Clinically apparent adverse reactions to intra-wound vancomycin powder in early onset scoliosis are rare

Abstract

PurposeSpine surgeons have increasingly used intraoperative application of topical vancomycin powder (TVP) to prevent surgical site infections (SSIs). The goals of this study were to define the rate of pharmacological adverse reaction to TVP in young patients undergoing posterior spinal surgery and to summarise institutional variation in TVP dosing.MethodsThis retrospective observational study included ten spine centres in the United States and one in Europe. Patients with early onset scoliosis who underwent posterior spine surgery were eligible for inclusion. Age, weight, TVP dose and surgery type were recorded. Surgeries where patient age was > 12 years were excluded. Pharmacological adverse reactions were defined as clinical instances of Red Man Syndrome, rash, nephrotoxicity, proteinuria, hepatotoxicity or ototoxicity. The rate of pharmacological adverse reaction to TVP was calculated. Dosing practices were summarised.ResultsPatient age was in the range of seven months to 12 years (median ten years). Of 1398 observations, there was one possible pharmacological adverse reaction. This was in a ten-year-old, 20.4-kg female patient with neuromuscular sco-liosis undergoing growing rod implantation. She was dosed with 1500 mg of TVP and immediately developed a transient rash without systemic symptoms. This abated over minutes without any medical intervention. There were no other adverse reactions in the sample. The population rate of pharmacological adverse reaction was 0.072% (95% confidence interval 0 to 0.4). Significant variability in dosing practices existed between centres.ConclusionPharmacological adverse reactions to TVP are rare. Future work may establish evidence-based guidelines for TVP dosing based on patient weight and other variables.

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

“…61 A recent systematic review of DeFrancesco et al found only one case of adverse drug reaction (transient rash) in almost 1400 children undergoing posterior spinal surgery for early onset scoliosis, a rate of only 0.072%. 62 In addition, patients in this study that had previously shown adverse drug reactions to intravenous vancomycin did not react to intrawound vancomycin powder. Nonunion of bone is another potential complication of local antibiotics at high concentrations.…”

Intrawound low-dose vancomycin is superior to high-dose in controlling the risk of wound dehiscence in spine surgeries

“…[ 37 , 38 ] Based on this, we and other authors therefore encourage more clinical trials for lower doses of intrawound vancomycin. [ 39 , 40 ] The use of intrawound vancomycin may increase the incidence of gram-negative and polymicrobial postoperative infections in our study; however, it is under debate in the literature. [ 41 ] BMI showed an association in our study with wound infection and dehiscence, which is consistent with the findings in the literature of an increased incidence of wound complications with higher BMI.…”

Vancomycin Flushing Syndrome After the Use of Vancomycin-Impregnated Bone Graft During Spine Surgery

“…Intrawound vancomycin in pediatric spine surgeries has been considered relatively safe in the pediatric age group as well. A 2017 study by the Children’s Spine Study Group reviewed 1,398 patients and reported only 1 possible adverse reaction in the form of rash without any systemic effects 19,20 . All the reports of adverse reactions are in adults with multiple comorbidities.…”