Infection Reducing Strategies in Sacroneuromodulation: A Systematic Review

To determine the effect of infection-reducing strategies on postoperative complications for adult patients receiving sacroneuromodulation (SNM).

A systematic search of PubMed, Web of Science, Embase, Ovid, various EBSCOHost databases, and ClinicalTrials.gov was initially performed on December 21, 2023, and updated on March 25, 2024. Studies with patients receiving SNM for any indication were included if they reported specific infection-reducing intervention(s) as well as at least one outcome(s) of interest (infection, device explant, or surgery-related complications). Abstracts and potentially relevant full-text manuscripts were double screened. The percentage of reported infections from each study was extracted and studies were categorized by interventions. Meta-analysis and meta-regression were used to characterize the impact of different interventions across studies. Time to infection and colonization results were extracted when available. The quality of studies was assessed using Grading of Recommendations Assessment, Development, and Evaluation criteria (GRADE).

Of 6172 abstracts screened, 16 studies met the inclusion criteria. An additional study that met inclusion criteria but was published after the search was included based on editorial recommendation. Study sizes ranged from 23 to 1930 participants, with 5679 participants across all included studies. Most studies were retrospective, and overall, the evidence was low in quality. There was a wide range of infection rates after SNM (0%-22.2%). Fifteen studies reported preoperative antibiotics (commonly cefazolin, cefoxitin, vancomycin, gentamicin). Six studies reported antibiotics administered before and up to 7 days after surgery. Eight studies reported the use of specific irrigation solution at the time of SNM placement. One study reported on the use of an antimicrobial pouch at the time of SNM. Eleven studies reported on specific skin preparation solutions (chlorhexidine (CHG), iodine-based, or both). One study reported explant rate without specifically reporting the rate of infection. No difference in infection was clearly identified on pooled analysis between different skin preparation solutions (CHG based, iodine based, or both) or between major classes of preoperative antibiotics. In addition, no difference in the pooled infection rate was found between studies reporting pre- and postoperative antibiotics or irrigation solution compared to those that did specify these interventions. Time to infection was assessed with eight studies reporting time to infection < 3 months, three studies reporting time to infection > 3 months, and five studies did not specify the time to infection.

There was significant heterogeneity among included studies regarding specific antibiotic or infection-reducing interventions. We recommend surgeons use antibiotics based on availability, regional antibiotic resistance, and patient colonization factors until higher level evidence is available.

PROSPERO (CRD42024498513).