Infectious Prophylaxis with Intrawound Vancomycin Powder in Orthopedic Surgeries: Systematic Review with Meta-Analysis

Sadigursky, David; Sousa, Mariana Drummond; Cajaíba, Yasmin Galvão Linhares; Martins, Rodrigo Rêgo; Lobão, Diogo Maciel Vieira

doi:10.1016/j.rbo.2017.12.003

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Review Article • Rev. bras. ortop. 54 (6) • Nov-Dec 2019 • https://doi.org/10.1016/j.rbo.2017.12.003 copy

Infectious Prophylaxis with Intrawound Vancomycin Powder in Orthopedic Surgeries: Systematic Review with Meta-Analysis^* * Work developed at the Orthopedic Trauma Clinic, Centro de Estudos em Ortopedia e Traumatologia (COT-CEOT), Salvador, BA, Brazil. Originally Published by Elsevier.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Despite many existing strategies used to reduce the rates of surgical site infection (SSI), these are still fairly frequent complications that pose a challenge for orthopedic surgeons. Therefore, the search for more effective methods of perioperative infection prophylaxis became a main subject of research, with the goal of decreasing postoperative morbidity, mortality, and costs. Thus, the present study sought to assess the effectiveness of intra-wound vancomycin powder in orthopedic surgery SSI prophylaxis.

A systematic review and meta-analysis study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols 2015 (PRISMA-P 2015). A comprehensive literature search was performed to identify controlled studies on the rates of SSI with or without the local use of vancomycin powder. Exclusion and inclusion criteria were applied. A meta-analysis with random effects was performed.

Out of 412 titles that met the criteria, 7 studies regarding spine surgery were included: 4 prospective and 3 retrospective studies. A total of 6,944 cases were identified, and they were divided into 2 groups: the control group (3,814 patients), to whom intrawound vancomycin was not administered, and the intervention group (3,130 patients), to who vancomycin was administered locally. We observed that 64 (2.04%) patients in the intervention group developed SSI, in contrast to 144 (3.75%) patients in the control group. The results of the meta-analysis showed that the local use of vancomycin powder had an statistically significant protective effect against SSI in cases of spine surgery, with a relative risk (RR) of 0.59 and a 95% confidence interval (95%CI) of 0.35-0.98.

The use of prophylactic intrawound vancomycin powder has a protective effect against SSI in spine surgeries; however, further prospective trials are needed to endorse its use in orthopedic surgeries.

Keywords
vancomycin; surgical wound infection; orthopedics

	PICO inclusion criteria
Indicators	Results according to the PICO protocol
Project	Cohort studies and case-control clinical trials
Population	Patients undergoing orthopedic surgery with and without the prophylactic administration of vancomycin powder directly at the surgical site
Intervention	Prophylaxis: vancomycin topical powder
Comparison	No prophylactic topical administration of vancomycin powder
Outcome	Rates of incidence of surgical site infections

							Infection
Authors and year of publication	Study design	Level of evidence	Follow-up	Sample	Intervention group	Control group	Vancomycin	Control	Type of spinal surgery	Difference between groups
O'Neill et al,²⁰20 O'Neill KR, Smith JG, Abtahi AM, et al. Reduced surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powder. Spine J 2011;11 (07):641-646 2011	Retrospective case review	3	C: 30 weeks; V: 24 weeks (mean) > 2 m:C - 73%; V - 80%	110	56	54	0%CI: 06% p = 0.02	7 (13%) 5 - 25%CI 5 deep 2 superficial	Posterior fusion; instrumentation (traumatic lesions)	Similar Characteristics between the groups (p > 0.05)
Tubaki et al,¹¹11 Tubaki VR, Rajasekaran S, Shetty AP. Effects of using intravenous antibiotic only versus local intrawound vancomycin antibiotic powder application in addition to intravenous antibiotics on postoperative infection in spine surgery in 907 patients. Spine 2013;38(25):2149-2155 2013	Controlled randomized prospective essay	2	Min. 12 weeks	907	433	474	7 (1.61%) 6 deep 1 superficial 6 instrumented	8 (1.68%) 6 deep 2 superficial 6 instrumented	Open; instrumented or not; any level	Similar distribution between the groups (randomized)
Hill et al,²⁵25 Hill BW, Emohare O, Song B, Davis R, Kang MM. The use of vancomycin powder reduces surgical reoperation in posterior instrumented and noninstrumented spinal surgery. Acta Neurochir (Wien) 2014;156(04):749-754 2014	Comparative retrospective cohort	3	Min. 1 month; C - 10.03 months V - 8.76months	300	150	150	3% superficial (10/300) 5/150 Deep 0% (95%CI: 0-2.4%) (p = 0.0297)	5/150 4% (n = 6) (95%CI: 1.5-8.5%)	Instrumented or not posterior access	p < 0.05: age, lumbar surgery, MD, type of surgery, surgery duration (covariate analysis with no difference for predictors of deep SSI)
Devin et al,²⁸28 Devin CJ, Chotai S, McGirt MJ, et al. Intrawound vancomycin decreases the risk of surgical site infection after posterior spine surgery-a multicenter analysis. Spine 2018;43(01):65-71 2018	Prospective multicentric observational (secondary analysis)	2	30 days	2,056	966	1,090	Total SSI: 2.2% (n = 21)	5.1% (n = 56)	Elective (degenerative, tumoral, trauma)	p < 0.05: Intervention group: more MD, corticoid use, arthrodesis
							p < 0.001 RR: 2.5 (95%CI: / 1.5-4.1)
							Deep SSI: 0.7% (n = 7)	3.9% (n = 42)
							p < 0.001 RR: 5.9 (95%CI: 2.6-13.2)
Hey et al,⁶6 Hey HW, Thiam DW, Koh ZS, et al. Is intraoperative local vancomycin powder the answer to surgical site infections in spine surgery? Spine 2017;42(04):267-274 2017	Comparative retrospective cohort	3	30-90 days	389	117	272	18/389 (4.6%) 1 (0.9%) 1 deep	17 (6.3%) 10 deep 7 superficial	Open, instrumented	p < 0.05: smoking, spine pathology, surgical access, blood loss, OR surgery duration adjusted for SSI: smoking and duration; p > 0.05
							p = 0,0495 / OR: 0.13 (95%CI: 0.02-0.99)
Chotai et al,²⁷27 Chotai S,Wright PW, Hale AT, et al. Does intrawound vancomycin application during spine surgery create vancomycin-resistant organism? Neurosurgery 2017;80(05):746-753 2017	Observational prospective 2 cohort	2	90 days	2,802	1,215	1,587	1.6% (n = 20)	2.5% (n = 40)	Elective; with or without instrumentation, degenerative or oncological	Similar characteristics between the groups (p > 0.05)
							All deep (return to SC); p = 0.02
Mirzashahi B et al,²⁶26 Mirzashahi B, Chehrassan M, Mortazavi SMJ. Intrawound application of vancomycin changes the responsible germ in elective spine surgery without significant effect on the rate of infection: a randomized prospective study. Musculoskelet Surg 2018;102 (01):35-39. Doi: 10.1007/s12306-017-0490-z https://doi.org/10.1007/s12306-017-0490-... 2018	Controlled randomized prospective essay	2	90 days	380	193	187	Total: 3.9% 5.2% (n = 10) All deep p = 0.2	2.7% (n = 5)	Open (tumoral, degenerative, trauma, deformities); posterior access	Similar distribution between the groups (randomized)

Authors and year of publication	Dose/Vancomycin application	Infection Criteria	Microbiological profile^b b Results of cultures made in cases submitted to surgical debridement (deep SSIs).	Vancomycin Complications	Antibiotic Prophylaxis IV (anesthesic induction + duration)	Number of Instituitions/surgeons	SSI treatment	Conclusions
O'Neill et al,²⁰20 O'Neill KR, Smith JG, Abtahi AM, et al. Reduced surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powder. Spine J 2011;11 (07):641-646 2011	1 the g over fascia, muscle and SCCT, avoiding the dura and the bone graft	Superficial - wound inspection Deep - axial imaging s/n (MRI)	Deep SSIs (5): MRSA 4/5; Polyflora: 1/5. Superficial SSIs: no culture (no debr.)	None	Cefazolin 1g + 1g 8/8 h 24h Allergy: clindamycin 900 mg	Unicentric Intervention - 01; control: multiple	2 superficial: local care and ATB 5 deep: debr. + ATB IV 01 death	The topical use of powdered vancomycin has protective effects against SSIs
Tubaki et al,¹¹11 Tubaki VR, Rajasekaran S, Shetty AP. Effects of using intravenous antibiotic only versus local intrawound vancomycin antibiotic powder application in addition to intravenous antibiotics on postoperative infection in spine surgery in 907 patients. Spine 2013;38(25):2149-2155 2013	1 g over the fascia, muscle and SCCT, avoiding the dura and the bone graft	Superficial and deep. Diagnostic method not specified.	C: 1 E. coli and 2 S. aureus. V: 1 S. aureus and 2 Klebsiella	None	Cefuroxim 750 mg + 750 mg 8/8 24-48h	Unicentric: multiple	Superficial: local care + ATB; deep: debr. + ATB IV	Vancomycin powder has no protective effect against SSIs and may not be effective when the basal rate of infection is low.
Hill et al,²⁵25 Hill BW, Emohare O, Song B, Davis R, Kang MM. The use of vancomycin powder reduces surgical reoperation in posterior instrumented and noninstrumented spinal surgery. Acta Neurochir (Wien) 2014;156(04):749-754 2014	1-2 g directly over the whole exposed tissue	Superficial - skin; deep - TCSC subfascial	Gram+ in 4/6 deep SSIs (66.7%): 4 MRSA; 1 Enterococcus (control group)	None	Cefazolin 1g + 2g 8/8 h 24h Allergy: Vancomycin	Unicentric: Intervention - 01; Control - 01	Superficial: wound care or cephalexin OA 10 days; deep: irrigation; surgical debr. + ATB OA or IV; 6 SSIs (control): 12 debr.	Topical vancomycin may be effective, especially in deep SSI prophylaxis that requires surgical debridement
Devin et al,²⁸28 Devin CJ, Chotai S, McGirt MJ, et al. Intrawound vancomycin decreases the risk of surgical site infection after posterior spine surgery-a multicenter analysis. Spine 2018;43(01):65-71 2018	1 g/10 cm of incision over the fascia, muscle and SCCT, avoiding the dura and the bone graft	Visual aspect of operatory wound + MRI with contrast for all cases of suspicion. Deep: return to SC	Does not apply	None	Cefazolin 1g + 1g 8/8 h 24h Allergy: clindamycin 900 mg	Multicentric: multiple	Superficial: empirical ATB OA Deep: debr. +/- Implant removal +culture with ATB IV + av. infectologist	Topical vancomycin reduces the risk of SSI and the prospect of returning to the SC.

Hey et al.,⁶6 Hey HW, Thiam DW, Koh ZS, et al. Is intraoperative local vancomycin powder the answer to surgical site infections in spine surgery? Spine 2017;42(04):267-274 2017	1 g directly over the whole exposed tissue	Independent and trained nurse. CDC definition for deep or superficial SSIs^a	General: P. aeruginosa - 6 (35,2%); MRSA - 4 (22%). V: 1 P. aeruginosa; C: 4 MRSA; 1 coagulase-negative staphylococci; 1 Bacillus cereus; 5 P. aeruginosa; 2 E. coli; 3 Klebsiella pneumoniae (p < 000.1 for causing microorganism)	None	Cefazolin 1g + 1g 8/8 h 24h Allergy: vancomycin 1 g	Unicentric: Multiple (intervention- 03; control-03)	13 out of 18 with SSI; surgical treatment: 01 V -fusion revision + debr. +ATB 3 months; 10 C - debr.; 2 C - debr. + implant removal	Topical vancomycin significantly reduces the morbidity and the rate (shorter time of onset and duration) of SSIs in instrumented surgeries, with P. aeruginosa being the main germ.
Chotai et al,²⁷27 Chotai S,Wright PW, Hale AT, et al. Does intrawound vancomycin application during spine surgery create vancomycin-resistant organism? Neurosurgery 2017;80(05):746-753 2017	1 g/10 cm of incision over the fascia, muscle and SCCT, avoiding the dura and the bone graft	Visual aspect of operatory wound + MRI with contrast for all cases of suspicion. Deep = return to SC	V: less S. aureus (32%/65%; p = 0.003); More gram-; Ø vancomycin-resistant S. aureus. 1º S. aureus: 57%, 2º S. epidermidis: 5%	None	Cefazolin 1 g + 1 g 8/8h 24h Allergy: clindamycin 900 mg	Unicentric: multiple	Superficial: empirical ATB OA; deep: debr. +/- implant removal + culture with ATB IV + av. infectologist	Topical vancomycin significantly reduces the risk of SSI and is not related to the increase in MRSA
Mirzashahi et al,²⁶26 Mirzashahi B, Chehrassan M, Mortazavi SMJ. Intrawound application of vancomycin changes the responsible germ in elective spine surgery without significant effect on the rate of infection: a randomized prospective study. Musculoskelet Surg 2018;102 (01):35-39. Doi: 10.1007/s12306-017-0490-z https://doi.org/10.1007/s12306-017-0490-... 2018	1 g or 2 g (2 g for obese patients or > 3 fusion levels) directly over the wound	Definition of the CDC for deep or superficial SSIs	V: Acinetobacter and P. aeruginosa (20%); C: S. aureus and Acinetobacter; (40%) 1 MRSA	None	Cefazolin 1 g or 2 g Allergy: clindamycin 900 mg	Unicentric: multiple	Deep (all): debr. + irrigation + ATB IV and av. infectologist No implant removal	Topical vancomycin Is not related to the reduction in the risk of SSI, but may change SSI microbiological profile

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[1] Address for correspondence, David Sadigursky, MD, MSc, Clínica Ortopédica Traumatológica, Centro de Estudos em Ortopedia e Traumatologia (COT-CEOT), Salvador, BA, Brasil. (e-mail: davidsad@gmail.com).

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Infectious Prophylaxis with Intrawound Vancomycin Powder in Orthopedic Surgeries: Systematic Review with Meta-Analysis* * Work developed at the Orthopedic Trauma Clinic, Centro de Estudos em Ortopedia e Traumatologia (COT-CEOT), Salvador, BA, Brazil. Originally Published by Elsevier.

Abstract

Infectious Prophylaxis with Intrawound Vancomycin Powder in Orthopedic Surgeries: Systematic Review with Meta-Analysis^* * Work developed at the Orthopedic Trauma Clinic, Centro de Estudos em Ortopedia e Traumatologia (COT-CEOT), Salvador, BA, Brazil. Originally Published by Elsevier.