Surgical field and skin preparation

Is topical antibiotic use necessary to prevent surgical site infection following oculoplastic surgery?

PURPOSE

To assess whether oculoplastic surgeries can be performed without any topical and systemic antibiotics, in a "100% antibiotic free" fashion.

METHOD

We conducted a multicenter retrospective study between November 2017 and December 2022. Patients who underwent an oculoplastic procedure were screened. Patients who received preoperative or postoperative systemic antibiotics were excluded. Intraoperative IV antibiotics were allowed. Patients were divided into two groups: those who were treated with local antibiotics ointments (LATB group) and those who were treated without local antibiotics ointments (LATB free group) postoperatively. The primary outcome was the incidence of surgical site infections (SSI). The relationship between the use of local antibiotics and the occurrence of SSI was assessed using Fisher's exact test. The alpha risk was set to 5% and two-tailed tests were used.

RESULTS

Among the 947 procedures included, 617 were included in the LATB group and 330 in the LATB free group. 853 and 80 procedures were classified Altemeier class 1 (clean) and class 2 (clean-contaminated) surgeries, respectively. Overall, 310 (32.73%) procedures were performed without any systemic nor topical antibiotics (100% antibiotic free fashion). SSI occured in four (4/617; 0.65%) and five (5/330; 1.52%) procedures in the LATB and LATB free group respectively, without any statistical difference between the groups (p = 0.290). A subgroup analysis was carried out by excluding the procedures performed under prophylactic intraoperative intravenous antibiotics and did not reveal any statistical difference between the two groups (p = 0.144). All SSI patients were treated with systemic antibiotics with favorable outcomes. Postoperative wound dehiscence was the only risk factor associated with postoperative SSI (p = 0.002).

CONCLUSION

This study suggests that performing a "100% antibiotic free" oculoplastic surgery without systemic and topical antibiotics is reasonable in Altemeier class 1 and class 2 procedures.

Antibiotic use in spine surgery: A narrative review based in principles of antibiotic stewardship

Background

A growing emphasis on antibiotic stewardship has led to extensive literature regarding antibiotic use in spine surgery for surgical prophylaxis and the treatment of spinal infections.

Purpose

This article aims to review principles of antibiotic stewardship, evidence-based guidelines for surgical prophylaxis and ways to optimize antibiotics use in the treatment of spinal infections.

Methods

A narrative review of several society guidelines and spine surgery literature was conducted.

Results

Antibiotic stewardship in spine surgery requires multidisciplinary investment and consistent evaluation of antibiotic use for drug selection, dose, duration, drug-route, and de-escalation. Developing effective surgical prophylaxis regimens is a key strategy in reducing the burden of antibiotic resistance. For treatment of primary spinal infection, the diagnostic work-up is vital in tailoring effective antibiotic therapy. The future of antibiotics in spine surgery will be highly influenced by improving surgical technique and evidence regarding the role of bacteria in the pathogenesis of degenerative spinal pathology.

Conclusions

Incorporating evidence-based guidelines into regular practice will serve to limit the development of resistance while preventing morbidity from spinal infection. Further research should be conducted to provide more evidence for surgical site infection prevention and treatment of spinal infections.

Best products for skin antisepsis

BACKGROUND

Skin antiseptics are used for several purposes before surgical procedures, for bathing high-risk patients as a means of reducing central line-associated infections and other health care associated infections.

METHODS

A PubMed search was performed to update the evidence on skin antiseptic products and practices.

RESULTS

Current guidelines for prevention of surgical site infections (SSIs) recommend preoperative baths or showers with a plain or antimicrobial soap prior to surgery, but do not make recommendations on the timing of baths, the total number of baths needed, or about the use of chlorhexidine gluconate (CGH)-impregnated cloths. Randomized controlled trials have demonstrated that pre-operative surgical hand antisepsis using an antimicrobial soap or alcohol-based hand rub yields similar SSI rates. Other studies have reported that using an alcohol-based hand rub caused less skin irritation, was easier to use, and required shorter scrub times than using antimicrobial soap. Current SSI prevention guidelines recommend using an alcohol-containing antiseptic for surgical site infection. Commonly used products contain isopropanol combined with either CHG or with povidone-iodine. Surgical site preparation protocols for shoulder surgery in men may need to include coverage for anaerobes. Several studies suggest the need to monitor and improve surgical site preparation techniques. Daily bathing of intensive care unit (ICU) patients with a CHG-containing soap reduces the incidence of central line-associated bloodstream infections (CLABSIs). Evidence for a similar effect in non-ICU patients is mixed. Despite widespread CHG bathing of ICU patients, numerous barriers to its effective implementation exist. Measuring CHG levels on the skin is useful for identifying gaps in coverage and suboptimal skin concentrations. Using alcohol-based products with at least 2% CHG for skin preparation prior to central line insertion reduces CLABSIs.

CONCLUSIONS

Progress has been made on skin antisepsis products and protocols, but improvements in technique are still needed.

Extended skin cleaning on the shoulder with chlorhexidine reduces the cutaneous bacterial load but fails to decrease suture contamination in patients undergoing arthroscopy rotator cuff repair

BACKGROUND

It remains unclear whether preoperative skin cleaning of the chin, neck, and chest with chlorhexidine soap can reduce suture contamination by Cutibacterium acnes in patients undergoing arthroscopic rotator cuff repair.

METHODS

This study included patients who underwent primary arthroscopic rotator cuff repair. Exclusion criteria included age <18 years, previous shoulder surgery, history of shoulder infection, and allergy to chlorhexidine. Patients were randomized into 3 groups. Patients in the control group cleaned their skin with soap and water, as usual. Patients in the shoulder group cleaned their shoulders with chlorhexidine soap 3 days before surgery, whereas patients in the extended shoulder group additionally cleaned their chest, back, neck, and face with chlorhexidine soap. On the day of surgery, skin swab samples were obtained from the shoulder after surgical draping. After rotator cuff repair, sutures were cut from the anchor ends. Both traditional culture methods and polymerase chain reaction (PCR) were used.

RESULTS

Ninety patients were enrolled (32 in the control group, 29 in the shoulder group, and 29 in the extended shoulder group) in the present study. The culture-positive rate from the posterior shoulder skin samples in the extended shoulder group (17.2%) was significantly lower than that in the control (40.6%) and shoulder (48.3%) groups (P = .036), whereas the culture-positive rates were not different among the 3 groups in other skin samples as well as the suture samples. The detection rates of C acnes in suture samples were 12.5%, 13.8%, and 17.2% in the control, shoulder, and extended shoulder groups, respectively (P = .603).

CONCLUSION

Extensive skin cleaning of the shoulder region with chlorhexidine helps reduce the shoulder cutaneous bacterial load, but the detection of C acnes suture contamination in patients undergoing arthroscopic rotator cuff repair remained untouched regardless of the use of chlorhexidine soap in skin cleaning on the preoperative days.

Does the use of intrawound povidone-iodine irrigation and local vancomycin powder impact surgical site infection rate in adolescent idiopathic scoliosis surgery?

PURPOSE

Surgical site infection (SSI) is a major complication after adolescent idiopathic scoliosis (AIS) surgery, with an incidence ranging from 0.5 to 7%. Intraoperative wound decontamination with povidone-iodine (PVP-I) irrigation and/or vancomycin powder in adult spinal surgery has gained attention in the literature with controversial results. The aim of this study was to investigate the impact of using intrawound PVP-I irrigation and local vancomycin powder (LVP) on the incidence of early SSI in AIS surgery.

METHODS

All AIS patients who underwent posterior spinal fusion between October 2016 and December 2019 were retrospectively reviewed. The incidence of early SSI was reported and compared between 2 groups defined by the treating spinal surgeons' preferences: group 1-intrawound irrigation with 2L of PVP-I and application of 3 g LVP before closure and control group 2-patients that did not receive either of these measures.

RESULTS

Nine early cases of SSI (2.9%) were reported among the 307 AIS posterior spinal fusion patients. Incidence of SSI in group 1 (2/178 = 1.1%) was significantly lower than in group 2 (7/129 = 5.4%; p = 0.04). There were no adverse reactions to the use of PVP-I and LVP in our study. At latest follow-up, rate of surgical revision for mechanical failure with pseudarthrosis was significantly lower in group 1 (2/178 = 1.1%) than in group 2 (9/129 = 7.0%; p = 0.01).

CONCLUSION

Intraoperative use of intrawound PVP-I irrigation and vancomycin powder is associated with a significant reduction of early SSI after AIS spine surgery.

LEVEL OF EVIDENCE IV

Retrospective study.

Surgical solutions for preoperative skin preparation in total hip arthroplasty: A cost-effectiveness analysis of Betadine® and Chloraprep™

OBJECTIVE

The purpose of our study was to compare the cost of surgical site skin preparation using ChloraPrep™ (2% chlorhexidine gluconate [CHG] and 70% isopropyl alcohol [IPA]) with skin cleansing using Betadine® Surgical Scrub and Betadine® 5% solution (povidone-iodine [PVI]) in total hip arthroplasty (THA).

HYPOTHESIS

The hypothesis was that the ChloraPrep™ skin disinfection protocol reduces the cost of perioperative antisepsis.

METHODS

A prospective database was created for all THAs performed at our university hospital between November 1st, 2020, and December 31st, 2020. Each surgeon was randomly assigned one type of antiseptic prior to the start of the study: one surgeon to the ChloraPrep™ group and one to the Betadine® group. In both groups, the enrollment stopped at the 15th patient. The costs related to consumables, waste disposal, and operating room occupancy time of each protocol were then assessed for each patient.

RESULTS

The mean duration of the ChloraPrep™ protocol was 3.5±0.3minutes compared to 13.5±0.9minutes for the Betadine® protocol. The overall cost of a surgical site skin preparation involving all three steps was on average €46.8±4.2 for the ChloraPrep™ group compared to €155±10.9 for the Betadine® group (p<0.0001).

DISCUSSION

Not only is the effectiveness of ChloraPrep™ already recognized but it also appears to have health economic benefits. However, further studies are needed to confirm this finding.

LEVEL OF EVIDENCE

III, case control study.

Pre-Admission Use of Chlorhexidine-Impregnated Gauze for Skin Preparation Reduces the Incidence of Peri-Prosthetic Joint Infection after Primary Total Knee Arthroplasty: A Prospective Cohort with Retrospective Controls

Background: Peri-prosthetic joint infection (PJI) has long been a devastating complication after total knee arthroplasty (TKA), with native skin flora always identified as the causative agents. The aim of this study was to investigate the efficacy of pre-admission use of chlorhexidine-impregnated gauze for pre-operative skin preparation on infection rates after primary TKA surgeries. Patients and Methods: Patients undergoing TKAs performed from January 2017 until January 2021 were prospectively recruited. The experimental group included patients who used chlorhexidine-impregnated gauze the evening before surgery for skin preparation. These patients were compared with a retrospective cohort of TKAs performed during the previous four years without this step as control group. During a one-year follow-up, complications including PJI and superficial infections were collected as the primary outcomes for analysis. Results: A total of 1,218 TKAs in the experimental group and 1,033 TKAs in the control group were included in the study. A total of seven (0.6%) cases of PJI were identified in the experimental group, whereas 16 (1.5%) cases were diagnosed in the control group; a significant difference was detected (χ² = 5.245; p = 0.022). Eighteen (1.5%) cases of superficial infection were identified in the experimental group, and 28 (2.7%) cases were observed in the control group; a significant difference was found between groups (χ² = 4.243; p = 0.039). No significant differences were found on other wound-related complications. Conclusions: Pre-admission use of chlorhexidine-impregnated gauze for skin preparation was found to be an effective practice in reducing the incidence of PJI after TKA procedures, which has the potential of being utilized for patients undergoing TKA surgeries.

Protocol for a systematic review of good surgical practice guidelines for experimental rodent surgery

Objective

Surgery is an integral part of many experimental studies. Aseptic and minimal invasive surgical technique and optimal perioperative and post-operative care are prerequisites to achieve surgical success and best possible animal welfare outcomes. Good surgical practice cannot only improve the animal’s postoperative recovery, but also study outcome and validity. There seems to be a lack of implementation of good surgical practice during rodent surgery. The aim of this systematic review is to identify, critically evaluate and compare the currently recommended standards and underlying guidelines for rodent surgery—and finally to compile a comprehensive guideline of good surgical practice for rodent surgery.

Search strategy

PubMed, Embase and Web of Science were searched to identify guidelines published in peer-reviewed journals. To identify grey literature and unpublished guidelines, we will perform a Google search for published guidelines and search laboratory animal sciences books for relevant book chapters. Additionally, we will conduct a survey among animal researchers enquiring about the guidelines they use.

Screening and study selection

For publications retrieved by the systematic search, unique references are screened by two reviewers, first for eligibility based on title and abstract and subsequently for final inclusion based on full text. Eligibility of books is based on title and content, final inclusion based on chapter full text. Guidelines are either retrieved by Google searches or a survey. Google searches will be conducted by at least four of the authors. Thereafter, guidelines will be screened by two of the authors.

Data extraction and synthesis

We will extract data from publications, book chapters and guidelines. Based on the extracted data, we will perform a descriptive synthesis of the bibliographical details, guideline development and endorsement, and the prevalence of individual recommendations, including subgroup analysis of the guidance per continent or country and differences between peer-reviewed versus non-peer-reviewed guidance.

Efficacy of Three Povidone Iodine Formulations against Cutibacterium acnes Assessed through In Vitro Studies: A Preliminary Study

Cutibacterium acnes (C. acnes, formerly known as Propionibacterium acnes) is the major causative agent of prosthetic joint infections (PJI). Treatment of PJI with antibiotics is difficult due to antibiotic resistance and adverse side effects on patients’ health. Proper disinfection of the surgical site using a variety of povidone iodine formulations could prevent C. acnes infection. In the current study, the efficacy of the three povidone iodine (PVP-I) formulations, viz: PVP-I 10% dermic solution, PVP-I 5% alcoholic solution and PVP-I 4% scrub, was tested against C. acnes, in vitro, in the presence of interfering substances mimicking soiling conditions. C. acnes strain ATCC 6919 was used to test the bactericidal activity of the povidone iodine formulations according to the modified dilution-neutralization method described in French Norm EN standard 13727. A 3-log reduction in the bacterial cell count in 60 s was considered to be significant. The results showed that under experimental conditions, the three PVP-I formulations displayed bactericidal activity against the micro-organism, Cutibacterium acnes, and that the lowest concentration of povidone-iodine active against C. acnes was 0.4%. These results are encouraging as PVP-I offers a low-cost and efficient method of disinfection.

Evaluation of the antiseptic activity of 5% alcoholic povidone-iodine solution using four different modes of application: a randomized open-label study

BACKGROUND

Before some invasive procedures, such as injections, surgical incision or intravascular catheter insertions, alcoholic antiseptics (e.g., alcoholic povidone-iodine [PVP-I]) are widely used to prevent infection.

AIM

This randomized, open-label study investigated the impact of mode of application (which includes both application technique and volume) on the antiseptic activity of 5% alcoholic PVP-I solution.

METHODS

Alcoholic PVP-I was administered on the backs of healthy adults using four modes of application: A, concentric circle method, 3mL; B, concentric circle method, 10 mL; C, back-and-forth friction method, 3 mL; D, back-and-forth friction method, 10 mL.

PRIMARY ENDPOINT

antiseptic activity of alcoholic PVP-I, assessed via change from baseline in log₁₀/cm² colony-forming units (CFU) count for total aerobic and facultative anaerobic bacteria. Safety was monitored.

FINDINGS

113 healthy participants were screened; 32 were randomized. Alcoholic PVP-I showed significant antiseptic activity with all modes of application (p<0.001 for each), providing an overall mean decrease from baseline in CFU count of >3 log₁₀/cm² (p<0.001). Significantly greater efficacy was seen with back-and-forth friction (modes C and D) versus concentric circles (modes A and B): covariate adjusted change in log₁₀/cm² CFU count 0.22; 90% confidence intervals: 0.07, 0.37 (p=0.017). No safety issues were observed.

CONCLUSION

Alcoholic PVP-I demonstrated high antiseptic activity for all modes of application. Greater efficacy was achieved with back-and-forth friction versus concentric circles, showing that application technique may influence antiseptic activity; these findings suggest that when comparing the efficacy of antiseptic substances (e.g., alcoholic PVP-I and alcoholic chlorhexidine [CHX]), comparable application techniques should be used.

Preoperative Optimization and Tips to Avoiding Surgical Complications Before the Incision

In preparation for surgery, it is important for surgeons to have a detailed discussion with patients about the risks, benefits, and alternatives to surgery. Patient optimization, ensuring the patient is in the best medical condition before surgery, is also an important aspect of patient care that the surgeon must consider. Although complications cannot be eliminated, there are often opportunities to optimize patients, so these risks can be minimized based on current evidence-based medicine. To minimize the risk of complications, the surgeon should take an active role in each step of the patient's care beginning with the history and physical examination, obtaining the correct preoperative labs, and continuing through positioning, draping, and prepping before making an incision.

Enhanced recovery after surgery for major orthopedic surgery: a narrative review

Background

With increasing interest in enhanced recovery after surgery (ERAS), the literature on ERAS in orthopedic surgery is also rapidly accumulating. This review article aims to (1) summarize the components of the ERAS protocol applied to orthopedic surgery, (2) evaluate the outcomes of ERAS in orthopedic surgery, and (3) suggest practical strategies to implement the ERAS protocol successfully.

Main body

Overall, 17 components constituting the highly recommended ERAS protocol in orthopedic surgery were identified. In the preadmission period, preadmission counseling and the optimization of medical conditions were identified. In the preoperative period, avoidance of prolonged fasting, multimodal analgesia, and prevention of postoperative nausea and vomiting were identified. During the intraoperative period, anesthetic protocols, prevention of hypothermia, and fluid management, urinary catheterization, antimicrobial prophylaxis, blood conservation, local infiltration analgesia and local nerve block, and surgical factors were identified. In the postoperative period, early oral nutrition, thromboembolism prophylaxis, early mobilization, and discharge planning were identified. ERAS in orthopedic surgery reduced postoperative complications, hospital stay, and cost, and improved the patient outcomes and satisfaction with accelerated recovery. For successful implementation of the ERAS protocol, various strategies including the standardization of care system, multidisciplinary communication and collaboration, ERAS education, and continuous audit system are necessary.

Conclusion

The ERAS pathway enhanced patient recovery with a shortened length of stay, reduced postoperative complications, and improved patient outcomes and satisfaction. However, despite the significant progress in ERAS implementation in recent years, it has mainly focused on major surgeries such as arthroplasty. Therefore, further efforts to apply, audit, and optimize ERAS in various orthopedic surgeries are necessary.

Safety of 222 nm UVC Irradiation to the Surgical Site in a Rabbit Model

For the prevention of surgical site infection (SSI), continuous disinfection could be helpful. Short wavelength ultraviolet radiation C (UVC) is highly bactericidal but shows cytotoxicity. Radiation of UVC with a wavelength of 222 nm to the skin is considered to be safe because it only reaches the stratum corneum. However, the safety of 222 nm irradiation to the surgical field not covered with skin is unknown. The purpose of this study was to examine the safety of 222 nm UVC irradiation on a surgical field in a rabbit model. Five types of tissue were surgically exposed and irradiated with 222 or 254 nm UVC. Immunohistological assessment against cyclobutane pyrimidine dimer (CPD), an index of DNA damage by UVC, was performed. The CPD-positive cell rate was significantly higher in the 254 nm group than in the other groups in all tissues. A 222 nm group showed significantly more CPD than control in fat tissue, but no significant difference in all other tissues. In fat tissue collected 24 h after irradiation, the 254 nm group showed higher CPD than the other groups, while the 222 nm group had reduced to the control level. These data suggest that 222 nm UVC irradiation could be a new method to safely prevent SSI.

Meta-analysis of the efficacy of preoperative skin preparation with alcoholic chlorhexidine compared to povidone iodine in orthopedic surgery

Preoperative skin preparation is an effective method to prevent surgical site infections (SSI). Alcoholic chlorhexidine (CHG) and povidone iodine (PV-I) are the most widely used antiseptic agents. This meta-analysis aims to determine their efficacy in reducing natural bacterial skin flora in clean orthopedic surgery. A systematic search was conducted through current literature up to June 2021 to identify clinical randomized trials that compared the efficacy of alcoholic chlorhexidine and povidone iodine in reducing bacterial skin colonization after preoperative skin preparation. A meta-analysis was conducted. Of 235 screened articles, 8 randomized controlled trials were included. The results of the meta-analysis demonstrate a significantly lower positive culture rate in the chlorhexidine group than in the povidone iodine group (RR = 0.53, 95% Cl: 0.32-0.88). The present data show the superiority of chlorhexidine in reducing the normal bacterial flora compared to povidone iodine in clean orthopedic surgery.

Review of Pre-Operative Skin Preparation Options Based on Surgical Site in Orthopedic Surgery

Background: Surgical site infections (SSIs) are a primary contributor to surgical morbidity and mortality, causing a substantial financial burden on the healthcare system. Specifically, Cutibacterium acnes contributes greatly to infections in the shoulder and spine regions. Prevention of infection is crucial to improve patient outcomes and reduce costs. This article reviews current surgical skin preparation solutions, the unique distribution of organisms at common orthopedic surgical sites, and recommends solutions based on surgical location. Methods: A search of electronic databases (PubMed, MEDLINE, and Embase) was conducted for relevant literature until December 2020. Sources were compiled based on title and abstract, then full texts were read for possible inclusion. This review summarizes the most recent publications in the field of SSIs and preparation solutions. Results: The mechanism and efficacy of alcohol-, iodine-, and chlorhexidine-based preparations were reviewed, along with experimental preparations. This article identifies common colonization patterns for the shoulder, elbow, hip, knee, spine, foot, and ankle, and discusses recommendations for preparations based on current evidence. Recommendations: For shoulder and elbow operations, we recommend ChloraPrep™ (CareFusion, BD, El Paso, TX), DuraPrep™ (3M Health Care, St. Paul, MN), or Betadine^® applied with 4 × 4 gauze sponge, three-day pre-operative benzyl peroxide, and application of 3% hydrogen peroxide before skin preparation. For the hip and knee, we recommend application of 2% chlorhexidine gluconate (CHG) cloth the night before and morning of surgery and either DuraPrep or iodine-alcohol skin prep prior to surgery. For spine surgeries, we recommended ChloraPrep. For foot and ankle, our recommendations are: ChloraPrep or DuraPrep, submersion of foot in 70% ethanol/10% isopropyl alcohol for five minutes prior to procedure, application with a bristled brush, and a second vigorous scrub with 4 × 4 soaked gauze. Conclusions: The current surgical skin preparations have both benefits and drawbacks. We recommend that orthopedic surgeons choose a skin preparation based on surgical site and prevalence of unique skin flora there.

Review, analysis, and education of antiseptic related ocular injury in the surgical settings

Preoperative skin antiseptic preparation is the gold standard for prevention of surgical infection. However, improper use of antiseptics may lead to severe ocular damage. Currently, the most common surgical antiseptics can be divided into aqueous-based and alcohol-based disinfectants, with chlorhexidine and iodine/iodophors being the two major components. Chlorhexidine has a persistent antimicrobial effect and is resistant to neutralization by blood or organic products in surgical wounds. Nevertheless, due to its toxicity to the ears, meninges, and eyes, application of chlorhexidine should be prohibited in these surgical fields. Iodine/iodophor is better tolerated by the ocular surface and is the recommended antiseptic for ophthalmic or head and neck surgeries close to the periocular area. Alcohol is less pricey and has a rapid antiseptic effect, though its desiccating effect and flammability restrict the use in mucosal or laser surgeries. The single or combined use of these antiseptics may inadvertently induce severe ocular damage, especially during time-consuming head and neck surgeries with prone, hyperextension, or lateral tilt positions, or surgeries under general anesthesia. Apart from the choice of antiseptics, appropriate selection and attachment of bio-occlusive dressings are key to avoiding antiseptic-related ocular injuries. In this review, we provided a comprehensive summary of the characteristics of antiseptics used in surgical settings and the possible mechanisms and outcomes of antiseptic-related ocular injuries. The prevention, diagnosis, and acute management of these complications were also discussed.

The application of topical vancomycin powder for the prevention of surgical site infections in primary total hip and knee arthroplasty: A meta-analysis

BACKGROUND

Surgical site infections (SSIs), particularly periprosthetic joint infections (PJI), following a primary total joint arthroplasty (TJA) impose a major burden by increasing morbidity, mortality, disability rate, and health expenditure. Surgeons are increasingly using topical vancomycin powder as a preventative measure, but the effectiveness of this method has been debated in TJA. Thus, we designed a meta-analysis to compare the outcomes after primary TJA between a group treated with topical vancomycin powder and an untreated control group aiming to answer: (1) whether the application of topical vancomycin powder can reduce the infection rate after primary total joint replacement; (2) are the main types of pathogens causing SSIs after the application of topical vancomycin powder different from those of patients not using topical vancomycin?

MATERIALS AND METHODS

A meta-analysis was conducted in accordance with the PRISMA guidelines. We included retrospective cohort studies and prospective randomized controlled trials of patients who underwent primary total joint arthroplasty with and without vancomycin powder application before wound closure and reported the SSI rates. The English literature in the PubMed (MEDLINE), EMBASE, Web of Science, and the Cochrane Library databases was comprehensively searched. Literature search, data extraction, and quality assessment were conducted by 2 authors. The main outcomes were SSI and PJI rates, and the secondary outcome was the bacterial spectrum. Statistical analyses were performed with the Review Manager (RevMan) Version 5.3.

RESULTS

Six retrospective cohort studies and 3 prospective cohort studies with 4512 participants were included (2354 in vancomycin group and 2158 in the control group). In the TJA group, the vancomycin powder-treatment resulted in a significantly lower proportion of patients with SSIs (relative risk [RR]=0.40, 95% confidence interval [CI]=0.27-0.61 [p<0.001]) or PJI (RR=0.37, 95% CI=0.23-0.60 (p<0.001)). In the total hip arthroplasty group, the vancomycin powder treatment decreased the rate of SSIs and PJI by 66% (RR=0.34, 95% CI=0.15-0.78 [p=0.01]) and 74% (RR=0.26, 95% CI=0.10-0.67 (p=0.005)), respectively. In the total knee arthroplasty group, the vancomycin powder decreased the rate of SSIs and PJI by 67% (RR=0.43, 95% CI=0.26-0.70 [p<0.001]) and 66% (RR=0.44, 95% CI=0.25-0.77 [p=0.004]) respectively. Staphylococcus aureus (or methicillin-sensitiveStaphylococcus aureus) (6 in vancomycin group versus 11 in control group) was the most common pathogenic bacteria, followed by Staphylococcus epidermidis (1 in vancomycin group versus 2 in control group) and methicillin-resistant Staphylococcus aureus (2 in vancomycin group versus 4 in control group). Pseudomonas aeruginosa was the main gram-negative pathogen, with 3 cases in the control group and 1 case in the vancomycin powder-treatment group.

DISCUSSION

The local application of vancomycin powder could significantly decrease the rate of SSIs and PJI in primary TJA without modifying the spectrum of bacteria involved. We recommend topical administration of the vancomycin powder before wound closure after a full evaluation of the patients.

LEVEL OF EVIDENCE

III; meta-analysis.

Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining

A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting.