Surgical site infection in spinal surgery: detection and management based on serial C-reactive protein measurements

OBJECT: C-reactive protein (CRP) is a well-known sensitive laboratory parameter that shows an increase within 6 hours after the onset of bacterial infection. In relation to surgery, a normal CRP response is a rapid increase followed by a gradual reduction, eventually returning to the normal range. The goal of this study was to determine the diagnostic significance of CRP as a detector for early onset surgical site infection in spinal surgery and to discuss effective medical treatment through clinical interpretation and application of the measured CRP values. METHODS: A prospective study was performed in 348 consecutive cases involving patients who underwent spinal surgery under general anesthesia between February and September 2008. Blood samples were obtained preoperatively and on postoperative Days 1, 3, and 5 in patients undergoing single-level decompression surgery. An additional blood specimen was obtained at postoperative Day 7 in patients requiring more extensive surgeries. Recorded laboratory results were compared with the patients' clinical course to determine the diagnostic significance of CRP. All of the patients received intravenous prophylactic antibiotic therapy. Once an abnormal response of CRP, indicated by a tendency toward continuous elevation, was noted on Day 5 or Day 7, the prophylactic antibiotics were replaced with another regimen and administration was resumed along with careful observation for signs of surgical site infection. RESULTS: Monitoring of CRP revealed a characteristic increase and decrease pattern in 332 of 348 patients (95.4%) showing a normal clinical course with regard to early infectious complications. The mean measured CRP (reference range < 4 mg/L) averaged 14.9 +/- 20.3 mg/L on Day 1, 15.4 +/- 25.1 mg/L on Day 3, and 7.9 +/- 13.3 mg/L on Day 5. In contrast, there were 16 cases (4.6%) of abnormal CRP responses resulting in the resumption of intravenous antibiotic treatment, which included a second rise (in 12 cases) and a steady rise (in 4) in the CRP value. Five (1.4%) of 16 patients experienced infectious complications related to spinal surgery. Three patients (0.9%) received long-term antibiotic therapy for 4-6 weeks; however, all patients recovered with medical treatment alone and did not experience gross wound disruption or subsequent discitis. As a predictor for early wound infection, the sensitivity, specificity, positive predictive value, and negative predictive value for abnormal CRP responses were calculated as 100%, 96.8%, 31.3%, and 100%, respectively. CONCLUSIONS: The above results demonstrate that CRP screening is a simple and reliable test for the detection of early infectious complications after spinal surgery. Close observation and appropriate medical management should be performed in a timely fashion when abnormal CRP responses are observed at 5 or 7 days after surgery.