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

Abstract

<b><i>Objective:</i></b> 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. <b><i>Methods:</i></b> 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. <b><i>Results:</i></b> 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 (<i>p</i> 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. <b><i>Conclusion:</i></b> 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.

Rescuing Infected Deep Brain Stimulation Therapies in Severely Affected Patients

“…The duration of antibiotic treatment varied among our patients, ranging from 4 to 21 days, with an average of 8.5 days of intravenous antibiotics. The bacteria causing the infections were mostly, except for Patient 2, bacteria from the normal skin flora, consistent with findings in other publications [2,3,11,12,40,41,46]. Tabaja et al, in their publication, reported treating infections with cefazolin, cefuroxime, or vancomycin, which were used as single-shot antibiotics in the initial surgery as well.…”

“…Most of these publications focused on indications for deep brain stimulation, with only 42 publications addressing infected hardware (Figure 5). Among these publications, most concentrated on identifying risk factors for infections to prevent them [1,[14][15][16][17][18][19][20][21]39,40]. For cardiac pacemakers und spinal cord stimulation devices, the infection rates are similar, ranging between 2 and 3%, as in current DBS studies.…”

A meta‐analysis examined the effect of intrawound vancomycin on surgical site wound infections in non‐spinal neurosurgical operation

“…However, additional studies are still required to demonstrate these prospective associations and to associate the impact of intrawound vancomycin on the consequences studied. This was suggested also in previous similar meta-analyses study which showed similar promising outcomes [25][26][27][28][29][30][31] Well-conducted randomised controlled trials are needed to assess these factors and the combination of different ages, gender, ethnicity, and other variants of subjects; because our meta-analysis study could not answer whether different gender, ages, and ethnicity are related to the results.…”

Do Antibiotic-Impregnated Envelopes Prevent Deep Brain Stimulation Implantable Pulse Generator Infections? A Prospective Cohort Study

“…Peri-operative antibiotic use is strongly associated with lower infection rate [ 6 ] and may have contributed to the relatively low infection rate in this study. Given the low infection rate, our study did not confirm potential risk factors reported in retrospective series including primary [ 7 ] or repeat implantation [ 8 ], operation time, body mass index, age, sex, diabetes [ 9 ], smoking, indication, capsulotomy, post-operative ICU admission [ 10 ], anti-thrombotic medication use [ 11 ], antibiotic wash, chlorhexidine skin preparation [ 12 ] (20), topical vancomycin powder [ 13 ], glycerol [ 14 ], or preoperative MRSA screening and treatment [ 15 ].…”

“…Establishing the potential efficacy of an intervention to reduce infection is complicated by low baseline rates of infection, small effect size, and resultant need for large trials [ 13 ]. This study assessed patients encountered in routine functional neurosurgical practice undergoing replacement of depleted IPG was designed prior to the results of WRAP-IT, which identified benefit of antibiotic pouch use in higher risk cardiac patients.…”