Is It Cost Effective to Obtain Fungal and Acid-Fast Bacillus Cultures during Spine Debridement?

Mark J Lambrechts; Devin D St Clair; Jinpu Li; James L Cook; Bradley S Spence; Emily V Leary; Theodore J Choma; Donald K Moore; Christina L Goldstein

doi:10.31616/asj.2021.0169

Is It Cost Effective to Obtain Fungal and Acid-Fast Bacillus Cultures during Spine Debridement?

Asian Spine J. 2022 Aug;16(4):519-525. doi: 10.31616/asj.2021.0169. Epub 2021 Nov 18.

Authors

Mark J Lambrechts¹, Devin D St Clair¹, Jinpu Li¹, James L Cook^{1

2}, Bradley S Spence¹, Emily V Leary¹, Theodore J Choma¹, Donald K Moore¹, Christina L Goldstein³

Affiliations

¹ Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA.
² Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, USA.
³ Department of Orthopaedic Spine Surgery, University of Colorado at Colorado Springs, Colorado Springs, CO, USA.

Abstract

Study design: Retrospective study.

Purpose: To identify the rate of positive acid-fast bacillus (AFB) and fungal cultures during spine debridement, determine whether these infections are more common in certain spine segments, identify comorbidities associated with these infections, and determine whether the universal performance of fungal and AFB cultures during spine debridement is cost effective.

Overview of literature: Spine infections are associated with significant morbidity and costs. Spine fungal and AFB infections are rare, but their incidence has not been well documented. As such, guidance regarding sample procurement for AFB and fungal cultures is lacking.

Methods: A retrospective review of medical record data from patients undergoing spine irrigation and debridement (I&D) at the University of Missouri over a 10-year period was performed.

Results: For patients undergoing spine I&D, there was a 4% incidence of fungal infection and 0.49% rate of AFB infection. Steroid use was associated with a higher likelihood (odds ratio, 5.62; 95% confidence interval, 1.33-23.75) of positive fungal or AFB cultures. Although not significant, patients undergoing multiple I&D procedures had higher rates of positive fungal cultures during each subsequent I&D. Over a 10-year period, if fungal cultures are obtained for each patient, it would cost our healthcare system $12,151.58. This is compared to an average cost of $177,297.64 per missed fungal infection requiring subsequent treatment.

Conclusions: Spine fungal infections occur infrequently at a rate of 4%. Physicians should strongly consider obtaining samples for fungal cultures in patients undergoing spine I&D, especially those using steroids and those undergoing multiple I&Ds. Our AFB culture rates mirror the false positive rates seen in previous orthopedic literature. It is unlikely to be cost effective to send for AFB cultures in areas with low endemic rates of AFB.

Keywords: Antifungal agents; Bacillus; Cost-benefit analysis; Cost-savings; Fungi; Lumbar spine; Surgical wound infection.