The efficacy of intrawound vancomycin powder and povidone-iodine irrigation to prevent surgical site infections in complex instrumented spine surgery

Lemans, Justin V C; Öner, F. Cumhur; Wijdicks, Sebastiaan P.J.; Ekkelenkamp, Miquel B.; Charles, Hubert; Kruyt, Moyo C.

doi:10.1016/j.spinee.2019.05.592

Cited by 30 publications

(33 citation statements)

References 19 publications

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“…3 It is widely used in many forms in orthopaedic surgery (bone cement in routine arthroplasty, intravenous (IV) infusion to treat prosthetic joint infection, and topical powder on spinal surgery wounds), with results showing that it reduces infection significantly. 21,24 A number of other surgical specialties utilize antibiotics and antimicrobials, either topically on wounds or in solution to immerse and wrap implants before surgery, and reports have shown significant reductions in infection. 11,30,33 Cardiothoracic surgery has been at the forefront of this, with surgeons applying vancomycin powder to sternotomy wounds following the results of a seminal paper in 1989 33 and now implanting cardiac electronic devices enveloped in a degradable antimicrobial sleeve.…”

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confidence: 99%

Vancomycin Wrap for Anterior Cruciate Ligament Surgery: Molecular Insights

et al. 2021

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Background: The use of the vancomycin wrap to pretreat the hamstring graft in anterior cruciate ligament reconstruction (ACLR) has grown in popularity since it was first described in 2012 and has significantly reduced rates of postoperative infection. However, it remains unknown if this antibiotic treatment affects the molecular composition of the graft. Purpose: To establish whether treatment with vancomycin at 5 mg/mL, the most commonly used concentration, alters the molecular function of the hamstring graft in ACLR. Study Design: Controlled laboratory study. Methods: Surplus hamstring tendon collected after routine ACLR surgery was used for in vitro cell culture and ex vivo tissue experiments. Vancomycin was used at 5 mg/mL in RPMI or saline diluent to treat cells and tendon tissue, respectively, with diluent control conditions. Cell viability at 30, 60, and 120 minutes was assessed via colorimetric viability assay. Tendon cells treated with control and experimental conditions for 1 hour was evaluated using semiquantitative reverse transcription analysis, immunohistochemistry staining, and protein quantitation via enzyme-linked immunosorbent assay for changes in apoptotic, matrix, and inflammatory gene and protein expression. Results: Vancomycin treatment at 5 mg/mL significantly reduced tenocyte viability in vitro after 60 minutes of treatment ( P < .05); however, this was not sustained at 120 minutes. Vancomycin-treated tendon tissue showed no significant increase in apoptotic gene expression, or apoptotic protein levels in tissue or supernatant, ex vivo. Vancomycin was associated with a reduction in inflammatory proteins from treated tendon supernatants (IL-6; P < .05). Conclusion: Vancomycin did not significantly alter the molecular structure of the hamstring graft. Reductions in matrix protein and inflammatory cytokine release point to a potential beneficial effect of vancomycin in generating a homeostatic environment. Clinical Relevance: Vancomycin ACL wrap does not alter the molecular structure of the ACL hamstring graft and may improve graft integrity.

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confidence: 99%

Vancomycin Wrap for Anterior Cruciate Ligament Surgery: Molecular Insights

et al. 2021

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“…13 Additional studies have reported precipitous decreases in infection rates with vancomycin powder prophylaxis in spine surgeries, such as instrumented posterior cervical spine fusions (15% to 0%), posterior spinal fusions for trauma (13% to 0%), and complex posterior instrumented spine surgery (10% to 5%). 14,15,24 Given the recent economic changes in orthopedic reimbursement, including the trend toward bundle payments, minimizing costs while improving efficacy and patient outcomes is more important than ever before. [25][26][27] There is a dearth of published data on the economic burden of infection after lumbar laminectomy with fusion, but the limited studies that have described these costs have uniformly shown the tremendous economic burden of an infected spinal surgery, particularly with implants.…”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

The Cost-Effectiveness of Vancomycin Powder in Lumbar Laminectomy

Kerbel

Kirchner

Sunkerneni

et al. 2019

Global Spine Journal

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Study Design: Break-even cost analysis. Objective: The goal of this study is to examine the cost-effectiveness of vancomycin powder for preventing infection following lumbar laminectomy. Methods: The product cost of vancomycin powder was obtained from our institution’s purchasing records. Infection rates and revision costs for lumbar laminectomy and lumbar laminectomy with fusion were obtained from the literature. A break-even analysis was then performed to determine the absolute risk reduction (ARR) in infection rate to make prophylactic application of vancomycin powder cost-effective. Analysis of lumbar laminectomy with fusion was performed for comparison. Results: Costing $3.06 per gram at our institution, vancomycin powder was determined to be cost-effective in lumbar laminectomy if the infection rate of 4.2% decreased by an ARR of 0.015%. Laminectomy with fusion was also determined to be cost-effective at the same cost of vancomycin powder if the infection rate of 8.5% decreased by an ARR of 0.0034%. The current highest cost reported in the literature, $44.00 per gram of vancomycin powder, remained cost-effective with ARRs of 0.21% and 0.048% for laminectomy and laminectomy with fusion, respectively. Varying the baseline infection rate did not influence the ARR for either procedure when the analysis was performed using the product cost of vancomycin at our institution. Conclusions: This break-even analysis demonstrates that prophylactic vancomycin powder can be highly cost-effective for lumbar laminectomy. At our institution, vancomycin powder is economically justified if it prevents at least one infection out of 6700 lumbar laminectomy surgeries.

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“…Previous studies have indicated that the costs associated with SSIs approximate USD 3.3 billion spend annually and over USD 20,000 per case [1]. The application of topical, intrawound vancomycin powder (VP) as an adjuvant to perioperative intravenous antibiotic use has been extensively studied in spine surgery [2][3][4][5]. Multiple studies have reported reductions in SSIs following spine surgeries with instrumentation of hardware [3,[6][7][8].…”

Section: Introductionmentioning

confidence: 99%

Use of Topical Vancomycin Powder to Reduce Surgical Site Infections after Deep Brain Stimulation Surgery: UCSF Experience and Meta-Analysis

Kondapavulur

Burke

Volz

et al. 2021

Stereotact Funct Neurosurg

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Objective: Surgical site infection (SSI) is the most common serious complication of deep brain stimulation (DBS) implantation surgery. Here, we report a single-surgeon experience on the efficacy of topical, intrawound vancomycin powder (VP) in reducing SSI for DBS surgery and present the first systematic review and meta-analysis examining the effect of topical vancomycin on SSI in patients after DBS surgery. Methods: For the retrospective review, all unique patients undergoing DBS surgery at UCSF for new hardware implantation or internal pulse generator (IPG) replacement by a single surgeon from September 2013 to March 2019, with at least 1 year of follow-up data, were included. For the meta-analysis, we included all primary studies that compared SSIs with and without application of topical vancomycin in DBS surgeries. Results: 368 unique patients met inclusion criteria; 195 patients received topical VP (VP group) and 173 did not (control). 99/195 patients in the VP group underwent new DBS implantation and 96/195 had IPG replacement. 71/173 patients in the control group had new DBS implantation and 102/173 had IPG replacement. There were 10 total cases of SSI: 4 patients from the VP group (3 new implants and 1 IPG replacement) and 6 patients from the control group (3 new implants and 3 IPG replacements), resulting in SSI rates of 2.1 and 3.5%, respectively (p value = 0.337). Including our retrospective analysis, 6 studies met inclusion criteria for the systematic review and meta-analysis. In the 4 studies that examined primary DBS implants, 479 total patients received topical VP and 436 did not; mean odds ratio for SSI with topical vancomycin was 0.802 (95% confidence interval [CI] 0.175–3.678). Across the 5 studies that examined IPG implantations or replacements, 606 total patients received topical VP while 1,173 patients did not; mean odds ratio for SSI with topical vancomycin was 0.492 (95% CI 0.164–1.475). In either case, topical VP application did not significantly decrease risk of SSI. Conclusion: Surgical infections after DBS surgery are uncommon events, with studies demonstrating mixed results on whether topical vancomycin reduces this risk. Our single-institution retrospective analysis and systematic review of prior studies both demonstrated no significant SSI rate reduction with topical VP. This is likely due to low baseline SSI rates, resulting in a small effect size for prevention. Given the cost-effectiveness, simplicity, and low risk, topical, intrawound VP remains a treatment option to further reduce risk of SSI, particularly in settings with higher baseline infection rates.

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The efficacy of intrawound vancomycin powder and povidone-iodine irrigation to prevent surgical site infections in complex instrumented spine surgery

Cited by 30 publications

References 19 publications

Vancomycin Wrap for Anterior Cruciate Ligament Surgery: Molecular Insights

Vancomycin Wrap for Anterior Cruciate Ligament Surgery: Molecular Insights

The Cost-Effectiveness of Vancomycin Powder in Lumbar Laminectomy

Use of Topical Vancomycin Powder to Reduce Surgical Site Infections after Deep Brain Stimulation Surgery: UCSF Experience and Meta-Analysis

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