Local Application of Vancomycin in Spine Surgery Does Not Result in Increased Vancomycin-Resistant Bacteria-10-Year Data

Local vancomycin administration in Orthopaedic Surgery - A systematic review of comparative studies

Background

There is still controversy surrounding the routine use of vancomycin locally in primary orthopaedic surgery procedures. Therefore, the aim of this review is to assess how local vancomycin impacts the rates and microbiology of surgical site infections.

Methods

A systematic electronic search of MEDLINE, EMBASE, and Web of Science was carried out for all comparative studies comparing locally applied vancomycin to control for primary orthopaedic surgery procedures published before August 14, 2022.

Results

A total of 61 studies with 65,671 patients were included for analysis. Forty-six studies used vancomycin powder, 12 studies with grafts soaked in vancomycin, two studies used vancomycin irrigation, and one study administered vancomycin interosseously. There were 15 studies (of 26) in spine surgery, five (of 14) in arthroplasty, ten (of 11) in sports medicine, and two (of five) in trauma surgery that found statistically significant decreases in overall infection rates when applying local vancomycin. Only one study (in spine surgery) found significant increases in infection rates with local vancomycin application. For spine surgery, local vancomycin application had the greatest proportion of gram-negative bacteria (40.7%) isolated compared to S. aureus (42.4%) in controls. In arthroplasty and trauma surgery, there were increases in the proportions of gram-negative bacteria when vancomycin was added. There were no reported systemic adverse reactions associated with local vancomycin use in any of the studies.

Conclusion

Applying local vancomycin during primary orthopaedic surgery procedures may reduce the rates of infections in multiple different orthopaedic specialties, particularly in spine surgery and sports medicine. However, careful consideration should be applied when administering local vancomycin during specific orthopaedic procedures given the heterogeneity of included studies and breadth of surgeries included in this review.

Level of evidence

Level III. A systematic review of level I - III studies.

Surgical site infection prophylaxis with intra-wound vancomycin powder for uninstrumented spine surgeries: a meta-analysis

PURPOSE

It is unclear if intra-wound vancomycin powder significantly reduces the infection rate for uninstrumented spine surgery. The purpose of this study is to compare the rate of surgical site infection (SSI) in uninstrumented spine surgery that used vancomycin powder against controls.

METHODS

A search was performed on PUBMED/MEDLINE, Cochrane Database and Embase on 14 October 2022. Search keywords were "vancomycin, spine surgery, uninstrumented and spinal surgery." Instrumented cases were excluded. Type of surgery, type of treatment and incidence of infection among experimental or control were recorded.

RESULTS

288 articles were obtained from a literature search. 16 studies met inclusion criteria. 6/16 studies that reported on the infection rate using vancomycin were obtained. There were 1376 control cases with 20 cases of post-operative infection (1.45% overall). There were 795 cases that received prophylactic intra-wound vancomycin powder with 10 cases of infection reported (1.26%). There was no significant difference in infections between cases that received vancomycin compared to control. On subgroup analysis, studies that had a high rate of infection (Strom and Cannon) had a significant difference on the rate of infection with the use of vancomycin compared to control.

DISCUSSION AND CONCLUSION

The current study was unable to conclude that vancomycin decreased the rate of surgical site infections. Vancomycin use may be useful in populations that have a high rate of infection. Limitations in this study include the small number of studies that report on the use of vancomycin on uninstrumented spine surgery.

Intrawound application of vancomycin reduces the proportion of fracture-related infections in high-risk tibial plateau fractures

INTRODUCTION

Despite the improvements in surgical techniques and the use of prophylactic intravenous antibiotics, the fracture-related infection (FRI) incidence after high-risk tibial plateau fractures remains high. This study aimed to evaluate the clinical effect of the intrawound application of vancomycin on the FRI after high-risk tibial plateau fracture surgery.

METHODS

A total of 243 patients who underwent high-risk tibial plateau fracture surgery from May 2013 to June 2021 were retrospectively reviewed. Of these, 233 cases were enrolled. Considering the preoperative patient condition, surgeons applied vancomycin powder directly into the surgical site before wound closure in 105 cases (intrawound application of vancomycin powder with preoperative intravenous cephalosporin). The remaining 128 cases served as the control group (preoperative intravenous cephalosporin alone). Clinical data and surgical details were recorded. The Cox proportional hazards regression analysis was used to assess risk factors for FRI. The Kaplan-Meier method and the log rank test illustrated the infection status of patients based on the application of intrawound vancomycin. The primary outcome was an FRI within one year. Secondary outcomes included bacterial culture and vancomycin-related complications.

RESULTS

Our study demonstrated a significant difference in the incidence of FRI between the vancomycin group and the control group (3.8% versus 10.9%; p=0.041). Multivariable Cox regression showed the intrawound application of vancomycin powder decreased the rate of FRI. There were no complications related to intrawound vancomycin observed during follow-up. The presence of Gram-positive FRI was higher in the control group compared with the vancomycin group.

CONCLUSIONS

Intrawound application of vancomycin was associated with a significant lower rate of FRI after high-risk tibial plateau fracture surgery compared to the control group.

Evidence-based guideline for the prevention and management of perioperative infection

BACKGROUND

We have updated the guideline for preventing and managing perioperative infection in China, given the global issues with antimicrobial resistance and the need to optimize antimicrobial usage and improve hospital infection control levels.

METHODS

We conducted a comprehensive evaluation of the evidence for prevention and management of perioperative infection, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Revisions were made to the guidelines in response to feedback from the experts.

RESULTS

There were 17 questions prepared, for which 37 recommendations were made. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the meta-analysis results, recommendations were graded using the Delphi method to generate useful information.

CONCLUSIONS

This guideline provides evidence to perioperative antimicrobial prophylaxis that increased the rational use of prophylactic antimicrobial use, with substantial improvement in the risk-benefit trade-off.

Incidence of Surgical Site Infections and Acute Kidney Injuries After Topical Antibiotic Powder Application in Orthopaedic Trauma Surgery

OBJECTIVES

To compare the incidence of deep surgical site infections (SSI) and acute kidney injuries (AKI) in patients who did and did not receive topical antibiotics during the open treatment of fractures.

DESIGN

Retrospective comparative cohort.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Three hundred ninety-six patients undergoing open fixation of fractures.

INTERVENTION

The topical antibiotic group included 78 (20%) patients. Vancomycin only was used in 28 (7%) patients with the median dose (interquartile range) of 1 g (1-2 g) and vancomycin/tobramycin was used in 48 (12%) patients with a median dose (interquartile range) of 2 g (1-2 g)/1.2 g (1.2-1.2 g).

MAIN OUTCOME MEASUREMENTS

Deep SSI requiring debridement and AKI (>50% increase in creatinine compared with preoperative level).

RESULTS

There was no detectable difference in SSI between the topical antibiotic and control groups (13% vs. 10%, odds ratio (OR) 1.3, 95% confidence interval (CI) 0.6 to 2.9). Variables associated with SSI on multivariate analysis included open fracture (OR 3.2, CI 1.5 to 6.5) and an American Society of Anesthesiologists classification of >2 (OR 2.7, CI 1.3 to 5.3). There was no detectable difference in AKI between the topical antibiotic and control groups (1 (2%) vs. 7 (5%); OR 0.3, CI 0.04 to 3).

CONCLUSION

There was no detectable difference, with wide confidence intervals, in SSI and AKI between the topical antibiotic and control groups. Further studies need to be conducted to evaluate the relationship between topical antibiotics and clinical outcomes in orthopaedic trauma surgery.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of Local Delivery of Vancomycin and Tobramycin on Bone Regeneration

OBJECTIVE

A bone defect rat model was established to investigate the osteogenic effect of local delivery two antibiotics (vancomycin and tobramycin powder) on bone regeneration.

METHODS

Twenty-four Sprague-Dawley (SD) male rats (6 to 8 weeks, 200 to 250 g) were used in this study. All these rats were randomly divided into four groups. Based on dose conversion between rat and human via body surface area, the rat dose of two antibiotics was 88μg/g and 176 μg/g for vancomycin and tobramycin, respectively. Con group (no antibiotic), Van group (vancomycin, 88 μg/g), Tob group (tobramycin 176 μg/g), and Van+Tob group (vancomycin 88μg/g combined with tobramycin 176 μg/g). A 5.0-mm full-thickness standardized mandibular bone defect was performed with a drill in each rat and different antibiotic powders were placed over the bone defect space, respectively. All these animals were sacrificed after 12 weeks post-operation. The mandible bones were harvested for further radiographic and histologic analysis. The bone volume/total volume (BV/TV) ratio, bone volume (BV), and bone fractional area (BFA) in the defect area via micro-computed tomography (μCT scanning) were further analyzed. Then, we performed a histological assessment via hematoxylin and eosin (H&E) and Masson's trichrome staining to analyze bone regeneration and also analyze the number of osteoblasts per filed.

RESULTS

There were no postoperative deaths, signs of vancomycin-related or tobramycin-related toxicity, or signs of systemic illness in any of the four groups. All wounds healed well, and no complications or surgical site infection were observed in all rats. From the μCT scans analyses, there was less bone regeneration in the Van group than in the Con group (BV/TV: F = 64.29, R²  = 0.9602; P = 0.0052; BFA: F = 76.17, R²  = 0.9662, P = 0.0007; BV: F = 194.4, R²  = 0.9865, P = 0.0022). However, when the tobramycin and vancomycin were combined, an increase in bone defect re-ossification was found in the Van+Tob group than in the Van group (BV/TV: F = 64.29, R²  = 0.9602, P = 0.0033; BFA: F = 76.17, R²  = 0.9662, P = 0.0006; BV: F = 194.4, R²  = 0.9865, P = 0.0033). Routine H&E and Masson staining supported the finding of μCT scanning. Quantitative indices confirmed that both the bone regeneration and the number of osteoblasts per filed in the defect area was higher in the Van+Tob group than in the Van group (percentage of bone tissue: F = 145.7, R²  = 0.9562, P = 0.0008; number of osteoblasts per file; F = 67.3, R²  = 0.9098, P < 0.0001). There was no significant difference between the Con group and the Van+Tob group on the number of osteoblasts each field (F = 145.7, R²  = 0.9562, P > 0.9999).

CONCLUSION

For bone defect, local application of vancomycin combined with tobramycin was recommended over vancomycin alone. This animal study presents data suggesting that the use of local delivery of vancomycin and tobramycin should be investigated further in clinical studies.

Intrawound Antibiotic Powder in Acetabular Fracture Open Reduction Internal Fixation Does Not Reduce Surgical Site Infections

OBJECTIVES

To compare the risks of surgical site infection (SSI) and postoperative complications after acetabular fracture open reduction internal fixation (ORIF) in patients receiving topical intrawound antibiotic powder compared with those not receiving antibiotic powder (control group).

DESIGN

Retrospective cohort.

SETTING

Level I trauma center.

PATIENTS AND INTERVENTION

We reviewed 789 acetabular fracture ORIF cases from 2010 to 2019 at our institution, with mean follow-up of 18 months (3-112 months). Overall, 326 patients comprised the control group and 463 received topical antibiotic powder (294 vancomycin and 169 vancomycin/tobramycin).

MAIN OUTCOME MEASUREMENT

The study groups were compared for risk of SSI, seroma formation, wound dehiscence, acute kidney injury (AKI), and other postoperative complications.

RESULTS

There were 63 total SSI (8.0%), 50 (6.3%) deep SSI and 13 suprafascial SSI (1.6%) cases. There was no difference in the risk of total SSI (8.3% vs. 7.8%, P = 0.80) or deep SSI (6.1% vs. 6.5%, P = 0.64). This was confirmed by multivariate analysis adjusting for covariates (odds ratio = 0.93; 95% confidence interval, 0.52-1.67; P = 0.80). Similar results were demonstrated when comparing the control group with the vancomycin and vancomycin/tobramycin subgroups. The control group and antibiotic powder groups had similar risks of all outcomes of interest, including seroma formation (1.8% vs. 1.7%, P = 1.00), wound dehiscence (1.2% vs. 2.2%, P = 0.42), total AKI (5.2% vs. 8.2%, P = 0.12), and RIFLE classification AKI (injury; 0.9% vs. 2.2%, P = 0.50).

CONCLUSIONS

The addition of topical intrawound antibiotic powder, whether vancomycin alone or vancomycin/tobramycin before closure, does not reduce the risk of SSI after acetabular fracture ORIF compared with standard normal saline irrigation alone.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.