Prophylactic Intrawound Vancomycin Powder in Minimally Invasive Spine Stabilization May Cause an Acute Inflammatory Response

Abstract

IntroductionSurgical site infections (SSIs) with methicillin-resistant Staphylococcus aureus are serious complications of spinal instrumentation surgery. Many spine surgeons are concerned that using prophylactic vancomycin powder will lead to certain risks: the development of multidrug-resistant pathogens, anaphylactic reactions, and organ toxicity. Minimally invasive spine stabilization (MISt) is associated with shorter operation times and less blood loss and may therefore require the use of less vancomycin powder, which may reduce these risks. This retrospective comparative study of patients who underwent MISt at a single institution aimed to evaluate the complications (such as allergy, SSIs, and organ toxicity) and the local and serum levels associated with using prophylactic intrawound vancomycin powder compared with IV cefazolin alone. MethodsThirty-four patients received intrawound vancomycin powder (1 g) applied during wound closure in minimally invasive posterior lumbar interbody fusion (MIS-PLIF). This group was compared with 133 control patients who did not receive vancomycin. White blood cell counts and C-reactive protein (CRP) levels were measured for both groups on postoperative days (PODs) 1, 3, and 7 and were statistically analyzed. In the vancomycin group, serum vancomycin levels were measured on PODs 1, 3, 7, and 14; drain vancomycin levels and postoperative blood loss were determined on PODs 1 and 2. ResultsThe CRP levels on PODs 1 and 3 were significantly higher in the vancomycin group than in the control group (P<0.001, P=0.024). In the vancomycin group, mean drain levels trended downward from 313 μg/mL (POD 1) to 155 μg/mL (POD 2). These levels correlated negatively with drain drainage volume on both days (POD 1: r=-0.48, P=0.015; POD 2: r=-0.47, P=0.019). Mean serum vancomycin levels also trended downward from 2.3 μg/mL (POD 1) to 1.7 μg/mL (POD 14). ConclusionsOur results unexpectedly demonstrated that the local application of vancomycin powder causes an acute inflammatory response and the long-term detection of low serum vancomycin levels. Less than 1 g of intrawound vancomycin powder may be useful only at high risk of SSI.

A Meta-analysis of the efficacy of topical antibiotics in spinal surgery for the prevention of surgical site infection

“…The proportion of Gram-negative bacilli in the group infected with vancomycin powder was 46.4% in SSIs, whereas the proportion of Gram-negative bacilli in the group infected with non-vancomycin powder was 30.1%. [43] According to the data of this analysis, the dosage of local antibiotics used in most studies was primarily controlled within the range of 1 to 2g. In cases where the skin incision exceeded 20cm, 2g of antibiotics were administered to prevent infection in the wound.…”

“…They also found that the application of vancomycin powder topically resulted in an acute inflammatory response. [43] Additionally, administering less than 1g of vancomycin powder topically during minimally invasive posterior lumbar disc fusion may decrease the likelihood of SSIs. [44] Further studies are required to ascertain the ideal dosage of antibiotics following spinal surgery.…”

Operative Treatment and Outcomes of Pediatric Patients with an Extremity Bone Tumor

“…A 2021 trial that included 980 patients with high-risk tibial fractures showed a 3.4% absolute reduction in the risk of deep periprosthetic joint infection with the use of topical vancomycin powder 29 . In the spine literature, comparative studies have supported the benefit of vancomycin powder to reduce the rate of deep infection, although a randomized trial on this topic did not demonstrate a benefit 30,31 and other single-center studies have noted increased C-reactive protein with use of vancomycin powder, as well as a correlation with culture-negative seromas 32,33 . Our findings do not clearly support the use of local antibiotic powder to lower the risk of infection in primary resections, although we noted no evidence of increased antibiotic-related complications with its use.…”