SCS trial antibiotics?

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Baron Samedi

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In training, all patients got IV Ancef or Clinda if allergic and did not routinely go home with po. At my current set up, giving IV antibiotics is problematic for logistic reasons. I tried doing a literature review, but most articles I found relate more to implants.

What are others doing for their trials? Only IV ABX? PO alternative? No ABX?

Any actual papers or guidelines I should reference?
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I believe when I looked it up in the past literature said antibiotics didn't make a big difference and weren't necessary for trials.

That being said, I give IV abx preprocedure and then PO abx while the leads are hanging out. Bacitracin around the lead insertion site. Meningitis isn't something I want to ever see.

As a matter of fact, I'd use the chlorhexidine impregnated pad dressings we use for central lines if I had them available.
 
Ancef preop and Keflex PO during trial. Why? That's how I was taught. From what I know there is no evidence for ABx during a trial.
 
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We use PO anabiotic’s pre-procedure and then 500 mg of Keflex twice a day during the trial. We do this because if a patient gets infection it’s always better to say that we had them on anabiotic‘s versus not. The NACC guidelines they were posted above or a decent starting point but regarding post up antibiotics after a implant, there’s a paper by Dr. Hoelzer that showed clear benefit to postop anabiotic’s so everyone gets Keflex twice a day for five days after implant as well.
 
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Office trial, rocephin 1000mg im. In ASC gentamicin and 2g ancef, if pcn allergy clinda. For the duration of the trial I risk stratify, diabetics and those with history of infection with prior surgeries will get po bactrim DS. Most people without risk don't get antibiotics. I document on my op note reason for po antibiotics going home.
 
Ancef IM Preop + keflex Po during trial
 
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I do not use antibiotics routinely during a trial and have never had an infection. I use preop IV weight-based antibiotics in the ASC. In the office i give 1000mg PO keflex 1 hour prior to the trial. This should get you above 3 MIC (I looked it up a long time ago so correct me if I’m wrong). That’s it!


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pmrmd said:
IV Ancef/clinda pre and no orals during but leads under Ioban. 5 day trial.
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So after you place trial leads you cover everything under Ioban, or you trial through Ioban like an implant?

If the former, can you post a pic sometime? I kind of like that idea.
 
lobelsteve said:
you got it backwards.
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If I'm leaving metal implanted under skin, I'm going to give abx. Treating just like an Ortho implant. Trial is covered with a sterile dressing that doesn't get removed until sterile leads are removed. Postop abx seem unnecessary.

But I'm just a simple country doctor, what do I know?
 
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Green Grass said:
If I'm leaving metal implanted under skin, I'm going to give abx. Treating just like an Ortho implant. Trial is covered with a sterile dressing that doesn't get removed until sterile leads are removed. Postop abx seem unnecessary.
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Your rationale is confusing to me, and the reason people usually use PO ABx during the trial is bc there's no such thing as a truly sterile dressing, and you have a direct access point at the lead as it exits.

Occlusive dressings have been shown to be effective for 48 hrs only.

Do what you're going to do, and I'm sure your practice is probably successful with your way of doing things but your rationale is odd IMO.

You can't treat SCS like an ortho implant bc it isn't an ortho implant.

I am pretty sure I've read that PO ABx post implant increase the risk of infxn.

I use IV ABx preop, irrigate, and then use vancomycin powder in the pocket and midline wound (powder split 70/30 pocket to midline).

Again, none of this is make or break, and you're probably as successful as anyone else here...
 
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Green Grass said:
If I'm leaving metal implanted under skin, I'm going to give abx. Treating just like an Ortho implant. Trial is covered with a sterile dressing that doesn't get removed until sterile leads are removed. Postop abx seem unnecessary.

But I'm just a simple country doctor, what do I know?
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Hopefully enough to read the SCIP guidelines?
 
Green Grass said:
If I'm leaving metal implanted under skin, I'm going to give abx. Treating just like an Ortho implant. Trial is covered with a sterile dressing that doesn't get removed until sterile leads are removed. Postop abx seem unnecessary.

But I'm just a simple country doctor, what do I know?
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Green Grass said:
You could read the SCIP guidelines and base your clinical decisions off of that. No one will fault you.

Or, better yet, you could read this Spinal Cord Stimulator Implant Infection Rates and Risk Factors: A Multicenter Retrospective Study. - PubMed - NCBI and follow the data.
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I agree that your logic is a bit confusing. Simulators are not Ortho implants and should not be treated the same. You referenced a very good paper that clearly states using postop antibiotics and occlusive dressings decrease the rate of infection...so use both after implants. For a trial we still don’t have good data regarding anabiotics or not during the trial but most of us agree that it makes sense if you have leads hanging out of the body you should probably put them on antibiotics just to be safe.
 

Here is your leg to stand on:

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onlinelibrary.wiley.com onlinelibrary.wiley.com

Not a strong leg. Retrospective review suggesting further studies needed. Also goes against SCIP guidelines and thus a non-starter for anyone implanting at a hospital. Up side: potential reduced risk of infection. Down side: AAD and C diff.
 
basing clinical decisions on retrospective studies is tenuous. Level 2 or Level 3 evidence.

pls use more robust data.

in fact, from the same issue of Neuromodulation, this study suggests that local care and changes in healthcare practice reduces risk of implant infection markedly:

www.ncbi.nlm.nih.gov

A Multidisciplinary Infection Control Bundle to Reduce the Number of Spinal Cord Stimulator Infections - PubMed

Multidisciplinary measures to reduce SSIs reduced the number of SCS associated infections in our study setting.
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
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I like the decolonization plan. I've been doing that (forgot to mention in previous post).

That PLUS irrigation and vancomycin powder is great IMO.

Irrigation - I do it, but it probably doesn't do anything. I'm not religious with it. I think dead space around the IPG is what causes infxn, that and smoking.
 
Hospitals around me have terrible infection rates. I assume the worst and cover the patient during the trial and post implant (3days).

I don’t think anybody would fault you for being cautious , if an antibiotic complication occurs (ie VT, c diff, ARF). It’s not like stim trial abx usage has the same impact as routine pcp practices.
 
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Green Grass said:
If I'm leaving metal implanted under skin, I'm going to give abx. Treating just like an Ortho implant. Trial is covered with a sterile dressing that doesn't get removed until sterile leads are removed. Postop abx seem unnecessary.

But I'm just a simple country doctor, what do I know?
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No evidence for any antibiotics past 24 hours postop. Period.


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I started a stim trial last Thursday, uncomplicated placement to T8. He has had a headache since then - back of head, neck is stiff and now he says his ears are “full” as well. Neck ROM is preserved. No fevers and not positional. Headache does not respond to NSAIDs but briefly improved after a BM (he was constipated for 4 days after the trial). The stimulator is giving him 100% pain improvement. How much a concern would meningitis be with this time frame? I asked him to turn off the stim for a few hours to see if the headache changed.
 
Agast said:
I started a stim trial last Thursday, uncomplicated placement to T8. He has had a headache since then - back of head, neck is stiff and now he says his ears are “full” as well. Neck ROM is preserved. No fevers and not positional. Headache does not respond to NSAIDs but briefly improved after a BM (he was constipated for 4 days after the trial). The stimulator is giving him 100% pain improvement. How much a concern would meningitis be with this time frame? I asked him to turn off the stim for a few hours to see if the headache changed.
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Sometimes the fentanyl with sedation causes some impressive constipation, but I would be more worried about COVID than a PDPH/meningitis based on that presentation. If the headache gets worse after trial lead removal, then consider that it was a slow leak. Either way, get the leads out as you've gone long enough.
 
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Agast said:
I started a stim trial last Thursday, uncomplicated placement to T8. He has had a headache since then - back of head, neck is stiff and now he says his ears are “full” as well. Neck ROM is preserved. No fevers and not positional. Headache does not respond to NSAIDs but briefly improved after a BM (he was constipated for 4 days after the trial). The stimulator is giving him 100% pain improvement. How much a concern would meningitis be with this time frame? I asked him to turn off the stim for a few hours to see if the headache changed.
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I would image the leads, pull them(your trial's good to go anyways), get a CBC, and call the patient daily and check for resolution or progression.
 
Orin said:
Sometimes the fentanyl with sedation causes some impressive constipation, but I would be more worried about COVID than a PDPH/meningitis based on that presentation. If the headache gets worse after trial lead removal, then consider that it was a slow leak. Either way, get the leads out as you've gone long enough.
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Yeah, I didn’t mention he took his trial to a church luncheon and had a great time. COVID as headache-only seems like a stretch. I’ll see if I can get him to pull the leads.
 
Agast said:
Yeah, I didn’t mention he took his trial to a church luncheon and had a great time. COVID as headache-only seems like a stretch. I’ll see if I can get him to pull the leads.
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I've personally never had a patient pull their own leads and I wouldn't start on a guy where meningitis is on the ddx. I'd def want to see what the entry site looks like.
 
Baron Samedi said:
I've personally never had a patient pull their own leads and I wouldn't start on a guy where meningitis is on the ddx. I'd def want to see what the entry site looks like.
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I mean, I’ll see if I can get him to come in so I can pull them lol. I sutured the heck out of them.
 
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Agast said:
I started a stim trial last Thursday, uncomplicated placement to T8. He has had a headache since then - back of head, neck is stiff and now he says his ears are “full” as well. Neck ROM is preserved. No fevers and not positional. Headache does not respond to NSAIDs but briefly improved after a BM (he was constipated for 4 days after the trial). The stimulator is giving him 100% pain improvement. How much a concern would meningitis be with this time frame? I asked him to turn off the stim for a few hours to see if the headache changed.
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Eek. You got this call Monday and still left leads in for another 48h? Not something I’d have messsed around with. This kind of complaint, patient gets seen back in office and leads come out immediately.
 
paindoc007 said:
Eek. You got this call Monday and still left leads in for another 48h? Not something I’d have messsed around with. This kind of complaint, patient gets seen back in office and leads come out immediately.
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No, I got it around 6 pm today and he lives an hour away.

In sort of an unfortunate perfect storm, we’ve not had power for the last few days and the roads are hazardous from freezing rain...so I am asking him to come in so I can examine him with a flashlight in a cold empty building.
 
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Agast said:
No, I got it around 6 pm today and he lives an hour away.

In sort of an unfortunate perfect storm, we’ve not had power for the last few days and the roads are hazardous from freezing rain...so I am asking him to come in so I can examine him with a flashlight in a cold empty building.
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Texas?
 
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