Does Intraoperative Use of Vancomycin Powder Increase the Risk of Gram-Negative Infections?

OBJECTIVEWound infections following spinal surgery for deformity place a high toll on patients, providers, and the health care system. The prophylactic application of intraoperative vancomycin powder has been shown to lower the infection risk after thoracolumbar decompression and fusion for deformity correction. The purpose of this study was to assess the microbiological patterns of postoperative surgical site infections (SSIs) after prophylactic use of vancomycin powder in adult patients undergoing spinal deformity surgery.METHODSAll cases involving adult patients who underwent spinal deformity reconstruction at Duke University Medical Center between 2011 and 2013 with a minimum of 3 months of clinical follow-up were retrospectively reviewed. In all cases included in the study, crystalline vancomycin powder was applied to the surgical bed for infection prophylaxis. Baseline characteristics, operative details, rates of wound infection, and microbiological data for each case were gathered by direct medical record review.RESULTSA total of 1200 consecutive spine operations were performed for deformity between 2011 and 2013. Review of the associated records demonstrated 34 cases of SSI, yielding an SSI rate of 2.83%. The patients’ mean age (± SD) was 62.08 ± 14.76 years. The patients’ mean body mass index was 30.86 ± 7.15 kg/m2, and 29.41% had a history of diabetes. The average dose of vancomycin powder was 1.41 ± 2.77 g (range 1–7 g). Subfascial drains were placed in 88% of patients. All SSIs occurred within 30 days of surgery, with deep wound infections accounting for 50%. In 74% of the SSIs cultures were positive, with about half the organisms being gram negative, such as Citrobacter freundii, Proteus mirabilis, Morganella morgani, and Pseudomonas aeruginosa. There were no adverse clinical outcomes related to the local application of vancomycin.CONCLUSIONSOur study suggests that in the setting of prophylactic vancomycin powder use, the preponderance of SSIs are caused by gram-negative organisms or are polymicrobial. Further randomized control trials of prophylactic adjunctive measures are warranted to help guide the choice of empirical antibiotic therapy while awaiting culture data.

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Does Intrawound Vancomycin Application During Spine Surgery Create Vancomycin-Resistant Organism?

Neurosurgery ◽

10.1093/neuros/nyw097 ◽

2017 ◽

Vol 80 (5) ◽

pp. 746-753 ◽

Cited By ~ 32

Author(s):

Silky Chotai ◽

Patty W. Wright ◽

Andrew T. Hale ◽

Whitney A. Jones ◽

Matthew J. McGirt ◽

...

Keyword(s):

Staphylococcus Aureus ◽

Spine Surgery ◽

Fluid Collection ◽

Resistant Organism ◽

Site Infection ◽

Gram Negative ◽

Minimal Inhibitory Concentrations ◽

Vancomycin Powder ◽

Vancomycin Resistant ◽

Culture Negative

Abstract BACKGROUND: Surgical site infection (SSI) following spine surgery is a morbid and expensive complication. The use of intrawound vancomycin is emerging as a solution to reduce SSI. The development of vancomycin-resistant pathogens is an understandable concern. OBJECTIVE: To determine the occurrence of vancomycin-resistant SSI in patients with and without use of intrawound vancomycin. METHODS: Patients undergoing elective spine surgery were dichotomized based on whether intrawound vancomycin was applied. Outcome was occurrence of SSI requiring return to the operating room within postoperative 90 days. The intrawound culture and vancomycin minimal inhibitory concentrations (MIC) were reviewed. Analyses were conducted to compare the pathogen profile and MIC for vancomycin in patients who received vancomycin and those who did not. RESULTS: Of the total 2802 patients, 43% (n = 1215) had intrawound vancomycin application during the index surgery. The use of vancomycin was associated with significantly lower deep SSI rates (1.6% [n = 20] vs 2.5% [n = 40], P = .02). The occurrence of Staphylococcus aureus SSI was significantly lower in the patients who had application of intrawound vancomycin (32% vs 65%, P = .003). None of the patients who had application of intrawound vancomycin powder, and subsequently developed an S aureus SSI, demonstrated pathogens with resistance to vancomycin. All patients had MIC < 2 μg/mL, the vancomycin susceptibility threshold. The occurrence of gram-negative SSI (28% vs 7%) and culture negative fluid collection (16% vs 5%) was higher in the vancomycin cohort. CONCLUSIONS: The use of intrawound vancomycin during the index spine surgery was protective against SSI following spine surgery. The application of intrawound vancomycin during index surgery does not appear to create vancomycin-resistant organisms in the event of an SSI.

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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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Do Dose-Dependent Microbial Changes Occur during Spine Surgery as a Result of Applying Intrawound Vancomycin Powder?: A Systematic Literature Review

Asian Spine Journal ◽

10.4184/asj.2018.12.1.162 ◽

2018 ◽

Vol 12 (1) ◽

pp. 162-170 ◽

Cited By ~ 10

Author(s):

Lunli Xie ◽

Jun Zhu ◽

Shunhong Luo ◽

Yu Xie ◽

Dan Pu

Keyword(s):

Wound Infection ◽

Spine Surgery ◽

Gram Negative Bacteria ◽

Gram Negative ◽

Vancomycin Dose ◽

Additional Information ◽

Perioperative Antibiotics ◽

Vancomycin Powder ◽

The Relationship ◽

Dose Dependent

<p>We analyzed dose-dependent effects of vancomycin on wound infection bacteria and investigated the relationship between dose and microbial imbalances in patients treated with intrawound vancomycin powder during spine surgery. Numerous trials have confirmed that using intrawound vancomycin powder during spine surgery may decrease postoperative wound infection rates. However, potential risks include changes in wound infection bacteria, inhibition of bone fusion, and systemic toxicity. We searched PubMed for articles published since October 2016 with the following terms: “local vancomycin” or “intrawound vancomycin” or “intraoperative vancomycin” or “intrawound vancomycin” or “topical vancomycin” and “spinal surgery” or “spine surgery.” We also screened the reference lists of included articles for additional studies and extracted data related to dose, infecting bacteria, sample size, infection rate and types, location of spine surgery, and perioperative antibiotics used. Our review includes one prospective and nine retrospective studies. Overall, 1 or 2 g local vancomycin powder was used in 2,394 patients. Gram-negative bacteria were dominant in patients in whom 1 g vancomycin powder was used, whereas gram-positive bacteria were dominant in those in whom 2 g powder was used. The exact mechanism underlying this dose-dependent trend remains unclear, although it may be attributed to the pharmacological characteristics of vancomycin. The included studies showed that trends in infection bacteria may change after the use of topical vancomycin powder. In addition, the observed increase in gram-negative bacteria when intrawound vancomycin powder is used has generated considerable attention. The present results differ from previous results but do not provide additional information regarding vancomycin dose and microbial changes in infected wounds. Additional large randomized controlled trials are needed to determine the relationship between vancomycin dose and the types of wound infection bacteria in patients treated with intrawound vancomycin powder during spine surgery.</p>

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Prophylactic Topical Antibiotics in Fracture Repair and Spinal Fusion

Advances in Orthopedics ◽

10.1155/2021/1949877 ◽

2021 ◽

Vol 2021 ◽

pp. 1-14

Author(s):

Eric K. Kim ◽

Claire A. Donnelley ◽

Madeline Tiee ◽

Heather J. Roberts ◽

Ericka Von Kaeppler ◽

...

Keyword(s):

Spinal Fusion ◽

Observational Studies ◽

Meta Analysis ◽

Fracture Repair ◽

Gram Positive ◽

Local Antibiotics ◽

Gram Negative ◽

Topical Antibiotics ◽

Vancomycin Powder ◽

Spinal Fusions

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, I2 = 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, I2 = 52.4%) and in fracture repair (OR 0.49, 95% CI: 0.37–0.65, I2 = 43.8%). Vancomycin powder decreased the risk of Gram-positive SSIs (OR 0.37, 95% CI: 0.27–0.51, I2 = 0.0%) and had no effect on Gram-negative SSIs (OR 0.95, 95% CI: 0.62–1.44, I2 = 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.

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A Freeze-Etch Study of Acinetobacter SP. Grown on a Hydrocarbon Substrate

Proceedings, annual meeting, Electron Microscopy Society of America ◽

10.1017/s0424820100050883 ◽

1974 ◽

Vol 32 ◽

pp. 174-175

Author(s):

C. L. Scott ◽

W. R. Finnerty

Keyword(s):

Membrane System ◽

Structural Distortion ◽

Intracytoplasmic Membrane ◽

Gram Negative ◽

Sectioned Material ◽

Acinetobacter Sp

Acinetobacter sp. HO-1-N, a gram-negative hydrocarbon oxidizing bacterium previously designated Micrococcus cerificans, has been shown to sequester the hydrocarbon into intracytoplasmic pools as a result of growth on this substrate. In hydrocarbon grown cells, an intracytoplasmic membrane system was also observed along with a doubling of cellular phospholipids (Z). However, using conventional dehydration and embedding procedures in preparing thin sectioned material, the hydrocarbon is extracted from the cells. This may lead to structural distortion, consequently, the freeze-etch technique was applied to preserve the integrity of the cell.

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Bacterial-Mucosal Cell Junctional Complexes

Proceedings, annual meeting, Electron Microscopy Society of America ◽

10.1017/s0424820100050731 ◽

1974 ◽

Vol 32 ◽

pp. 144-145

Author(s):

Roger C. Wagner

Keyword(s):

Intestinal Wall ◽

Rat Colon ◽

Mucosal Cell ◽

Gram Negative Bacteria ◽

Gram Negative ◽

Mucosal Cells ◽

Mucosal Lining ◽

Degenerative Alterations ◽

Junctional Complexes ◽

Intestinal Mucosal Cells

Bacteria exhibit the ability to adhere to the apical surfaces of intestinal mucosal cells. These attachments either precede invasion of the intestinal wall by the bacteria with accompanying inflammation and degeneration of the mucosa or represent permanent anchoring sites where the bacteria never totally penetrate the mucosal cells.Endemic gram negative bacteria were found attached to the surface of mucosal cells lining the walls of crypts in the rat colon. The bacteria did not intrude deeper than 0.5 urn into the mucosal cells and no degenerative alterations were detectable in the mucosal lining.

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Microanatomy of the Periplasm of Bacillus Licheniformis

Proceedings, annual meeting, Electron Microscopy Society of America ◽

10.1017/s0424820100065365 ◽

1971 ◽

Vol 29 ◽

pp. 262-263

Author(s):

B.K. Ghosh

Keyword(s):

Cell Wall ◽

Plasma Membrane ◽

Bacillus Licheniformis ◽

External Environment ◽

Permeability Barrier ◽

Periplasmic Space ◽

Modified Technique ◽

Gram Positive ◽

Gram Negative ◽

Gram Positive Bacteria

Periplasm of bacteria is the space outside the permeability barrier of plasma membrane but enclosed by the cell wall. The contents of this special milieu exterior could be regulated by the plasma membrane from the internal, and by the cell wall from the external environment of the cell. Unlike the gram-negative organism, the presence of this space in gram-positive bacteria is still controversial because it cannot be clearly demonstrated. We have shown the importance of some periplasmic bodies in the secretion of penicillinase from Bacillus licheniformis.In negatively stained specimens prepared by a modified technique (Figs. 1 and 2), periplasmic space (PS) contained two kinds of structures: (i) fibrils (F, 100 Å) running perpendicular to the cell wall from the protoplast and (ii) an array of vesicles of various sizes (V), which seem to have evaginated from the protoplast.

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Rapid demonstration of septic or infectious arthritis due to Gram-negative bacteria

Proceedings, annual meeting, Electron Microscopy Society of America ◽

10.1017/s0424820100123830 ◽

1992 ◽

Vol 50 (1) ◽

pp. 686-687

Author(s):

Jacob S. Hanker ◽

Paul R. Gross ◽

Beverly L. Giammara

Keyword(s):

Chronic Arthritis ◽

Blood Cultures ◽

Gram Negative Bacteria ◽

Infectious Arthritis ◽

Bacterial Arthritis ◽

Gram Positive ◽

Gram Negative ◽

Gram Positive Bacteria

Blood cultures are positive in approximately only 50 per cent of the patients with nongonococcal bacterial infectious arthritis and about 20 per cent of those with gonococcal arthritis. But the concept that gram-negative bacteria could be involved even in chronic arthritis is well-supported. Gram stains are more definitive in staphylococcal arthritis caused by gram-positive bacteria than in bacterial arthritis due to gram-negative bacteria. In the latter situation where gram-negative bacilli are the problem, Gram stains are helpful for 50% of the patients; they are only helpful for 25% of the patients, however, where gram-negative gonococci are the problem. In arthritis due to gram-positive Staphylococci. Gramstained smears are positive for 75% of the patients.

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Ultrastructure of periplasmic bodies in gram-negative bacteria

Proceedings, annual meeting, Electron Microscopy Society of America ◽

10.1017/s0424820100160753 ◽

1990 ◽

Vol 48 (3) ◽

pp. 640-641

Author(s):

Xie Nianming ◽

Ding Shaoqing ◽

Wang Luping ◽

Yuan Zenglin ◽

Zhan Guolai ◽

...

Keyword(s):

Electron Microscope ◽

Campylobacter Jejuni ◽

Proteus Mirabilis ◽

Shigella Flexneri ◽

Morphological Description ◽

Gram Negative Bacteria ◽

Periplasmic Space ◽

Clostridium Tetani ◽

Gram Negative ◽

Brucella Canis

Perhaps the data about periplasmic enzymes are obtained through biochemical methods but lack of morphological description. We have proved the existence of periplasmic bodies by electron microscope and described their ultrastructures. We hope this report may draw the attention of biochemists and mrophologists to collaborate on researches in periplasmic enzymes or periplasmic bodies with each other.One or more independent bodies may be seen in the periplasmic space between outer and inner membranes of Gram-negative bacteria, which we called periplasmic bodies. The periplasmic bodies have been found in seven species of bacteria at least, including the Pseudomonas aeroginosa. Shigella flexneri, Echerichia coli. Yersinia pestis, Campylobacter jejuni, Proteus mirabilis, Clostridium tetani. Vibrio cholerae and Brucella canis.

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