Efficacy of prophylactic application of vancomycin powder in preventing surgical site infections after instrumented spinal surgery: A retrospective analysis of patients with high-risk conditions

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.

A meta-analysis examining the impact of intrawound treatment on reducing deep surgical site infections during instrumented spine surgery

The purpose of the meta-analysis was to evaluate and compare the effect of intrawound management on decreasing deep surgical site infections (SSIs) in instrumented spinal surgery (SS). The results of this meta-analysis were analysed, and the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were calculated using dichotomous or contentious random or fixed effect models. For the current meta-analysis, 29 examinations spanning from 2006 to 2022 were included, encompassing 11 181 people who had instrumented SS. Intrawound management had a significantly lower deep SSI when using vancomycin (OR, 0.34; 95% CI, 0.25-0.44, p < 0.001) and povidone-iodine as intrawound management (OR, 0.24; 95% CI, 0.13-0.42, p < 0.001) compared to control in instrumented SS subjects. The data that was looked at showed that using vancomycin and povidone-iodine as intrawound management had a much lower deep SSI than using a control group of instrumented SS subjects. However, given that some studies included a small number of subjects, attention should be given to their values.

Intrawound vancomycin powder in orthopaedic surgery as surgical site wound infection prophylaxis: A meta-analysis

A meta-analysis research was executed to appraise the consequence of intrawound vancomycin powder (IWVP) in orthopaedic surgery (OPS) as surgical site wound infection (SSWI) prophylaxis. Inclusive literature research till March 2023 was carried out and 2756 interconnected researches were revised. Of the 18 picked researches enclosed 13 214 persons with OPS were in the used researches' starting point, 5798 of them were utilising IWVP, and 7416 were control. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to appraise the consequence of the IWVP in OPS as SSWI prophylaxis by the dichotomous approaches and a fixed or random model. IWVP had significantly lower SSWIs (OR, 0.61; 95% CI, 0.50-0.74, P < .001), deep SSWIs (OR, 0.57; 95% CI, 0.36-0.91, P = .02), and superficial SSWIs (OR, 0.67; 95% CI, 0.46-0.98, P = .04) compared with control in persons with OPS. IWVP had significantly lower SSWIs, deep SSWIs, and superficial SSWIs compared with control in persons with OPS. However, when interacting with its values, caution must be taken and more research is needed to confirm this finding.

Ultrasound-guided percutaneous micro-drainage tube irrigation combined with high negative pressure tube drainage versus debridement with closed suction irrigation for treating deep surgical site infection after spinal surgery

It is difficult to avoid deep surgical site infection after spinal surgery. Debridement combined with closed suction irrigation (CSI) and other treatment methods lead to greater trauma and lower satisfaction. We developed a new method for the treatment of SSI, which has the advantages of less invasiveness and lower cost. The cohort of this retrospective study comprised 26 patients with SSI after undergoing spinal surgery in our hospital from August 2017 to March 2022. The patients were divided into CSI and microtube drainage group according to treatment methods. The durations of antibiotic use and hospital stay, hospitalization costs, and functional scores during follow-up were compared between the two groups. The only baseline characteristic that differed between the two groups was sex. Infection was controlled in both groups and there were no recurrences during follow-up. However, the length of hospital stay after the first operation and the total length of stay were significantly greater in the CSI group. Hospitalization costs and antibiotic costs were significantly higher in the CSI group. Additionally, the duration of intravenous antibiotic use was significantly longer in the CSI group. Both the CSI and microtube drainage groups had significantly improved of Short Form Health Survey (SF-36) scores 6 months postoperatively. However, 3 months postoperatively, SF-36 scores were significantly lower in the CSI group. Compared with debridement followed by CSI, percutaneous micro-drainage tube irrigation combined with high negative pressure tube drainage is a more efficient and economical means of treating SSI after spinal surgery.

Prophylactic Application of Vancomycin Powder in Preventing Surgical Site Infections After Spinal Surgery

OBJECTIVE

We sought to analyze the preventive effect of local vancomycin powder application on surgical site infection (SSI) in spinal surgeries and provide the basis for future clinical practice.

METHODS

Through PubMed, Medline, Elsevier, and the Cochrane Library, with MeSH words "vancomycin powder," "local/intraoperative/topical/intra-wound," "spine/spinal/lumbar/cervical/thoracolumbar," "surgery," "infection," and "SSI," we searched for case-control research papers on the impact of prophylactic application of vancomycin powder on the incidence of SSI and compared the rate of infection using RevMan 5.3 meta-analysis software.

RESULTS

A total of 1950 publications were found using the mesh words, and 50 of those studies were selected for final analysis. There were 34,301 cases in total, including 14,793 cases in vancomycin group and 19,508 cases in the control group. Results of meta-analysis showed that the incidence of SSI was significantly lower in the prophylactic vancomycin powder group than the control group (P < 0.001). Further subgroup analysis showed that the incidence of SSI was significantly lower in the prophylactic vancomycin powder group than the control group in spine surgeries with internal fixation, deformity correction, and deep tissue infections (P < 0.001). Meanwhile, there were no significant differences between the 2 groups concerning patients undergoing noninstrumented spine surgeries and the incidence of superficial tissue infection.

CONCLUSIONS

Overall, prophylactic application of vancomycin powder in spinal surgery can significantly reduce the incidence of SSI in deep tissues, and this effect is more prominent in patients undergoing internal fixation and deformity correction surgeries.

Intraoperative vancomycin powder to reduce surgical site infections after posterior spine surgery: a systematic review and meta-analysis

The purpose of the study was to evaluate the effect of local application of vancomycin powder (VP) to prevent surgical site infections (SSIs) after posterior spine surgery. A comprehensive search of Web of Science, EMBASE, Pubmed, Ovid, and Cochrane Library databases for articles published was performed to collect comparative studies of intrawound vancomycin in posterior spine surgery before March 2021. Two reviewers independently screened eligible articles based on the inclusion and exclusion criteria, assessed the study quality, and extracted the data. Revman 5.4 software was used for data analysis. A total of 22 articles encompassing 11 555 surgical patients were finally identified for meta-analysis. According to the information provided by the included literature, the combined odds ratio showed that topical use of VP was effective for reducing the incidence of SSIs (P< 0.00001) after posterior spine surgery without affecting its efficacy in the treatment of deep infections (P< 0.00001). However, there is no statistical significance in superficial infections. In a subgroup analysis, VP at a dose of 1, 2, and 0.5-2 g reduced the incidence of spinal SSIs. The result of another subgroup analysis suggested that local application of VP could significantly reduce the risk of SSIs, whether it was administered after posterior cervical surgery or thoracolumbar surgery. Moreover, the percentage of SSIs due to gram-positive germs (P< 0.00001) and MRSA (P< 0.0001) could reduce after intraoperative VP was used, but did not significantly reduce to gram-negative germs. The local application of VP appears to protect against SSIs, gram-positive germs, and MRSA (methicillin-resistant Staphylococcus aureus) infections after the posterior spinal operation.

Prophylactic Topical Antibiotics in Fracture Repair and Spinal Fusion

INTRODUCTION

The objective of this systematic review with meta-analysis is to determine whether prophylactic local antibiotics prevent surgical site infections (SSIs) in instrumented spinal fusions and traumatic fracture repair. A secondary objective is to investigate the effect of vancomycin, a common local antibiotic of choice, on the microbiology of SSIs.

METHODS

An electronic search of PubMed, EMBASE, and Web of Science databases and major orthopedic surgery conferences was conducted to identify studies that (1) were instrumented spinal fusions or fracture repair and (2) had a treatment group that received prophylactic local antibiotics. Both randomized controlled trials (RCTs) and comparative observational studies were included. Meta-analysis was performed separately for randomized and nonrandomized studies with subgroup analysis by study design and antibiotic.

RESULTS

Our review includes 44 articles (30 instrumented spinal fusions and 14 fracture repairs). Intrawound antibiotics significantly decreased the risk of developing SSIs in RCTs of fracture repair (RR 0.61, 95% CI: 0.40-0.93, I 2 = 32.5%) but not RCTs of instrumented spinal fusion. Among observational studies, topical antibiotics significantly reduced the risk of SSIs in instrumented spinal fusions (OR 0.34, 95% CI: 0.27-0.43, I 2 = 52.4%) and in fracture repair (OR 0.49, 95% CI: 0.37-0.65, I 2 = 43.8%). Vancomycin powder decreased the risk of Gram-positive SSIs (OR 0.37, 95% CI: 0.27-0.51, I 2 = 0.0%) and had no effect on Gram-negative SSIs (OR 0.95, 95% CI: 0.62-1.44, I 2 = 0.0%).

CONCLUSIONS

Prophylactic intrawound antibiotic administration decreases the risk of SSIs in fracture surgical fixation in randomized studies. Therapeutic efficacy in instrumented spinal fusion was seen in only nonrandomized studies. Vancomycin appears to be an effective agent against Gram-positive pathogens. There is no evidence that local vancomycin powder is associated with an increased risk for Gram-negative infection.