Effect of Intra‐wound Vancomycin for Spinal Surgery: A Systematic Review and Meta‐analysis

Abstract

Intra-site prophylactic vancomycin in spine surgery is an effective method of decreasing the incidence of postsurgical wound infection. However, there are differences in the prophylactic programs used for various spinal surgeries. Thus, this systematic review and meta-analysis aimed to evaluate the effectiveness of using intra-wound vancomycin during spinal surgery and to explore the effects of dose-dependence and the method of administration in a subgroup analysis. A total of 628 citations or studies were searched in PubMed, Ovid, Web of Science, and Google Scholar that were published before August 2016 with the terms "local vancomycin", "intra-wound vancomycin", "intraoperative vancomycin", "intra-site vancomycin", "topical vancomycin", "spine surgery", and "spinal surgery". Finally, 19 retrospective cohort studies and one prospective case study were eligible for inclusion in the systematic review and metaanalysis. The odds of developing postsurgical wound infection without prophylactic local vancomycin use were 2.83-fold higher than the odds of experiencing wound infection with the use of intra-wound vancomycin (95% confidence interval, 2.03-3.95; P = 0.083; I 2 = 32.2%). The subgroup analysis including the dosage and the method of administration, revealed different results compared to previous research. The value of I 2 in the 1-g group was 27.2%, which was much lower than in the 2-g group (I 2 = 57.6%). At the same time, the value of I 2 was 0.0% (P = 0.792, OR = 2.70) when vancomycin powder was directly sprinkled into all layers of the wound. However, there is high heterogenicity (I 2 = 60.0%, P = 0.007, OR = 2.83) when vancomycin powder is not exposed to the bone graft and instrumentation. There are differences found with the method of local application of vancomycin for reducing postoperative wounds and further studies are necessary, including investigations focusing on the dose-dependent effects during spinal or the topical pharmacokinetic and other orthopaedic surgeries.

What Are the Benefits and Risks Associated With the Use of Vancomycin Powder in the Wound During Total Ankle Arthroplasty (TAA) or Other Foot and Ankle Procedures?

“…The effectiveness of vancomycin powder has been documented more extensively in other orthopedic subspecialties than foot and ankle. 1,3-5,10 A systematic literature review by Kanj et al 5 showed local vancomycin-impregnated cement and powder to be associated with lower infection rates while also being safe and effective in clean orthopedic surgery. The authors especially recommended using local vancomycin in spine surgery, in which patients without local antibiotic prophylaxis were more than 4 times more likely to experience a deep postoperative wound infection.…”

“…Evaniew et al 4 concluded through their meta-analysis that there is a lack of high-quality evidence to inform the use of intrawound vancomycin in spine surgery. Xie et al 10 found from their meta- analysis on intrawound vancomycin in spinal surgery that the odds of developing postsurgical wound infection without prophylactic local vancomycin use were 2.83-fold higher than the odds of experiencing wound infection with the use of intrawound vancomycin. Furthermore, a retrospective review performed by Singh et al 8 that assessed the efficacy of intraoperative vancomycin powder administration on preventing deep SSI in high-energy lower extremity trauma (including tibial plateau fractures and pilon fractures) found that the rate of deep SSI between the groups was not significantly different.…”

Vancomycin bone and tissue concentrations following tibial intraosseous administration – evaluated in a porcine model

“…However, studies have shown that systemic vancomycin administration may not provide sufficient bone and tissue concentrations in some orthopaedic settings (Bue et al, 2015(Bue et al, , 2017Bryson et al, 2016;Mangram et al, 1999). Local vancomycin application has the potential to bypass these concerns by delivering high target-site concentrations without reaching toxic sideeffects (Sweet et al, 2018;Whiteside, 2016;Young et al, 2014;Wahl et al, 2017). Several local vancomycin applications and carriers are currently available, e.g.…”

“…powder, calcium sulfate, and irrigation. Particularly in implant surgery, local vancomycin application may be promising to prevent bacterial implant colonization (Whiteside, 2016;Young et al, 2014).…”

“…Intraosseous vancomycin administration into the proximal tibia is an easy and feasible local vancomycin application. Intraosseous vancomycin has previously been employed as a perioperative antibiotic prophylaxis in total knee replacement and revision surgery and suggested as enhancing the effectiveness of the perioperative antibiotic prophylaxis (Young et al, 2014;Harper et al, 2020;Young et al, 2018;Chin et al, 2018). These studies assessed vancomycin tissue concentrations by means of tissue specimens, which, however, is limited by its invasiveness, static sampling points, determination of the total, and not free drug concentration.…”