Continuous local antibiotic perfusion for spinal infection: a systematic review of reported cases

Abstract

Background Spinal infections are difficult to cure, especially when implants are present, because implant removal can destabilize the spine. Continuous local antibiotic perfusion (CLAP) delivers high-concentration antibiotic directly to the infected site. We systematically reviewed and descriptively synthesized the reported cases of CLAP for spinal infection. Methods MEDLINE, Embase, CENTRAL, International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov were searched from inception through October 1, 2025. Case reports and case series using CLAP for spinal infection were included. The primary outcome was the reoperation- and mortality-free proportion after CLAP, a pragmatic composite surrogate that does not equate to microbiological or clinical cure. Secondary outcomes included time to reported clinical stabilization, recurrence, high-concentration-antibiotic toxicity (renal and hepatic dysfunction), device-related events, and reoperation. Results Nine studies with 48 patients were included, and most had a surgical site infection (SSI) with instrumentation. A reoperation- and mortality-free course was recorded in 36 patients (75.0%). However, the mean follow-up was only 7.5±4.3 months, and this surrogate may misclassify unresolved or non-operatively managed infection, or patients lost to follow-up, as successes; the estimate should be interpreted with caution. Complete implant retention was reported in 51.1% of patients, while 35.6% required removal. CLAP was given for a mean of 16.1±9.3 days, and reoperation after CLAP occurred in 25.0%. No treatment-related toxicity or device-related problems were reported. Conclusions Across the reported cases, CLAP was used as one component of multimodal management—with systemic antibiotics, surgical source control, and, in nearly all cases, negative-pressure wound therapy (NPWT)—rather than as a stand-alone therapy. Because the evidence is uncontrolled and dominated by a single cohort, this review can describe how CLAP has been applied and what outcomes were reported, but cannot establish its independent effectiveness or safety; controlled prospective studies are needed. The protocol was registered on the Open Science Framework (OSF; https://osf.io/rk4g6/).