Local Intrawound Vancomycin Powder Decreases the Risk of Surgical Site Infections in Complex Adult Deformity Reconstruction

Theologis, Alexander A.; Demirkıran, Gökhan; Callahan, Matthew; Pekmezci, Murat; Ames, Christopher P.; Deviren, Vedat

doi:10.1097/brs.0000000000000533

Cited by 109 publications

(75 citation statements)

References 28 publications

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“…Multiple publications have advanced the use of intrawound vancomycin powder as a potentially effective means of reducing deep wound infections. 20,64 It is well recognized that older patients face greater risk for complications with ASD surgery. 22,49,55,66,67 The present study confirms this observation and provides potentially useful benchmarking data for expected complication rates based on patient age.…”

Section: Discussionmentioning

confidence: 99%

Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery

Smith

Klineberg

Lafage

et al. 2016

SPI

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300

178

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OBJECTIVE Although multiple reports have documented significant benefit from surgical treatment of adult spinal deformity (ASD), these procedures can have high complication rates. Previously reported complications rates associated with ASD surgery are limited by retrospective design, single-surgeon or single-center cohorts, lack of rigorous data on complications, and/or limited follow-up. Accurate definition of complications associated with ASD surgery is important and may serve as a resource for patient counseling and efforts to improve the safety of patient care. The authors conducted a study to prospectively assess the rates of complications associated with ASD surgery with a minimum 2-year follow-up based on a multicenter study design that incorporated standardized data-collection forms, on-site study coordinators, and regular auditing of data to help ensure complete and accurate reporting of complications. In addition, they report age stratification of complication rates and provide a general assessment of factors that may be associated with the occurrence of complications. METHODS As part of a prospective, multicenter ASD database, standardized forms were used to collect data on surgery-related complications. On-site coordinators and central auditing helped ensure complete capture of complication data. Inclusion criteria were age older than 18 years, ASD, and plan for operative treatment. Complications were classified as perioperative (within 6 weeks of surgery) or delayed (between 6 weeks after surgery and time of last follow-up), and as minor or major. The primary focus for analyses was on patients who reached a minimum follow-up of 2 years. RESULTS Of 346 patients who met the inclusion criteria, 291 (84%) had a minimum 2-year follow-up (mean 2.1 years); their mean age was 56.2 years. The vast majority (99%) had treatment including a posterior procedure, 25% had an anterior procedure, and 19% had a 3-column osteotomy. At least 1 revision was required in 82 patients (28.2%). A total of 270 perioperative complications (145 minor; 125 major) were reported, with 152 patients (52.2%) affected, and a total of 199 delayed complications (62 minor; 137 major) were reported, with 124 patients (42.6%) affected. Overall, 469 complications (207 minor; 262 major) were documented, with 203 patients (69.8%) affected. The most common complication categories included implant related, radiographic, neurological, operative, cardiopulmonary, and infection. Higher complication rates were associated with older age (p = 0.009), greater body mass index (p ≤ 0.031), increased comorbidities (p ≤ 0.007), previous spine fusion (p = 0.029), and 3-column osteotomies (p = 0.036). Cases in which 2-year follow-up was not achieved included 2 perioperative mortalities (pulmonary embolus and inferior vena cava injury). CONCLUSIONS This study provides an assessment of complications associated with ASD surgery based on a prospective, multicenter design and with a minimum 2-year follow-up. Although the overall complication rates were high, in interpreting these findings, it is important to recognize that not all complications are equally impactful. This study represents one of the most complete and detailed reports of perioperative and delayed complications associated with ASD surgery to date. These findings may prove useful for treatment planning, patient counseling, benchmarking of complication rates, and efforts to improve the safety and cost-effectiveness of patient care.

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Section: Discussionmentioning

confidence: 99%

Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery

Smith

Klineberg

Lafage

et al. 2016

SPI

Self Cite

300

178

View full text Add to dashboard Cite

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“…Therefore, the biggest theoretical concern is the increased risk of pseudarthrosis, which is particularly concerning as vancomycin is used in revision thoracolumbar spine surgery where a higher risk of SSI has been reported. 21 In prior retrospective series guiding current use, vancomycin dosing protocols are administered at the standard 1 g 4,9,17,18,22 or 2 g 11,16,23,25 and distributed evenly throughout the wound, regardless of wound size. Further in vivo studies are required to determine if safe levels are met, with a particular statistical emphasis on its impact on fusion rates.…”

Section: Dosage Effect On Complicationsmentioning

confidence: 99%

“…However, vancomycin use has been associated with a decreased infection rate, resulting in a cost savings of $244,402 per 100 thoracolumbar deformity procedures due to decreased readmission, reoperation, and medical management. 25 The benefits of using intrawound vancomycin are the ability to achieve a significantly higher minimal inhibitory concentration (MIC) in the wound bed, while minimizing the serum concentration of the drug and therefore lowering systemic absorption. Clinical studies show that serum vancomycin levels remain at normal therapeutic levels (15-20 mg/ml) 1 or subtherapeutic to undetectable levels, 7 while local wound concentrations exceed the MIC needed to treat most covered microbes.…”

mentioning

confidence: 99%

Complications from the use of intrawound vancomycin in lumbar spinal surgery: a systematic review

Ghobrial

Cadotte

Williams

et al. 2015

FOC

129

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OBJECT The use of intrawound vancomycin is rapidly being adopted for the prevention of surgical site infection (SSI) in spinal surgery. At operative closure, the placement of vancomycin powder in the wound bed—in addition to standard infection prophylaxis—can provide high concentrations of antibiotics with minimal systemic absorption. However, despite its popularity, to date the majority of studies on intrawound vancomycin are retrospective, and there are no prior reports highlighting the risks of routine treatment. METHODS A MEDLINE search for pertinent literature was conducted for studies published between 1966 and May 2015 using the following MeSH search terms: “intrawound vancomycin,” “operative lumbar spine complications,” and “nonoperative lumbar spine complications.” This was supplemented with references and known literature on the topic. RESULTS An advanced MEDLINE search conducted on May 6, 2015, using the search string “intrawound vancomycin” found 22 results. After a review of all abstracts for relevance to intrawound vancomycin use in spinal surgery, 10 studies were reviewed in detail. Three meta-analyses were evaluated from the initial search, and 2 clinical studies were identified. After an analysis of all of the identified manuscripts, 3 additional studies were included for a total of 16 studies. Fourteen retrospective studies and 2 prospective studies were identified, resulting in a total of 9721 patients. A total of 6701 (68.9%) patients underwent treatment with intrawound vancomycin. The mean SSI rate among the control and vancomycin-treated patients was 7.47% and 1.36%, respectively. There were a total of 23 adverse events: nephropathy (1 patient), ototoxicity resulting in transient hearing loss (2 patients), systemic absorption resulting in supratherapeutic vancomycin exposure (1 patient), and culture-negative seroma formation (19 patients). The overall adverse event rate for the total number of treated patients was 0.3%. CONCLUSIONS Intrawound vancomycin use appears to be safe and effective for reducing postoperative SSIs with a low rate of morbidity. Study disparities and limitations in size, patient populations, designs, and outcomes measures contribute significant bias that could not be fully rectified by this systematic review. Moreover, care should be exercised in the use of intrawound vancomycin due to the lack of well-designed, prospective studies that evaluate the efficacy of vancomycin and include the appropriate systems to capture drug-related complications.

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“…The search criteria yielded 671 abstracts, and 18 clinical studies involving vancomycin powder in spine surgery met the inclusion and exclusion criteria (Figure 1) (2,5,11,14,15,18,21,23,28,32,(35)(36)(37)(48)(49)(50)(51)(52). These included 1 randomized controlled trial (RCT), 13 comparative and 4 case series.…”

Section: Summary Of Literature Searchmentioning

confidence: 99%

The Use of Vancomycin Powder In Modern Spine Surgery: Systematic Review and Meta-Analysis of the Clinical Evidence

et al. 2015

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Local Intrawound Vancomycin Powder Decreases the Risk of Surgical Site Infections in Complex Adult Deformity Reconstruction

Abstract: 3.

Cited by 109 publications

References 28 publications

Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery

Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery

Complications from the use of intrawound vancomycin in lumbar spinal surgery: a systematic review

The Use of Vancomycin Powder In Modern Spine Surgery: Systematic Review and Meta-Analysis of the Clinical Evidence

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