Systemic Absorption and Nephrotoxicity Associated With Topical Vancomycin Powder for Fracture Surgery

Abstract

Objectives: To determine whether using topical vancomycin powder in fracture surgery may result in low levels of vancomycin in the serum and not result in nephrotoxicity. Design: Prospective observational at a single site as a substudy of the VANCO trial. Setting: Single, large urban level I trauma center. Patients/Participants: Fifty-eight patients with tibial plateau and pilon fractures randomized to the treatment arm at the principal investigator's site. Intervention: Topical vancomycin powder (1000 mg) applied directly in the wound over all metal implants at the time of wound closure. Main Outcome Measurements: Serum vancomycin levels at 1 hour and 6–8 hours after surgery. Secondary outcomes included serum creatinine before surgery, a day after surgery, and at 2 weeks postoperatively and complete blood count at 2 weeks postoperatively. Results: Except in 2 patients who also received intravenous vancomycin, none of the study patients had detectable (>5 µg/mL) serum vancomycin levels at 1 hour and 6–8 hours after surgery. One patient with a history of elevation of serum creatinine had a minor increase of serum creatinine but had undetectable vancomycin levels. None of the other patients had a clinically significant increase in creatinine levels. Conclusions: Despite its relatively widespread usage, little data exist regarding the systemic levels and nephrotoxicity associated with the topical use of vancomycin powder in orthopaedic fracture surgery. These prospective data indicate that there seems to be little clinical concern regarding toxicity associated with systemic absorption of vancomycin powder in this specific clinical application. Level of Evidence: Therapeutic Level IV. See instructions for authors for a complete description of levels of evidence.

Does cumulative topical antibiotic powder use increase the risk of drug induced acute kidney injury in fracture patients?

“…11,12 Current evidence suggests that topical antibiotics bear a much lower risk of AKI risks. 4,[13][14][15] In a recent cohort of 58 fracture patients who received a single 1,000 mg dose of intraoperative vancomycin powder, 4 blood samples were obtained six to eight hours after surgery, and vancomycin levels were measured. Association of intrawound vancomycin powder and intrawound tobramycin powder cumulative doses with drug-induced acute kidney injury.…”

“…The evidence to support the use of topical antibiotics to prevent surgical site infections in fracture patients continues to build. [2][3][4] Yet, some concern regarding nephrotoxicity from high-dose topical antibiotics in multiple surgeries persists. The results of this study suggest that, among patients with fractures, cumulative doses of local vancomycin powder do not increase the drug-induced AKI.…”

“… 11 , 12 Current evidence suggests that topical antibiotics bear a much lower risk of AKI risks. 4 , 13 - 15 In a recent cohort of 58 fracture patients who received a single 1,000 mg dose of intraoperative vancomycin powder, 4 blood samples were obtained six to eight hours after surgery, and vancomycin levels were measured. The vancomycin levels in all patients remained within or below the recommended therapeutic levels of vancomycin, and correlated with their IV antibiotic regimen.…”

“…Previous research suggests a minimal risk of an acute kidney injury (AKI) with a single 1,000 mg dose of intrawound vancomycin powder. 4 However, polytrauma patients often have multiple fractures treated with multiple surgeries. Subsequent doses of local antibiotics, or combinations of local antibiotics, can be given with each additional procedure.…”

Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures

“…Intrawound vancomycin powder is a low-cost intervention that can be easily incorporated into existing prophylactic protocols. In addition to the observed treatment benefits specific to reducing gram-positive infections, prior research 12,23,[26][27][28] suggests that topical antibiotics have little systemic exposure and minimal systemic toxicity compared with antibiotics administered intravenously. Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, of the manuscript; and decision to submit the manuscript for publication.…”