Intrawound application of vancomycin changes the responsible germ in elective spine surgery without significant effect on the rate of infection: a randomized prospective study

Assessing the Effectiveness of Antibiotic Irrigation to Reduce Bacterial Load at the Spinal Surgical Site: An In-Vitro Study

Introduction Intra-operative surgical site irrigation with antibiotics is believed to reduce the risk of infection in spine surgeries involving instrumentation. However, despite its frequent use, there is limited supporting evidence for this practice. This prospective in-vitro study aims to evaluate the effect of short-term antibiotic exposure on the growth of common pathogens associated with wound infections. Furthermore, this study aims to determine the optimal duration of antibiotic exposure to eradicate common surgical site infection organisms. Methods A suspension of one of three micro-organisms: (1) Staphylococcus aureus, (2) Staphylococcus epidermidis, or (3) Pseudomonas aeruginosa was added to 2-ml vials of an enriched medium, containing one of three antibiotics: (a) Vancomycin, (b) Gentamicin, or (c) Cefazolin. The final inoculum of each micro-organism was 103 CFU/ml, representing a contaminated surgical wound in spine surgery. Antibiotics were washed out from the suspension by a centrifugation technique after (i) 5 minutes, or (ii) 8 hours. The recovery of growth of the micro-organisms was monitored by laser light scattering technology. Results P. aeruginosa inoculated in vials with Gentamicin showed no 24-hour bacterial growth after 5-minute and 8-hour exposure to the antibiotic. Vials of all other bacteria-antibiotic combinations showed bacterial growth curves similar to the control vials after both 5-minute and 8-hour exposures to antibiotics, with no signs of bacterial growth inhibition. Conclusion The study demonstrated that Gentamicin effectively inhibited P. aeruginosa growth after both short-term (5-minute) and long-term (8-hour) exposures. However, no significant bacterial growth inhibition was observed with other bacteria-antibiotic combinations, regardless of the exposure time. These findings suggest that while Gentamicin may be effective against P. aeruginosa in the context of surgical site irrigation, the use of Vancomycin and Cefazolin does not appear to provide the same level of effectiveness for the other tested pathogens. Further studies are needed to evaluate alternative antibiotic strategies for broader infection control in spine surgeries.

Topical Antibiotic Prophylaxis for Preventing Surgical Site Infections of Clean Wounds: A Systematic Review and Meta-Analysis

Background: Topical antibiotic agents are not generally indicated for preventing of surgical site infections (SSIs) in clean incisions, and the drug concentrations that should be delivered to local incision sites remain uncertain. The aim of this study was to critically assess the efficacy of topical antibiotic agents in comparison with non-antibiotic agents for preventing SSIs in clean incisions by performing a systematic review and meta-analysis. Methods: We conducted a search of literature in PubMed, Embase, and Cochrane Databases and included randomized controlled trials (RCTs) on topical antibiotic use for patients with clean post-surgical incisions. The primary outcome was the incidence of SSI, presented as the event rate. Eleven RCTs were included. Results: Using random-effects modeling, the pooled risk ratio (RR) of developing a post-surgical incisions infection was 0.83 (95% confidence interval [CI], 0.61-1.16; I2, 0%). In subgroup analyses, no reductions in SSI were observed when topical antibiotic agents were used to treat incisions due to spinal (RR, 0.75; 95% CI, 0.40-1.38; I2, 0%), orthopedic (RR, 0.69; 95% CI, 0.37-1.29; I2, 0%), dermatologic (RR, 0.77; 95% CI, 0.39-1.55; I2, 65%), or cardiothoracic surgeries (RR, 1.31; 95% CI, 0.83-2.06; I2: 0%). The incidence of SSI across different operative phases did not differ for the application of topical antibiotic agents compared with non-antibiotic agents (RR, 0.80; 95% CI, 0.56-1.14; I2, 0%). Conclusions: The results of this meta-analysis show that topical antibiotic agents provide no clinical benefit for preventing SSI in clean incisions.

Is Vancomycin More Effective than Taurolidine? Comparative Analysis of Their Preventive Effect against Spinal Infection in 1000 Patients with Spinal Fusion

This study aimed to examine the effect of taurolidine irrigation on preventing surgical site infection by comparing the spinal infection rate after spinal fusion surgery using vancomycin powder application and taurolidine irrigation. Of 1081 participants, 369 underwent taurolidine irrigation, 221 underwent vancomycin powder application, and 491 were controls. Of the 20 surgical site infections (1.85%), 14 occurred in the control group (2.85%), 5 in the vancomycin group (2.26%), and 1 (0.27%) in the taurolidine group. Among the various variables, age at the time of surgery, smoking, surgical site, and hemovac removal time were significant in the univariate logistic regression. The final result was derived after variable selection using the stepwise method. In the univariate model, the odds ratios were 0.09 and 0.79 in each of the vancomycin and taurolidine groups compared to that of the control group. In the multivariate model, the odds ratios were 0.09 and 0.83 in each of the vancomycin and taurolidine groups compared to that of the control group. The preventive effect of vancomycin powder application was not statistically significant. However, the vancomycin group showed a less effective tendency than the taurolidine group. Taurolidine irrigation may be a good substitute for the vancomycin powder application.

Vancomycin Use in Posterior Lumbar Interbody Fusion of Deep Surgical Site Infection

Objective

To retrospectively analyze if the use of topical intraoperative vancomycin powder reduces deep surgical site infection (DSSI) after posterior lumbar interbody fusion.

Methods

All spinal surgeries for lumbar degenerative disease and underwent posterior fixation interbody fusion between January 2013 and December 2018 were reviewed. A total of 891 patients were included, of which 527 patients (treatment group) received intraoperatively topical vancomycin powder; the others were served as control group. The primary outcomes were the overall incidence of DSSI and the effect of vancomycin on its development. The secondary outcome was risk factors for DSSI. Data on the baseline characteristics, postoperative complications, perioperative risk factors, and one-year postoperative prognoses were extracted from the medical records.

Results

A total of 20 patients met the diagnostic criteria for DSSI (2.24%), of which 7 patients (1.33%) in the treatment group and 13 patients (3.57%) in the control group. There was a significant difference in the incidence of DSSI between the groups (P = 0.026). Multivariate logistic regression analysis with stepwise backward elimination showed that the local use of vancomycin powder was an independent protective factor for DSSI (odds ratio (OR): 0.25, P = 0.01), whereas high body mass index (BMI) (OR: 1.21, P = 0.005), drinking (OR: 5.19, P = 0.005), urinary tract infections (OR: 4.49, P = 0.021), diabetes mellitus (OR: 4.32, P = 0.03), and blood transfusions (OR: 3.67, P = 0.03) were independent risk factors for DSSI.

Conclusion

The intraoperative usage of vancomycin powder could reduce effectively decreases the incidence of DSSI after posterior lumbar interbody fusion for degenerative lumbar diseases. High BMI, diabetes mellitus, drinking, and urinary tract infections were independent risk factors for DSSI, whereas the local use of vancomycin protected against these factors.

Local vancomycin therapy to reduce surgical site infection in adult spine surgery: a randomized prospective study

PURPOSE

This prospective randomized controlled trial hypothesizes that intra wound vancomycin reduces postoperative infection.

METHODS

In this RCT study, the patients were randomly divided into two groups of treatment and control. In the treatment group, 1-2 g of intra wound vancomycin was used, and no drug was used for the control group. SSI and the type of microorganism causing postoperative infection were assessed at a three-month follow-up. Factors affecting postoperative infection such as age, sex, site of operation, surgical levels, and risk factors affecting postoperative infection, such as diabetes, blood pressure, ischemic heart disease, smoking, blood transfusion, BMI, neurologic deficit, CSF leakage, UTI, COPD and surgery time were examined in two groups.

RESULTS

In this study, 375 patients, including 187patients in the treatment group and 188 patients in the control group, were studied. Among the patients, 228 had surgery without instrumentation, and 147 had surgery with instrumentation. There were 12 cases of SSI in the treatment group and 11 in the control group, and there was no statistically significant difference between the two groups. There was no difference between the two groups with and without instrumentation in the evaluation of postoperative infection. In the subgroups with and without instruments, there was no significant difference between treatment and control groups. Due to the microorganism causing the infection, gram-negative bacteria were more common in the treatment group.

CONCLUSION

Intra-wound vancomycin has no effect on SSI; in addition, it can increase the rate of gram-negative infections.

Effectiveness of topical vancomycin in the prevention of spinal surgical site infections: a retrospective cohort study

BACKGROUND

The risk of surgical site infections (SSIs), particularly methicillin-resistant Staphylococcus aureus (MRSA) SSIs, after spinal surgeries is one of the most daunting experiences to patients and surgeons. Some authors suggest applying vancomycin powder on the wound before skin closure to minimize the risk of SSIs; however, this practice is not supported by well-established evidence. This study sought to assess the effectiveness of topical (i.e. intra-wound) vancomycin in minimizing the risk of SSIs in patients who underwent spinal surgeries at a Saudi hospital.

METHODS

A retrospective cohort study was conducted using the hospital database. Patients who underwent spinal surgeries from the period of 09/2013 to 09/2019 were included and followed up (observed from the time of the surgery) to 30 days (surgeries without implants) or 90 days (with implants). The odds ratio (OR) of the primary outcome between vancomycin treated versus non-treated patients was estimated using a logistic regression model adjusting for the measured confounders. A sensitivity analysis was conducted using propensity score analysis (inverse probability of treatment weighting [IPTW] with stabilized weights) to control for confounding by indication. All study analyses were completed using RStudio Version 1.2.5033.

RESULTS

We included 81 vancomycin treated vs. 375 untreated patients with 28 infections (8/81 vs. 20/375; respectively). The adjusted OR of SSIs between the two groups was 0.40 (95% confidence interval [CI] 0.11 to 1.34). The result of the propensity score analysis was consistent (OR: 0.97 [95% CI 0.35 to 2.68]).

CONCLUSIONS

We could not find a lower association of SSIs with intra-wound vancomycin in patients who underwent spinal surgeries. Further studies are needed to assess benefits of using topical vancomycin for this indication vs. the risk of antimicrobial resistance.

A meta-analysis of the local application of vancomycin powder to prevent surgical site infection after spinal surgeries

Objective

This study aimed to systematically analyze the effectiveness and safety of the local application of vancomycin powder to prevent surgical site infection (SSI) after spinal surgeries and provide guidance for clinical practice.

Methods

Two researchers independently searched PubMed, Web of Science, Elsevier, and China National Knowledge Infrastructure using the MeSH terms “spinal surgery,” “vancomycin,” “local,” “topical,” “prophylactic,” “surgical site infection,” and “SSI” to identify studies published between January 2010 and January 2020 on the local application of vancomycin powder for preventing SSI after spinal surgeries. The outcome assessment indicators were analyzed using RevMan 5.3 software.

Results

Three randomized controlled trials, two prospective studies, and 26 retrospective studies were included in the current research. The results of the meta-analysis revealed significant differences between the vancomycin and control groups (non-vancomycin group) concerning the incidence of SSI (risk ratio = 0.39, 95% confidence interval = 0.28–0.55, Z = 5.46), indicating that local application of vancomycin powder can significantly reduce the incidence of SSI.

Conclusion

Local application of vancomycin powder is an effective and safe method to prevent SSI after spinal surgeries.

Circulatory collapse during wound closure in spine surgery with an unknown cause: a possible adverse effect of topical application of vancomycin?

BACKGROUND

Vancomycin (VCM) is effective in fighting Gram-positive bacteria related severe infections, and topical application of VCM powder is widely used in orthopedic surgery to prevent wound infection. However, VCM could lead to infusion rate-dependent antibody-and complement-independent anaphylaxis reaction by inducing direct release of histamine.

CASE PRESENTATION

We retrospectively analyzed seven cases of severe hypotension and shock during wound closure or immediately after orthopedic surgery with unidentifiable reasons. We found that these cases were all associated with local application of VCM powder during wound closure process. Two patients experienced sudden cardiac arrest. Most of the cases (6/7) with circulatory collapse were discharged without severe sequelae. While one case with application of 3 g VCM developed cardiac arrest and remained in a coma due to hypoxic-hypoxic encephalopathy. The clinical presentations and the time of the shock onset were considered to be related with a VCM induced anaphylaxis reaction. However, as this was a retrospective study, and there was no laboratory examination performed, the conclusion was made upon differential diagnosis based on clinical manifestations and the timing of the shock.

CONCLUSIONS

Local application of VCM may not be as safe as was once believed and may lead to a related anaphylaxis. As VCM induced infusion-rate dependent, non-IgE mediated anaphylaxis is characterized by delayed occurrence, severe hypotension and even circulatory collapse, surgeons and anesthesiologists should be extra vigilant during and after VCM application.

[The effectiveness of local application of vancomycin powder in the prevention of surgical site infections in spine surgery: a meta-analysis]

OBJECTIVE

To perform a meta-analysis of studies examining the effectiveness of the local application of vancomycin powder for the prophylaxis of surgical site infections (SSIs) in spine surgery.

MATERIAL AND METHODS

Retrospective cohort studies and prospective randomized clinical trials were searched for in the Pubmed, EMBASE, Cochrane Library and eLibrary databases published from 2008 to December 2018. For the resulting variables, the odds ratio and 95% confidence interval were calculated using random and fixed effects models. Estimation of the degree of heterogeneity is estimated using the coefficient I². Statistically significant differences were considered differences p<0.05.

RESULTS

The meta-analysis included 28 clinical studies that included the results of the local application of vancomycin powder in 17,469 patients after performing various spinal surgical interventions. Two publications had a prospective, randomized, controlled study design. Topical application of vancomycin powder reduces the incidence of SSIs after spine surgery (p<0.0001). The use of vancomycin powder reduces the incidence of SSIs in patients operated on with stabilizing implants (p=0.004). On the other hand, the topical application of vancomycin powder did not affect the prevalence of SSIs in respondents who were operated on without the use of stabilizing implants (p=0.12) or due to deformities of the spine (p=0.06).

CONCLUSION

Topical application of vancomycin powder is highly effective in preventing the development of SSIs in patients after spinal surgical interventions.

Infection prevention in cervical spine surgery

Surgical site infections (SSI) following cervical spine surgery can lead to significant patient morbidity and costs. Prevention of SSIs is multifactorial and can be divided in to preoperative patient optimization and intraoperative surgical factors. We performed a literature review to identify methods that can be used to prevent SSI development specifically in the cervical spine. We also present specific surgical pearls and techniques that have the potential to significantly decrease rates of cervical SSIs.

Surgical Site Infection Prevention Following Spine Surgery

STUDY DESIGN

Literature review.

OBJECTIVES

Surgical site infection (SSI) following spine surgery leads to significant patient morbidity, mortality, and increased health care costs. The purpose of this article is to identify risk factors and strategies to prevent SSIs following spine surgery, with particular focus on avoiding infections in posterior cervical surgery.

METHODS

We performed a literature review and synthesis to identify methods that can be used to prevent the development of SSI following spine surgery. Specific pearls for preventing infection in posterior cervical spine surgery are also presented.

RESULTS

SSI prevention can be divided into patient and surgeon factors. Preoperative patient factors include smoking cessation, tight glycemic control, weight loss, and nutrition optimization. Surgeon factors include screening and treatment for pathologic microorganisms, skin preparation using chlorhexidine and alcohol, antimicrobial prophylaxis, hand hygiene, meticulous surgical technique, frequent irrigation, intrawound vancomycin powder, meticulous multilayered closure, and use of closed suction drains.

CONCLUSION

Prevention of SSI following spine surgery is multifactorial and begins with careful patient selection, preoperative optimization, and meticulous attention to numerous surgical factors. With careful attention to various patient and surgeon factors, it is possible to significantly reduce SSI rates following spine surgery.

Does the Application of Topical Intrawound Vancomycin Powder Affect Deep Surgical Site Infection and the Responsible Organisms after Spinal Surgery?: A Retrospective Case Series with a Historical Control Group

STUDY DESIGN

Retrospective case series with a historical control group.

PURPOSE

To compare the deep wound infection rates in patients undergoing spinal surgery with the application of topical intrawound vancomycin powder (TIVP) in the surgical site in addition to standard systemic prophylaxis with those in a matched historical cohort of patients for whom TIVP was not used.

OVERVIEW OF LITERATURE

Surgical site infection (SSI) after spine surgery is debilitating and is responsible for a significant increase in the health care costs, hospital stay, and morbidities. Although the application of TIVP before surgical closure is a promising method for reducing the SSI rate after spine surgery, its use is controversial, and currently, research trials are focusing on identifying its safety, efficacy, and the potential patient population.

METHODS

A group of 88 patients who underwent posterior spinal surgery with TIVP administration (treatment group) was compared to a historical control group of 70 patients who had received only standard systemic intravenous prophylaxis (control group) for the analysis of deep SSI rate and the involved organisms.

RESULTS

The overall rate of deep SSIs was 2.5% (4/158). All the SSIs were observed in patients who had posterior instrumentation and fusion for ≥3 levels. In the treatment group, the SSI rate was 3.4% (3/88), and the bacteria isolated were Escherichia coli (n=2) and Pseudomonas aeruginosa (n=1). In the control group, the infection rate was 1.4% (1/70), and the isolated bacteria were Morganella morganii and Staphylococcus epidermidis. No statistically significant association was found between the SSI rates of the treatment and control groups.

CONCLUSIONS

Although the difference in the SSI rates was not statistically significant, the present results suggest that TIVP administration could not reduce the risk of deep SSIs after spinal surgery. Moreover, TIVP administration might also affect the underlying pathogens by increasing the propensity for gram-negative species.

Infectious Prophylaxis with Intrawound Vancomycin Powder in Orthopedic Surgeries: Systematic Review with Meta-Analysis

Despite many existing strategies used to reduce the rates of surgical site infection (SSI), these are still fairly frequent complications that pose a challenge for orthopedic surgeons. Therefore, the search for more effective methods of perioperative infection prophylaxis became a main subject of research, with the goal of decreasing postoperative morbidity, mortality, and costs. Thus, the present study sought to assess the effectiveness of intra-wound vancomycin powder in orthopedic surgery SSI prophylaxis. A systematic review and meta-analysis study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols 2015 (PRISMA-P 2015). A comprehensive literature search was performed to identify controlled studies on the rates of SSI with or without the local use of vancomycin powder. Exclusion and inclusion criteria were applied. A meta-analysis with random effects was performed. Out of 412 titles that met the criteria, 7 studies regarding spine surgery were included: 4 prospective and 3 retrospective studies. A total of 6,944 cases were identified, and they were divided into 2 groups: the control group (3,814 patients), to whom intrawound vancomycin was not administered, and the intervention group (3,130 patients), to who vancomycin was administered locally. We observed that 64 (2.04%) patients in the intervention group developed SSI, in contrast to 144 (3.75%) patients in the control group. The results of the meta-analysis showed that the local use of vancomycin powder had an statistically significant protective effect against SSI in cases of spine surgery, with a relative risk (RR) of 0.59 and a 95% confidence interval (95%CI) of 0.35-0.98. The use of prophylactic intrawound vancomycin powder has a protective effect against SSI in spine surgeries; however, further prospective trials are needed to endorse its use in orthopedic surgeries.

Meta-analysis of topical vancomycin powder for microbial profile in spinal surgical site infections

OBJECTIVES

To systematically evaluate the impact of topical vancomycin powder for microbial profile in spinal surgical site infections.

METHODS

All available literature regarding the topical use of vancomycin powder to prevent postoperative spinal infections was retrieved from the MEDLINE, EMBASE, and Cochrane databases starting from the creation date and up until September 30, 2018.

RESULTS

A total of 21 studies involving 15,548 patients were reviewed. The combined odds ratio showed that topical use of vancomycin powder was effective for reducing the incidence of gram-positive bacterial infections in spinal surgical sites (OR 0.41, P < 0.00001) without affecting its efficacy in the prevention of polymicrobial infections (OR 0.30, P = 0.03). Additionally, it could significantly reduce the infection rate of methicillin-resistant staphylococcus (OR 0.34, P < 0.0001). However, topical vancomycin powder showed no advantage for preventing gram-negative bacterial infections (OR 0.94, P = 0.75).

CONCLUSIONS

Topical administration of vancomycin powder may not increase the rates of gram-negative bacterial or polymicrobial infections in spinal surgical sites. On the contrary, it can significantly reduce the infection rates of gram-positive bacteria, methicillin-resistant staphylococcus (MRS) and microorganism. Of course, the topical vancomycin powder cannot change the rates of gram-negative bacterial infections, which may be related to the antimicrobial spectrum of vancomycin. Due to the limited number of articles included in this study, additional large-scale and high-quality studies are needed to provide more reliable clinical evidence.

Risk Factors and Prevention of Surgical Site Infections Following Spinal Procedures

STUDY DESIGN

Focused literature review.

OBJECTIVE

The objective of this article was to help identify potential risk factors as well as strategies to help prevent surgical site infections (SSIs) in spine surgery.

METHODS

An article search was performed using PubMed, EMBASE, and the Cochrane database of systematic reviews using the terms "surgery" OR "surgical" AND "spine" OR "spinal" AND "infection". Systematic review articles, meta-analyses, and clinical trials with more than 100 patients were reviewed.

RESULTS

Both patient and perioperative factors contribute to the development of SSIs. Patient factors such as smoking, obesity, diabetes, Methicillin-resistant Staphylococcus aureus (MRSA) colonization, and malnutrition are all modifiable risk factors that can lead to SSIs. Procedural steps, including preoperative MRSA screening and treatment for colonization, preoperative antibiotics, skin preparation, minimizing operative time, antibiotic or betadine irrigation, avoiding personnel turnover, and postoperative wound care have also been shown to decrease infection rates.

CONCLUSION

There are several measures a spine practitioner may be able to take in the preoperative, intraoperative, and postoperative settings. Protocols to counsel patients regarding modification of preexisting risk factors and ensure adequate antimicrobial therapy in the perioperative period may be developed to reduce SSIs in spine surgery.

Effect of intrawound vancomycin application in spinal surgery on the incidence of surgical site infection: a meta-analysis

Background

Despite great advances in aseptic surgical techniques, surgical site infection (SSI) is still one of the main complications after spine surgery. SSI can bring tremendous physical, psychological, and economic challenges to patients. Intrawound vancomycin application is a much disputed method for the prevention of SSI after spine surgery.

Objective

The aim of this study is to review the current literature for studies on the intra-wound application of vancomycin powder and to analyze its effectiveness in the prevention of postoperative SSI.

Methods

PubMed, Medline, Elsevier, and CNKI were searched for the key words “vancomycin”, “local/intraoperative/topical/intra-wound”, “spine/spinal/lumbar/cervical/thoracolumbar surgery”, “infection”, and “SSI” in published studies on the effectiveness of intrawound vancomycin application to prevent postoperative SSI. RevMan 5.3 was used to compare the data extracted from the studies included.

Results

A total of 27 studies involving 17,321 patients were included in the final analysis. Among those patients, 7,423 patients were treated with vancomycin to prevent SSI, with 9,898 in control groups. SSI incidence after surgery in experimental groups was 0.39 times as high as control groups, and this difference was statistically significant (P<0.01). Among patients who underwent internal fixation, vancomycin application significantly reduced the incidence of postoperative SSI (OR 0.31 95% CI 0.19–0.50; P<0.01). Meanwhile, vancomycin did not affect SSI incidence in patients who did not receive internal fixation (P=0.17) or received deformity correction (P=0.25).

Conclusion

SSI incidence after spinal surgery can be significantly reduced by intrawound application of vancomycin in most circumstances. This method can be applied in various spinal procedures involving instrumentation to prevent postoperative SSI.