Evaluating the efficacy of topical vancomycin powder in the treatment of open lower extremity fractures

Abstract

Introduction Optimal management of lower extremity fractures includes early antibiotics administration, thorough irrigation and debridement, consideration of soft tissue injury, and definitive skeletal management. The purpose of this study was to evaluate the efficacy of topical vancomycin powder in the treatment of open lower extremity fractures. Methods This was a retrospective case control study in which open lower extremity fractures at our institution were reviewed for development of infection (including species and sensitivity if present) and the development of unanticipated wound complications requiring intervention. Patients from 2010-2015 were treated with standard of care consistent with evidence-based literature (IV antibiotics with external fixator, intramedullary nail, etc.). Patients from 2016–18 were additionally treated with vancomycin powder applied directly to the wound before closure. All patients were monitored per the treating surgeon’s standard follow-up protocol and had follow-up of at least two months. Results This retrospective case control study comprised 434 patients. The historical control group (n = 388 patients) and treatment group (n = 46 patients) were similar for age, sex, BMI (body mass index), diabetes, smoking status, and Injury Severity Score (ISS). There were 36 infections (9.28%) in the control group compared to four infections (8.70%) in the vancomycin powder group (p = 0.901). No significant difference was seen after adjusting for age, sex, BMI, diabetes, smoking status, and ISS. The vancomycin powder group experienced significantly more wound complications (15.2%) compared to the control group (6.4%; p = 0.039), which remained significant when adjusting for multiple covariates. Conclusions Topical vancomycin powder did not reduce the infection rate when applied in the surgical site of open lower extremity fractures. Instead, the addition of topical vancomycin powder resulted in significantly more wound complications in patients with open lower extremity fractures.

Do Intrawound Antibiotics Reduce the Incidence of Surgical Site Infections in Pelvic and Lower-Limb Trauma Surgery? A Systematic Review and Meta-analysis

“…Seven studies were qualitatively analyzed and included in the metaanalysis (see Table, Supplemental Digital Content 3, http://links.lww.com/JOT/B749). Six of the 7 included studies were retrospective case-control studies, [17][18][19][20][21][22] with the remaining study a randomized controlled trial. 23 Injuries investigated by the 7 studies included femoral shaft fractures, tibial plateau or pilon fractures, calcaneal fractures, pelvic ring injuries, and acetabular fractures (Table 1).…”

“…In 2 of the studies, the treatment group was established over a different time period compared with the control group. 18,21 This could introduce further confounders such as variability in surgical experience, altered microbiological profile within hospitals and changes in routine surgical practice or local protocols, potentially affecting the incidence of SSIs. Other confounders which have been shown to affect the risk of developing an SSI are operation length, increased intraoperative blood loss, and intraoperative blood transfusions.…”

“…Vancomycin inhibits cell wall synthesis of Gram-positive bacteria, whereas tobramycin targets protein synthesis of Gram-negative bacteria; therefore, a combination of both agents provides broader antibiotic cover than each drug in isolation. 27,28 Vaida et al 21 used vancomycin powder alone and found 55.6% of SSIs in their control group were caused by Gram-positive bacteria compared with 25% of SSIs in the intrawound antibiotic group. It is important to note, however, that there were only 4 infections identified in the treatment group, limiting conclusions that can be made from this result.…”

“…Multiple studies did not include superficial SSIs in analyses of the efficacy of intrawound antibiotics. 18,19,21,22 The definitions for superficial SSIs were not consistent across the studies that did provide data for this subset of infections. Cichos et al 17 defined SSIs as "positive bacterial cultures identified from samples acquired during irrigation and debridement" and further classified results into deep and superficial depending on the location of the infection relative to the fascia (infrafascial vs. suprafascial).…”

Prophylactic Topical Antibiotics in Fracture Repair and Spinal Fusion

“…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.…”