Korean J Pain.  2023 Jan;36(1):11-50. 10.3344/kjp.22397.

No more tears from surgical site infections in interventional pain management

  • 1Division of Infectious Diseases, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
  • 2Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea


As the field of interventional pain management (IPM) grows, the risk of surgical site infections (SSIs) is increasing. SSI is defined as an infection of the incision or organ/space that occurs within one month after operation or three months after implantation. It is also common to find patients with suspected infection in an outpatient clinic. The most frequent IPM procedures are performed in the spine. Even though primary pyogenic spondylodiscitis via hematogenous spread is the most common type among spinal infections, secondary spinal infections from direct inoculation should be monitored after IPM procedures. Various preventive guidelines for SSI have been published. Cefazolin, followed by vancomycin, is the most commonly used surgical antibiotic prophylaxis in IPM. Diagnosis of SSI is confirmed by purulent discharge, isolation of causative organisms, pain/tenderness, swelling, redness, or heat, or diagnosis by a surgeon or attending physician. Inflammatory markers include traditional (C-reactive protein, erythrocyte sedimentation rate, and white blood cell count) and novel (procalcitonin, serum amyloid A, and presepsin) markers. Empirical antibiotic therapy is defined as the initial administration of antibiotics within at least 24 hours prior to the results of blood culture and antibiotic susceptibility testing. Definitive antibiotic therapy is initiated based on the above culture and testing. Combination antibiotic therapy for multidrug-resistant Gramnegative bacteria infections appears to be superior to monotherapy in mortality with the risk of increasing antibiotic resistance rates. The never-ending war between bacterial resistance and new antibiotics is continuing. This article reviews prevention, diagnosis, and treatment of infection in pain medicine.


Anti-Bacterial Agents; Antibiotic Prophylaxis; Blood Culture; Cefazolin; C-Reactive Protein; Discitis; Drug Combinations; Drug Resistance; Bacterial; Guideline; Serum Amyloid A Protein; Surgical Wound Infection; Vancomycin


  • Fig. 1 The normal changes of useful perioperative inflammatory markers in a non-infection group for the detection of surgical site infection. The normal preoperative CRP value (< 0.5 mg/dL) increases up to 13.5 mg/dL on the 3rd day postoperatively. It will become theoretically normalized less than 0.5 mg/dL on the 16th day after 5 elimination half-lives (13 days) with a first-order elimination with a half-life of 2.6 days in a non-infection group after spine surgery [24,28]. The normal preoperative ESR value in the non-infection group is less than 10 mm/h and is elevated to an abnormal level from the 4th days and becomes normalized over 2 weeks postoperatively [32]. The normal preoperative WBC count is between 5,000 and 10,000/mm3. The WBC count has a peak up to 14,000/mm3 on the 1st day, maintains at the abnormal level of 11,000/mm3 on the 3rd day, and is normalized on the 7th day postoperatively [35]. The normal preoperative PCT level is less than 0.04 ng/mL, is increased up to 0.1 ng/mL on the 1st day postoperatively. Surgical site infection can be suspected if the value increased over 0.5 ng/mL from 1st day postoperatively as an early indicator of SSI [37]. SAA level reaches the maximum level up to 20 mg/L on the 3rd day, and significantly decreases but higher than the reference level (median value = 3 mg/L, less than 10 mg/L) on the 13th day [38]. The normal preoperative PSPN level is 55–184 pg/mL, and it is elevated within 2 hours and reaches the peak of less than 258 pg/mL within 3 hours. The elevated level of PSPN is normalized on the 7th day [43,44]. POD: postoperative day, CRP: C-reactive protein, ESR: erythrocyte sedimentation rate, WBC: white blood cell, PCT: procalcitonin, SAA: serum amyloid A, PSPN: presepsin.


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