Selection pressures of vancomycin powder use in spine surgery: a meta-analysis

Gande, Abhiram; Rosinski, Alex; Cunningham, Torin; Bhatia, Nitin; Lee, Yu-Po

doi:10.1016/j.spinee.2019.01.002

Cited by 65 publications

(32 citation statements)

References 34 publications

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“…Multiple systematic reviews and meta-analyses, however, have concluded that intraoperative application of vancomycin powder is associated with a decreased incidence of SSIs after certain orthopaedic procedures. 8,10,12 Combining this with the findings from the current investigation, we believe that the concentrations of vancomycin that have been used in clinical studies are safe with regard to tenocyte cytotoxicity.…”

Section: Discussionsupporting

confidence: 69%

Soaking of Autologous Tendon Grafts in Vancomycin Before Implantation Does Not Lead to Tenocyte Cytotoxicity

et al. 2020

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Background: Surgical site infections (SSIs) after anterior cruciate ligament (ACL) reconstruction procedures are an unfortunate complication. Soaking grafts in vancomycin before implantation has been reported to reduce the incidence of postoperative SSI after ACL reconstruction. There is potential for vancomycin to compromise graft integrity because of tenocyte toxicity. Purpose: To examine the in vitro toxicity of varying doses of vancomycin on human tenocytes. Study Design: Controlled laboratory study. Methods: Human patellar tenocytes were isolated and expanded in vitro. Tenocytes in culture were exposed to vancomycin at 5 different concentrations (400, 1600, 3200, 6400, and 12,800 μg/mL) and 3 time intervals (2, 6, and 24 hours). The control for all series was tenocyte exposure to only culture medium for each time interval. After treatment, a 10% Cell Counting Kit-8 solution in cellular growth medium was applied to the cells to examine cytotoxicity. A live/dead assay was used to assess tenocyte viability through fluorescence microscopy and flow cytometry. Results were analyzed statistically using multivariable logistic regression models with Tukey honest significant difference post hoc tests. Results: Vancomycin did not cause significant changes in tenocyte viability after 2 and 6 hours of incubation at any concentration between 0 and 12,800 µg/mL. Incubation with vancomycin for 24 hours led to a significant decrease in cell viability at higher concentrations. Conclusion: Tenocytes derived from human patellar tendons exposed to relatively high concentrations of vancomycin for short periods of time do not demonstrate significant cell death and toxicity. Clinical Relevance: Exposing tendons to vancomycin for a short period of time, such as before ACL reconstruction, is not likely to cause tenocyte toxicity because of vancomycin administration.

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Section: Discussionsupporting

confidence: 69%

Soaking of Autologous Tendon Grafts in Vancomycin Before Implantation Does Not Lead to Tenocyte Cytotoxicity

et al. 2020

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“…Apart from the above-mentioned local and systemic safety concerns, another demerit of unindicated use of TVP is the selection pressure that it may put on microorganisms, leading to the development of resistant strains and increased incidence of gram-negative infections. Gande et al, 37 in 2019, analyzed the selection pressures caused by widespread TVP use in adult spine surgeries and concluded that widespread TVP use increases the chances of polymicrobial and gram-negative SSIs and that TVP use should be restricted to high-risk groups. In our review also, we noted gram-negative coinfection in SSIs occurring in the TVP group.…”

Section: Discussionmentioning

confidence: 99%

“…The quality of the available evidence and the above-mentioned safety concerns make the recommendation of TVP for routine use in pediatric spine surgeries highly questionable. Given that consensus has not been achieved regarding the use of TVP in adults 37 , 38 and that FDA approval is lacking, its use in the pediatric population should be avoided unless future evidence gives us robust supportive data. The sporadic adverse effects in adults can only be extrapolated as a more frequent occurrence in the more delicate pediatric population.…”

Section: Discussionmentioning

confidence: 99%

Is Use of Topical Vancomycin in Pediatric Spine Surgeries a Safe Option in the Prevention of Surgical Site Infections? A Meta-analysis and Systematic Review of the Literature

Muthu

Chellamuthu

2020

Global Spine Journal

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Study Design: Systematic review and meta-analysis. Objective: To systematically review the available articles on topical vancomycin powder (TVP) use in pediatric spine surgeries exploring the usefulness and safety of such practice. Methods: We conducted an independent and duplicate electronic database search in PubMed, EMBASE, and Cochrane Library till March 2020 to identify all relevant literature on the use of TVP for pediatric spine surgeries. Surgical site infection (SSI) rate, specific reported complications, reoperation rate, microbial flora pattern in reported SSIs, and safety profile were the outcomes analyzed. Analysis was performed with the R platform using OpenMeta[Analyst] software. Results: No prospective studies were available to evaluate the use of TVP in pediatric spine surgeries for the prevention of SSIs. Neither standardized protocol, nor drug dosage, nor safety profile was established for pediatric use. Three retrospective cohort studies including 824 patients (TVP/control: 400/424) were included in the meta-analysis. There was low-quality evidence suggesting no significant difference between the 2 groups in SSI rate (RR = 0.474; 95% CI = [0.106,2.112]; P = .327) with significant heterogeneity ( I 2 = 70.14; P = .035). The TVP group showed a significant benefit on cost analysis in one of the included studies. However, TVP did not prevent gram-negative coinfection on SSI in the TVP group. Conclusion: From the literature available at present, TVP does not qualify to be recommended as a safe and useful option to prevent SSI following pediatric spine surgeries. High-quality prospective interventional studies are needed to arrive at a consensus on its use along with appropriate dosage and method of application.

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“…Vancomycin powder was found to decrease the rate of deep space infections requiring re-operation (164). Vancomycin powder should be restricted to procedures and patients most at risk of MRSA-related surgical site infection (165) (166) (167).…”

Section: Discussionmentioning

confidence: 99%

Pathway for Enhanced Recovery after Spinal Surgery-A Systematic Review of Evidence for use of Individual Components

Licina

Silvers

Laughlin

et al. 2020

Preprint

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Background Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on societal recommendations and qualitative reviews. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review. Methods We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined care components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). We searched the following databases (1990 onwards) MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two reviewers independently screened all citations, full-text articles, and abstracted data. A narrative synthesis was provided. Where applicable, we constructed Evidence Profile (EP) tables for each individual element. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. Confidence in cumulative evidence for each component of the pathway was classified according to the GRADE system. Results We identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We found specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables for 12/22 components. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components. Discussion We identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS. Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.

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Selection pressures of vancomycin powder use in spine surgery: a meta-analysis

Cited by 65 publications

References 34 publications

Soaking of Autologous Tendon Grafts in Vancomycin Before Implantation Does Not Lead to Tenocyte Cytotoxicity

Soaking of Autologous Tendon Grafts in Vancomycin Before Implantation Does Not Lead to Tenocyte Cytotoxicity

Is Use of Topical Vancomycin in Pediatric Spine Surgeries a Safe Option in the Prevention of Surgical Site Infections? A Meta-analysis and Systematic Review of the Literature

Pathway for Enhanced Recovery after Spinal Surgery-A Systematic Review of Evidence for use of Individual Components

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