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Cefazolin prophylaxis is associated with lower surgical site infection risk than vancomycin following elective spine
Michael S Kim1, Melissa R Romoff1, Ryan Beyer1
1Department of Orthopedic Surgery, University of California, Irvine, School of Medicine, 101 The City Dr S, Pavilion 3, Building 29A, Orange, CA 92868, United States.
Background:
Surgical site infection (SSI) remains a major cause of morbidity following elective spine surgery, with incidence rates up to 3%. Current guidelines recommend cefazolin as the first-line prophylactic antibiotic due to its efficacy against methicillin-sensitive Staphylococcus aureus (MSSA) and coagulase-negative staphylococci (CoNS). However, reported B-lactam allergies are commonly cited in clinical practice as a reason for substitution with vancomycin, which provides inferior coverage for MSSA and limited gram-negative activity. Prior single center studies suggest higher SSI risk with vancomycin, but large-scale evidence remains limited.
Methods:
A retrospective cohort analysis was conducted using the TriNetX US Collaborative Network (2015-2023). Adults undergoing elective spine surgery, including transforaminal or posterior interbody fusion (TLIF/PLIF), multilevel lumbar fusion, posterior cervical fusion, anterior cervical discectomy and fusions (ACDF), and microdiscectomy, were identified. Patients receiving perioperative cefazolin or vancomycin within 24 hours of surgery were included. 1:1 propensity score matching controlled for demographics, comorbidities, and infection risk factors. The primary outcome was 90-day SSI, assessed using ICD-10 diagnosis codes. Risk ratios (RR) were estimated using Cox proportional hazards models.
Results:
After matching, 12,996 patients were included across 5 procedure cohorts. Cefazolin prophylaxis was associated with lower or comparable SSI risk compared with vancomycin across all procedures. Statistically significant differences were observed for TLIF/PLIF (0.82% vs. 2.30%; RR 0.36, 95% CI 0.18-0.7; p = .0019) and microdiscectomy (0.34% vs. 0.69%; RR 0.50, 95% CI 0.27-0.93; p = .025). Nonsignificant trends favored cefazolin for posterior cervical fusion (0.88% vs. 1.41%), multilevel lumbar fusion (1.25% vs. 1.51%), and ACDF (0.30% vs. 0.54%).
Conclusions:
Cefazolin prophylaxis is associated with significantly lower SSI risk in elective spine procedures. These findings support cefazolin as the preferred perioperative antibiotic and emphasize the need for accurate B-lactam allergy assessment to optimize infection prevention and antimicrobial stewardship in spine surgery.
Insights
Cefazolin significantly reduces surgical site infection (SSI) risk in spine surgery compared to vancomycin. This highlights cefazolin as the preferred antibiotic for preventing SSIs and improving antimicrobial stewardship.
Area of Science:
- Orthopedics
- Infectious Disease
- Surgical Outcomes
Background:
- Surgical site infection (SSI) is a significant complication of elective spine surgery, with rates up to 3%.
- Cefazolin is recommended for SSI prophylaxis due to its efficacy against common pathogens like methicillin-sensitive Staphylococcus aureus (MSSA).
- Vancomycin is often substituted for cefazolin due to reported beta-lactam allergies, despite concerns about its coverage and potential for increased SSI risk.
Purpose of the Study:
- To compare the efficacy of cefazolin versus vancomycin in preventing SSI after elective spine surgery.
- To provide large-scale evidence on SSI rates associated with cefazolin and vancomycin prophylaxis.
- To inform antibiotic selection and antimicrobial stewardship practices in spine surgery.
Main Methods:
- A retrospective cohort analysis of adult patients undergoing elective spine surgery from 2015-2023 using the TriNetX US Collaborative Network.
- Included patients received perioperative cefazolin or vancomycin within 24 hours of procedures like TLIF/PLIF, lumbar fusion, cervical fusion, ACDF, and microdiscectomy.
- Propensity score matching was used to control for confounding factors, with 90-day SSI as the primary outcome assessed via ICD-10 codes.
Main Results:
- 12,996 patients were analyzed after 1:1 propensity score matching across five surgical cohorts.
- Cefazolin prophylaxis was associated with significantly lower SSI risk in transforaminal or posterior interbody fusion (TLIF/PLIF) and microdiscectomy procedures.
- While not always statistically significant, trends favored cefazolin for reduced SSI risk across posterior cervical fusion, multilevel lumbar fusion, and anterior cervical discectomy and fusions (ACDF).
Conclusions:
- Cefazolin prophylaxis is linked to substantially lower SSI rates in elective spine surgery compared to vancomycin.
- These findings support the use of cefazolin as the primary prophylactic antibiotic for spine procedures.
- Accurate assessment of beta-lactam allergies is crucial to optimize SSI prevention and antimicrobial stewardship.
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