The efficacy of intrawound vancomycin powder and povidone-iodine irrigation to prevent surgical site infections in complex instrumented spine surgery

Study Design:Narrative review.Objectives:Postoperative surgical site infections (SSIs) are among the most common acute complications in spine surgery and have a devastating impact on outcomes. They can lead to increased morbidity and mortality as well as greater economic burden. Hence, preventive strategies to reduce the rate of SSIs after spine surgery have become vitally important. The purpose of this article was to summarize and critically analyze the available evidence related to current strategies in the prevention of SSIs after spine surgery.Methods:A literature search utilizing Medline database was performed. Relevant studies from all the evidence levels have been included. Recommendations to decrease the risk of SSIs have been provided based on the results from studies with the highest level of evidence.Results:SSI prevention occurs at each phase of care including the preoperative, intraoperative, and postoperative periods. Meticulous patient selection, tight glycemic control in diabetics, smoking cessation, and screening/eradication of Staphylococcus aureus are some of the main preoperative patient-related preventive strategies. Currently used intraoperative measures include alcohol-based skin preparation, topical vancomycin powder, and betadine irrigation of the surgical site before closure. Postoperative infection prophylaxis can be performed by administration of silver-impregnated or vacuum dressings, extended intravenous antibiotics, and supplemental oxygen therapy.Conclusions:Although preventive strategies are already in use alone or in combination, further high-level research is required to prove their efficacy in reducing the rate of SSIs in spine surgery before evidence-based standard infection prophylaxis guidelines can be built.

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Does Vancomycin Powder Decrease Surgical Site Infections in Growing Spine Surgery?

The Journal of Bone and Joint Surgery (American) ◽

10.2106/jbjs.17.00459 ◽

2018 ◽

Vol 100 (6) ◽

pp. 466-471 ◽

Cited By ~ 25

Author(s):

George H. Thompson ◽

Connie Poe-Kochert ◽

Christina K. Hardesty ◽

Jochen Son-Hing ◽

R. Justin Mistovich

Keyword(s):

Spine Surgery ◽

Surgical Site Infections ◽

Vancomycin Powder ◽

Growing Spine

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The Association of Intraoperative Antibiotic and Surgical Site Infection After Lumbar Spine Surgery: Analysis of the Michigan Spine Surgery Improvement Collaborative

Neurosurgery ◽

10.1093/neuros/nyz310_178 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Hesham M Zakaria ◽

Karam P Asmaro ◽

Tarek R Mansour ◽

Rachel J Hunt ◽

Theresa A Elder ◽

...

Keyword(s):

Risk Factors ◽

Lumbar Spine ◽

Antibiotic Prophylaxis ◽

Spine Surgery ◽

Private Insurance ◽

Surgical Site Infections ◽

Antibiotic Usage ◽

Lumbar Spine Surgery ◽

Perioperative Antibiotics ◽

Vancomycin Powder

Abstract INTRODUCTION Surgical site infections (SSI) after lumbar spine surgery is costly and potentially preventable. A number of studies have shown the efficacy of vancomycin powder in preventing SSI, but there are few studies that have examined all the available perioperative antibiotics. We sought to examine associations between intraoperative antibiotic usage and SSI rates after lumbar spine surgery, as well as other risk factors for SSI, using a large prospective database. METHODS The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a large multi-institute collaborative. MSSIC was queried to test the association between intraoperative antibiotic irrigation (bacitracin, cefazolin, vancomycin, etc), intraoperative vancomycin powder only, a combination of the two, and postoperative antibiotics with SSI using generalized estimating equations (GEE) models; variables included: age, gender, BMI, diabetes, heart disease, scoliosis, previous spine surgery, preoperative ambulatory status, insurance type (public vs private), surgery type (fusion vs decompression alone), and number of surgical levels. RESULTS A total of 24 229 patients undergoing lumbar spine surgery were included in the multivariate analysis. Postoperative antibiotic prophylaxis did not affect SSI (OR 1.00, P = .987). Preoperative antibiotics were universally given, and further analysis of intraoperative antibiotic usage was done. All comparisons were done to no additional antibiotics used; using only intraoperative vancomycin powder was associated with lower SSI (OR 0.77, P = .286). Using antibiotic irrigation only was associated with a significantly higher rate of SSI (OR1 .42, P = .009). Using a combination intraoperative vancomycin and irrigation was again associated with higher SSI (OR 1.28, P = .127), but not as high as irrigation alone. Protective factors for SSI include independently ambulation (OR 0.80, P = .015) and private insurance (OR 0.74, P = .001). Risk factors for SSI include BMI (OR 1.33, P < .001), diabetes (OR 1.36, P < .001), fusion (OR 1.41, P = .001), and increasing surgical levels (OR 1.59, P = .006). CONCLUSION The use of postoperative antibiotic prophylaxis was not associated with SSI. Intraoperative antibiotic irrigation may be less effective than realized, and the use of intraoperative vancomycin powder alone may be effective in preventing SSI. The efficacy of intraoperative antibiotic irrigation in preventing infection requires further investigation. Other risk factors for SSI are confirmed.

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Intrawound Treatment for Prevention of Surgical Site Infections in Instrumented Spinal Surgery: A Systematic Comparative Effectiveness Review and Meta-Analysis

Global Spine Journal ◽

10.1177/2192568218786252 ◽

2018 ◽

Vol 9 (2) ◽

pp. 219-230 ◽

Cited By ~ 8

Author(s):

Justin V. C. Lemans ◽

Sebastiaan P. J. Wijdicks ◽

Willemijn Boot ◽

Geertje A. M. Govaert ◽

R. Marijn Houwert ◽

...

Keyword(s):

Relative Risk ◽

Randomized Controlled Trials ◽

Spine Surgery ◽

Spinal Surgery ◽

Meta Analysis ◽

Surgical Site Infections ◽

Controlled Trials ◽

Local Antibiotics ◽

Randomized Controlled ◽

Instrumented Spine Surgery

Study Design: Systematic review and meta-analysis. Objectives: To determine the efficacy of intrawound treatments in reducing deep surgical site infections (SSIs) in instrumented spinal surgery. Methods: The electronic databases MEDLINE, EMBASE, and Cochrane were systematically searched for intrawound treatments for the prevention of SSIs in clean instrumented spine surgery. Both randomized controlled trials and comparative cohort studies were included. The results of included studies were pooled for meta-analysis. Results: After full text- and reference screening, 20 articles were included. There were 2 randomized controlled trials and 18 observational studies. Sixteen studies investigated the use of intrawound antibiotics, and 4 studies investigated the use of intrawound antiseptics. The relative risk of deep SSI for any treatment was 0.26 (95% confidence interval [CI] 0.16-0.44, P < .0001), a significant reduction compared with controls receiving no treatment. For patients treated with local antibiotics the relative risk was 0.29 (95% CI 0.17-0.51, P < .0001), and patients treated with local antiseptics had a relative risk of 0.14 (95% CI 0.05-0.44, P = .0006). Conclusions: Both the use of antibiotic and antiseptic intrawound prophylactics was associated with a significant 3 to 7 times reduction of deep SSIs in instrumented spine surgery. No adverse events were reported in the included studies.

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Is Intraoperative Local Vancomycin Powder the Answer to Surgical Site Infections in Spine Surgery?

Spine ◽

10.1097/brs.0000000000001710 ◽

2017 ◽

Vol 42 (4) ◽

pp. 267-274 ◽

Cited By ~ 56

Author(s):

Hwee Weng Dennis Hey ◽

Desmond Wei Thiam ◽

Zhi Seng Darren Koh ◽

Joseph Shantakumar Thambiah ◽

Naresh Kumar ◽

...

Keyword(s):

Spine Surgery ◽

Surgical Site Infections ◽

Vancomycin Powder

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Semiquantitative Staphylococcus aureus Nasal Colony Reduction in Elective Orthopedic Surgery Reduces Surgical Site Infection

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1021 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s386-s386

Author(s):

Lisa Saidel ◽

Riki Yosipovich ◽

Ronit Nativ ◽

Orli Sagi ◽

Orly Shimoni ◽

...

Keyword(s):

Staphylococcus Aureus ◽

Knee Replacement ◽

Spine Surgery ◽

Nasal Swab ◽

Povidone Iodine ◽

Surgical Site Infections ◽

Study Cohort ◽

Quantitative Measurements ◽

Infection Complication

Background: Clean surgical procedures such as hip and knee replacement and spine surgery have a low infection complication rate; however, if infections occur, there is substantial morbidity and increased cost. Staphylococcus aureus causes 30% of surgical site infections (SSIs). S. aureus colonization increases the risk of developing SSI. Nasal povidone-iodine 5% application reduces the S. aureus colonization burden. Objective: We aimed to reduce SSIs by applying nasal povidone-iodine 5% prior to hip and knee replacement and spine surgery. Methods: Adult patients hospitalized for elective hip replacement, knee replacement, or spine surgeries from February 2018 through August 2019 comprised the study cohort. All patients received preoperative guidance in the outpatient clinic. On admission, the evening before surgery, a nasal swab for S. aureus colonization was performed, followed by povidone-iodine 5% application in both nostrils and body chlorhexidine gluconate 4% bathing. Application of these substances was repeated in the morning before surgery. Within 24 hours after surgery, an additional nasal swab for S. aureus colonization was taken. A 90-day follow-up for SSI was done. Data were compared with a similar 2016–2017 cohort without the preoperative measures. Results: In total, 186 patients were included: 85 underwent hip or knee replacement (age 69 ± 13.2 y, 66% men), and 101 spine surgery (age 55 ± 15.4 y, 52% men). At screening, 18.3% were colonized with methicillin-sensitive S. aureus and 1.6% colonized with methicillin-resistant S. aureus. Pre- and postsurgery data for the cohort appear in Table 1. The SSI rate per 100 patient days for hip and knee replacement and for spine surgery decreased from 0.29 and 4.0, respectively, in the 2016–2017 cohort to 0 and 0.99, respectively, in the present cohort. Conclusions: Nasal povidone-iodine 5% reduced the S. aureus colonization burden. The SSI rate in elective hip and knee replacement and spine surgery significantly decreased. We show that there is no need for S. aureus eradication presurgery; semiquantitative S. aureus nasal colony reduction should suffice in reducing SSIs. Further research is needed using quantitative measurements for S. aureus colonization.Funding: NoneDisclosures: None

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

Khirurgiya Zhurnal im N I Pirogova ◽

10.17116/hirurgia202006160 ◽

2020 ◽

pp. 60

Author(s):

I.A. STEPANOV ◽

V.A. BELOBORODOV ◽

V.E. BORISOV ◽

M.A. ALIEV ◽

V.V. SHEPELEV ◽

...

Keyword(s):

Spine Surgery ◽

Meta Analysis ◽

Surgical Site Infections ◽

Local Application ◽

Vancomycin Powder

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The effect of prophylactic vancomycin powder on infections following spinal surgeries: a systematic review

Neurosurgical FOCUS ◽

10.3171/2018.10.focus18470 ◽

2019 ◽

Vol 46 (1) ◽

pp. E11 ◽

Cited By ~ 12

Author(s):

Vincent Dodson ◽

Neil Majmundar ◽

Vanessa Swantic ◽

Rachid Assina

Keyword(s):

Systematic Review ◽

Spine Surgery ◽

Surgical Site Infections ◽

Control Group ◽

Control Groups ◽

Gram Negative ◽

Number Of Patients ◽

Vancomycin Powder ◽

Meta Analyses ◽

Experimental Group

OBJECTIVEThe use of vancomycin powder in spine surgery for prophylaxis against surgical site infections (SSIs) is well debated in the literature, with the majority of studies demonstrating improvement and some studies demonstrating no significant reduction in infection rate. It is well known in certain populations that vancomycin powder reduces the general rate of infection, but its effects on reducing the rate of infection due to gram-negative pathogens are not well reviewed. The goal of this paper was to review studies that investigated the efficacy of vancomycin powder as a prophylactic agent against SSI and demonstrate whether the rate of infections by gram-negative pathogens is impacted.METHODSAn electronic search of the published literature was performed using PubMed and Google Scholar in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A variety of combinations of the search terms “vancomycin powder,” “infection,” “spine,” “gram-negative,” “prophylaxis,” and “surgical site” was used. Inclusion criteria were studies that 1) described an experimental group that received intraoperative intrawound vancomycin powder; 2) included adequately controlled groups that did not receive intraoperative intrawound vancomycin powder; 3) included the number of patients in both the experimental and control groups who developed infection after their spine surgery; and 4) identified the pathogen-causing infection. Studies not directly related to this review’s investigation were excluded from the initial screen. Among the studies that met the criteria of the initial screen, additional reasons for exclusion from the systematic review included lack of a control group, unspecified size of control groups, and inconsistent use of vancomycin powder in the experimental group.RESULTSThis systematic review includes 21 studies with control groups. Vancomycin powder significantly reduced the relative risk of developing an SSI (RR 0.55, 95% CI 0.45–0.67, p < 0.0001). In addition, the use of vancomycin powder did not significantly increase the risk of infection by gram-negative pathogens (RR 1.11, 95% CI 0.66–1.86, p = 0.701).CONCLUSIONSThe results of this systematic review suggest that intrawound vancomycin powder is protective against SSI. It is less clear if this treatment increases the risk of gram-negative infection. Further studies are required to investigate whether rates of infection due to gram-negative pathogens are affected by the use of vancomycin powder.

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