Infection Reducing Strategies in Sacroneuromodulation: A Systematic Review

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

Methods: A systematic search of PubMed, Web of Science, Embase, Ovid, EBSCOHost, and ClinicalTrials.gov was initially performed on December 21, 2023, along with a follow-up search for more recent publications 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 outcome(s) of interest (infection, device explant, or surgery-related complications). Abstracts and potentially relevant full-text manuscripts were doubly screened. The percentage of reported infections from each study was extracted and studies were categorized by interventions. Time to infection and colonization results were extracted when available. Quality of studies was assessed using GRADE (Grading of Recommendations Assessment, Development, and Evaluation criteria).

Results: Of 6172 abstracts screened, 16 studies met the inclusion criteria. Study sizes ranged from 23-1930 participants, with 4246 participants in all included studies. Most studies were retrospective and overall the evidence was low in quality. Eleven studies reported on specific skin preparation solutions (Chlorhexidine (CHG), iodine-based, or both). One study (n=531) evaluated a preoperative protocol that included home CHG wipes, CHG skin solution, and additional iodine-based paint scrub, and reported a pre-protocol infection rate of 4.6% (4/87) and post-protocol infection rate of 0.9% (4/444). Eight studies reported using pre-operative antibiotics (commonly cefazolin, vancomycin, gentamicin, levofloxacin, and cefoxitin). A retrospective cohort (n=135) reported infection rates with preoperative cefazolin (17.1%, 6/35), vancomycin alone (2.0%, 1/50), and vancomycin plus gentamicin (1.96%,1/51); with an odds-ratio of 7.34 (1.25-54.77), p=0.01, for infection with preoperative cefazolin. Six studies reported antibiotics administered before and up to seven days after surgery. One retrospective cohort (n=232) reported no difference in infection rates between levofloxacin preoperatively and postoperatively (1.3%, 3/232) or cefazolin preoperatively and cefixime postoperatively (1.3%, 3/232). One study reported on the use of an antimicrobial pouch at the time of SNM (infection rate 0%, 0/85, in antimicrobial pouch vs 5.9%, 5/85, no antimicrobial pouch). Seven studies reported using irrigation solutions at the time of SNM placement. 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.

Conclusions: There was a wide range of infection rates after SNM among mostly retrospective studies (0-22.2%). There was significant heterogeneity among included studies regarding specific antibiotic or infection-reducing strategies. However, aseptic precautions such as preoperative and postoperative antibiotics, skin preparation solutions, and surgical techniques such as irrigation should be employed to reduce infection rates after SNM. Additional research is needed to optimize infection reduction strategies at the time of SNM.