Does Vancomycin Powder Decrease Surgical Site Infections in Growing 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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The efficacy of intrawound vancomycin powder and povidone-iodine irrigation to prevent surgical site infections in complex instrumented spine surgery

The Spine Journal ◽

10.1016/j.spinee.2019.05.592 ◽

2019 ◽

Vol 19 (10) ◽

pp. 1648-1656 ◽

Cited By ~ 7

Author(s):

Justin V.C. Lemans ◽

F. Cumhur Öner ◽

Sebastiaan P.J. Wijdicks ◽

Miquel B. Ekkelenkamp ◽

H. Charles Vogely ◽

...

Keyword(s):

Spine Surgery ◽

Povidone Iodine ◽

Surgical Site Infections ◽

Vancomycin Powder ◽

Instrumented Spine Surgery

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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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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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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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The Use of Vancomycin Powder for Surgical Prophylaxis Following Craniotomy

Neurosurgery ◽

10.1093/neuros/nyw127 ◽

2017 ◽

Vol 80 (5) ◽

pp. 754-758 ◽

Cited By ~ 17

Author(s):

Vinod Ravikumar ◽

Allen L. Ho ◽

Arjun V. Pendharkar ◽

Eric S. Sussman ◽

Kevin Kwong-hon Chow ◽

...

Keyword(s):

Ad Hoc ◽

Cost Savings ◽

Surgical Site Infections ◽

Control Group ◽

Infection Prophylaxis ◽

Potential Cost Saving ◽

Infection Rates ◽

Surgical Prophylaxis ◽

Potential Cost ◽

Vancomycin Powder

Abstract BACKGROUND: Intrawound vancomycin powder has been studied extensively in spinal fusion surgeries and been found to reduce rates of surgical site infections (SSIs) significantly. Despite its success in spinal surgeries, topical vancomycin has not been extensively studied with respect to cranial neurosurgery. OBJECTIVE: To evaluate the efficacy of intrawound topical vancomycin for prevention of SSIs following open craniotomies. METHODS: We retrospectively analyzed a large series of 350 patients from 2011 to 2015 in a pre/postintervention study of use of topical vancomycin to reduce postoperative craniotomy infection rates. We had a preintervention control group of 225 patients and a postintervention group of 125 patients that received intrawound topical vancomycin. RESULTS: Our preintervention incidence of SSI was 2.2% and this was significantly reduced to 0% following introduction of topical vancomycin (P < .5). An ad hoc cost analysis suggested a cost savings of ${\$}$59 965 with the use of topical vancomycin for craniotomies. CONCLUSION: Our study found a significant reduction in SSI rates after introduction of topical vancomycin. Thus, this simple intervention should be considered in all open craniotomy patients as both infection prophylaxis and a potential cost saving intervention.

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Letter to the Editor Regarding The Use of Vancomycin Powder in Modern Spine Surgery: Systematic Review and Meta-Analysis of the Clinical Evidence

World Neurosurgery ◽

10.1016/j.wneu.2015.06.019 ◽

2016 ◽

Vol 88 ◽

pp. 675 ◽

Cited By ~ 1

Author(s):

Nathan Evaniew ◽

Emilie P. Belley-Côté ◽

Moin Khan ◽

Michelle Ghert

Keyword(s):

Systematic Review ◽

Spine Surgery ◽

Clinical Evidence ◽

Meta Analysis ◽

Letter To The Editor ◽

Vancomycin Powder

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Reducing surgical site infections following craniotomy: examination of the use of topical vancomycin

Journal of Neurosurgery ◽

10.3171/2014.12.jns142092 ◽

2015 ◽

Vol 123 (6) ◽

pp. 1600-1604 ◽

Cited By ~ 33

Author(s):

Kalil G. Abdullah ◽

Mark A. Attiah ◽

Andrew S. Olsen ◽

Andrew Richardson ◽

Timothy H. Lucas

Keyword(s):

Primary Outcome ◽

Surgical Site Infections ◽

Primary Outcome Measure ◽

Secondary Outcome ◽

Time Interval ◽

Infection Rates ◽

Skin Flora ◽

Vancomycin Powder ◽

Subgaleal Space ◽

Typical Skin

OBJECT Although the use of topical vancomycin has been shown to be safe and effective for reducing postoperative infection rates in patients after spine surgery, its use in cranial wounds has not been studied systematically. The authors hypothesized that topical vancomycin, applied in powder form directly to the subgaleal space during closure, would reduce cranial wound infection rates. METHODS A cohort of 150 consecutive patients who underwent craniotomy was studied retrospectively. Seventy-five patients received 1 g of vancomycin powder applied in the subgaleal space at the time of closure. This group was compared with 75 matched-control patients who were accrued over the same time interval and did not receive vancomycin. The primary outcome measure was the presence of surgical site infection within 3 months. Secondary outcome measures included tissue pH from a subgaleal drain and vancomycin levels from the subgaleal space and serum. RESULTS Vancomycin was associated with significantly fewer surgical site infections (1 of 75) than was standard antibiotic prophylaxis alone (5 of 75; p < 0.05). Cultures were positive for typical skin flora species. As expected, local measured vancomycin concentrations peaked immediately after surgery (mean ± SD 499 ± 37 μg/ml) and gradually decreased over 12 hours. Vancomycin in the circulating serum remained undetectable. Subgaleal topical vancomycin was associated with a lower incidence of surgical site infections after craniotomy. The authors attribute this reduction in the infection rate to local vancomycin concentrations well above the minimum inhibitory concentration for antimicrobial efficacy. CONCLUSIONS Topical vancomycin is safe and effective for reducing surgical site infections after craniotomy. These data support the need for a prospective randomized examination of topical vancomycin in the setting of cranial surgery.

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