retrospective review of prospectively collected data. Objective. To determine the incidence and risk factors for the development of a urinary tract infection (UTI) after a posterior lumbar fusion procedure. Summary of Background Data. UTI after surgery is common and has important clinical consequences for both patients and the health care system. Few studies have examined UTI after spinal fusion procedures. Methods. Patients undergoing posterior lumbar fusion procedures during 2011 to 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Statistical comparisons were made using multivariate regression with adjustment for demographic, comorbidity, and operative characteristics. Results. A total of 10,825 patients met inclusion criteria. The incidence of a UTI was 1.77% (95% confidence interval ¼ 1.52%–2.02%). Independent risk factors for a UTI were greater age (for 50–59 yr, relative risk [RR] ¼ 1.0; 60–69 yr, RR ¼ 2.1; 70 yr, RR ¼ 3.5; P < 0.001), female sex (RR ¼ 2.2, P < 0.001), dependent functional status (RR ¼ 2.1, P ¼ 0.010), malnutrition (RR ¼ 2.3, P ¼ 0.004), diabetic status (for non– insulin-dependent diabetes, RR ¼ 1.5; for insulin-dependent diabetes, RR ¼ 1.9; P ¼ 0.011), and increased operative duration (for 120 – 179 min, RR ¼ 1.4; 180 – 239 min, RR ¼ 2.3; and for 240 min, RR ¼ 2.7; P < 0.001).
From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT; yDepartment of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL; and zNational Institute on Aging/ National Institutes of Health, Biomedical Research Center, Baltimore, MD. Acknowledgment date: February 26, 2015. First revision date: May 20, 2015. Acceptance date: May 20, 2015. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. Relevant financial activities outside the submitted work: board membership, consultancy, expert testimony, grants, royalties. Address correspondence and reprint requests to Kern Singh, MD, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St., Ste 300, Chicago, IL 60612; E-mail: [email protected] DOI: 10.1097/BRS.0000000000001003 Spine
Patients who developed a UTI had a greater risk for systemic sepsis than other patients (11.5% vs. 0.63%; adjusted RR ¼ 14.4, P < 0.001). Patients who developed a UTI had a greater risk for readmission than other patients (36.7% vs. 5.0%; adjusted RR ¼ 6.1, P < 0.001). Conclusion. UTIs occur in nearly 1 in 50 patients undergoing posterior lumbar fusion procedures. Patients who are older, female, dependent, malnourished, or diabetic are at greater risk and should be counseled and monitored accordingly. In addition, morbidity associated with a UTI in this population is substantial, as demonstrated by a 14-fold increase in the risk for systemic sepsis and a 6-fold increase in the risk for readmission. As such, increased preventative measures should be targeted to the patients identified here to be at greatest risk. Key words: age, diabetes mellitus, functional status, malnutrition, National Patient Safety Goal, National Surgical Quality Improvement Program, operative duration., posterior lumbar fusion procedures, preventable adverse event, readmission, sex, systemic sepsis, urinary catheterization, urinary tract infection. Level of Evidence: 3 Spine 2015;40:1785-1791
U
rinary tract infections (UTIs) are the most common nosocomial infections in the United States, accounting for more than one-third of all hospitalacquired infections nationwide.1 The majority of hospitalacquired UTIs are associated with indwelling urinary catheters.2 Indwelling catheters enable the formation of biofilms that facilitate the ascendance of microorganisms into the bladder. Previous studies have demonstrated substantial increases in morbidity3 and mortality4 as a result of UTIs among recently hospitalized patients. Recently, The Joint Commission designated reducing the rates of catheter-associated UTIs a ‘‘National Patient Safety Goal’’ for 2015.5 Similarly, the Centers for Medicare & Medicaid Services recently declared that catheter-associated UTIs are ‘‘preventable adverse events’’ for which reimbursement will be denied.6 In this context, quality improvement programs such as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) have made comparing risk-adjusted rates of UTIs a priority.7,8 www.spinejournal.com
1785
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
SURGERY Posterior lumbar fusion surgery is one of the most commonly performed spine procedures in the United States. Among commonly performed spine procedures, lumbar fusion procedures also have the highest rates of postoperative adverse events.9 Few studies have examined UTI after spine surgery.10,11 Moreover, these studies have been limited by either performance at a single center and small sample size10 or a heterogeneous population of spine procedures.11 The ACS-NSQIP is a nationwide surgical registry that prospectively follows patients for 30 days after major surgical procedures.7,8 The present study used the ACSNSQIP to specifically characterize the incidence, risk factors, and clinical implications of UTIs after posterior lumbar fusion procedures.
MATERIALS AND METHODS
The ACS-NSQIP database was accessed.8 Patients were identified who underwent posterior lumbar fusion surgery during 2011 to 2013. A patient was included if the Current Procedural Terminology code was 22612 (posterolateral lumbar fusion), 22630 (posterior lumbar interbody fusion/transforaminal lumbar interbody fusion), or 22633 (posterolateral lumbar fusion with posterior lumbar interbody fusion/transforaminal lumbar interbody fusion). Additional inclusion criteria were designation of the procedure as elective; fusion of 1, 2, or 3 levels; and complete demographic, comorbidity, and perioperative data. The information provided in the ACS-NSQIP database was used to characterize patients by demographic, comorbidity, and operative characteristics. Demographic characteristics included age (18–49, 50–59, 60–69, or 70 yr), sex (male or female), body mass index (24, 25–29, 30–34, or 35 kg/m2), and functional status (independent or dependent). Comorbidity characteristics included current smoker, malnutrition (preoperative albumin
