Vancomycin Powder Use in Fractures at High Risk of Surgical Site Infection

Qadir, Rabah; Costales, Timothy; Coale, Max; Mulliken, Alexandra; Zerhusen, Timothy; Joshi, Manjari; Castillo, Renan C.; Carlini, Anthony R.; O’Toole, Robert V.

doi:10.1097/bot.0000000000001863

Cited by 28 publications

(48 citation statements)

References 34 publications

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“…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.…”

Section: Discussionmentioning

confidence: 99%

“…Mounting evidence suggests that topical antibiotic powder placed in the surgical incision effectively prevents surgical site infections after fracture fixation surgery. [1][2][3] In contrast to intravenous antibiotics, locally applied antibiotics do not require sufficiently high systemic concentrations or adequate blood supply to reach the target site. Thus, topical antibiotics are believed to deliver higher local concentrations to the region of interest without unnecessary systemic exposure.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2022

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Aims There is increasing evidence to support the use of topical antibiotics to prevent surgical site infections. Although previous research suggests a minimal nephrotoxic risk with a single dose of vancomycin powder, fracture patients often require multiple procedures and receive additional doses of topical antibiotics. We aimed to determine if cumulative doses of intrawound vancomycin or tobramycin powder for infection prophylaxis increased the risk of drug-induced acute kidney injury (AKI) among fracture patients. Methods This cohort study was a secondary analysis of single-centre Program of Randomized Trials to Evaluate Pre-operative Antiseptic Skin Solutions in Orthopaedic Trauma (PREP-IT) trial data. We included patients with a surgically treated appendicular fracture. The primary outcome was drug-induced AKI. The odds of AKI per gram of vancomycin or tobramycin powder were calculated using Bayesian regression models, which adjusted for measured confounders and accounted for the interactive effects of vancomycin and tobramycin. Results Of the 782 included patients (mean age 48 years (SD 20); 59% male), 83% (n = 648) received at least one vancomycin dose (cumulative range 1 to 12 g). Overall, 45% of the sample received at least one tobramycin dose (cumulative range 1.2 to 9.6 g). Drug-induced AKI occurred in ten patients (1.2%). No association was found between the cumulative dose of vancomycin and drug-induced AKI (odds ratio (OR) 1.08 (95% credible interval (CrI) 0.52 to 2.14)). Additional doses of tobramycin were associated with a three-fold increase in the adjusted odds of drug-induced AKI (OR 3.66 (95% CrI 1.71 to 8.49)). Specifically, the risk of drug-induced AKI rose substantially after 4.8 g of tobramycin powder (7.5% (95% CrI 1.0 to 35.3)). Conclusion Cumulative doses of vancomycin were not associated with an increased risk of drug-induced AKI among fracture patients. While the risk of drug-induced AKI remains less than 4% with three or fewer 1.2 g tobramycin doses, the estimated risk increases substantially to 8% after four cumulative doses. Level of evidence: Therapeutic Level III Cite this article: Bone Jt Open 2022;3(4):284–290.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

et al. 2022

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“…This study found a reduction in the infection rate with the use of VP (35 patients) when compared with the control group (548 patients) (0% vs. 10.6%, p = 0.04). Although this falls into the realm of orthopaedic trauma, this is the only other study that looked at some type of foot fracture where VP was applied 45 .…”

Section: Sports—primary and Secondary Aclrmentioning

confidence: 99%

Local Application of Vancomycin in Orthopaedic Surgery—A Review

Nelson

Maez

Kump

et al. 2022

JBJS Journal of Orthopaedics for Physician Assistants

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The aim of this review was to report on the use of local application of vancomycin in various realms of orthopaedic surgery, discuss limitations on current studies, and identify potential areas for future research. Vancomycin powder has been used effectively and extensively to prevent surgical site infection in spine surgery, leading to an increased use in other orthopaedic subspecialties. Vancomycin soaking is an emerging technique used in anterior cruciate ligament reconstruction to presoak grafts before implantation. The potential effect to surrounding structures that result from using high localized concentrations of vancomycin is an area of the literature that may be beneficial to further understand. Given the increasing use of locally applied vancomycin, it is essential to understand the spectrum of benefits and safety and continue to analyze the results of emerging studies to guide the future safe practice of surgeons. It is also important to consider population-level effects, such as antimicrobial resistance, that may be associated with more frequent use of vancomycin. Our review concluded that the current literature is limited to mainly retrospective or observational studies, and it would be beneficial to conduct more randomized control trials and prospective studies.

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“…Fourteen fracture studies were included, with three RCTs, two prospective observational studies, and nine retrospective studies (Table 2) [50][51][52][53][54][55][56][57][58][59][60][61][62][63]. A total of 4,635 patients were included.…”

Section: Fracture Repairmentioning

confidence: 99%

Prophylactic Topical Antibiotics in Fracture Repair and Spinal Fusion

Kim

Donnelley

Tiee

et al. 2021

Advances in Orthopedics

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Introduction. The objective of this systematic review with meta-analysis is to determine whether prophylactic local antibiotics prevent surgical site infections (SSIs) in instrumented spinal fusions and traumatic fracture repair. A secondary objective is to investigate the effect of vancomycin, a common local antibiotic of choice, on the microbiology of SSIs. Methods. An electronic search of PubMed, EMBASE, and Web of Science databases and major orthopedic surgery conferences was conducted to identify studies that (1) were instrumented spinal fusions or fracture repair and (2) had a treatment group that received prophylactic local antibiotics. Both randomized controlled trials (RCTs) and comparative observational studies were included. Meta-analysis was performed separately for randomized and nonrandomized studies with subgroup analysis by study design and antibiotic. Results. Our review includes 44 articles (30 instrumented spinal fusions and 14 fracture repairs). Intrawound antibiotics significantly decreased the risk of developing SSIs in RCTs of fracture repair (RR 0.61, 95% CI: 0.40–0.93, I2 = 32.5%) but not RCTs of instrumented spinal fusion. Among observational studies, topical antibiotics significantly reduced the risk of SSIs in instrumented spinal fusions (OR 0.34, 95% CI: 0.27–0.43, I2 = 52.4%) and in fracture repair (OR 0.49, 95% CI: 0.37–0.65, I2 = 43.8%). Vancomycin powder decreased the risk of Gram-positive SSIs (OR 0.37, 95% CI: 0.27–0.51, I2 = 0.0%) and had no effect on Gram-negative SSIs (OR 0.95, 95% CI: 0.62–1.44, I2 = 0.0%). Conclusions. Prophylactic intrawound antibiotic administration decreases the risk of SSIs in fracture surgical fixation in randomized studies. Therapeutic efficacy in instrumented spinal fusion was seen in only nonrandomized studies. Vancomycin appears to be an effective agent against Gram-positive pathogens. There is no evidence that local vancomycin powder is associated with an increased risk for Gram-negative infection.

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Vancomycin Powder Use in Fractures at High Risk of Surgical Site Infection

Cited by 28 publications

References 34 publications

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

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

Local Application of Vancomycin in Orthopaedic Surgery—A Review

Prophylactic Topical Antibiotics in Fracture Repair and Spinal Fusion

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