Use Of Intrawound Vancomycin Powder Research Articles

Intrawound Vancomycin Powder in Primary Total Hip Arthroplasty: A Prospective Quality Control Study

BackgroundThe purpose of this retrospective analysis of a prospective quality control project was to determine whether the use of intrawound vancomycin powder (IVP) decreases the rate of periprosthetic joint infection (PJI) within 90 days following primary total hip arthroplasty (THA). MethodsFrom October 2021 to September 2022, a prospective quality control project was undertaken in which 10 high-volume THA surgeons alternated between using and not using IVP each month while keeping other perioperative protocols unchanged. A retrospective analysis of the project was performed to compare the group of patients who received IVP to the group of patients who did not. The primary outcome was a culture positive infection within 90 days following primary THA. Secondary outcomes included gram-positive culture, overall reoperation rate, wound complications, readmission, and wound complications within 90 days post-operatively. A total of 1,193 primary THA patients were identified for analysis. There were 523 (43.8%) patients who received IVP and were included in the IVP group, while 670 (56.2%) did not and were included in the non-IVP group. Age, body mass index, and sex were similar between the 2 groups (P > .25). ResultsThe IVP group had a higher rate of culture positive joint infections (1.7 [0.8, 3.2] versus 0.3% [0.04, 1.1], P = .01) than the non-IVP group. All PJI’s were found to have gram positive bacteria in both groups. The IVP group had a higher overall reoperation rate than the non-IVP group (6.1 [4.2, 8.5] versus 2.4% [1.4, 3.9], P < .01). The IVP group had a higher reoperation rate for any wound complication compared to non-IVP patients (2.7 [1.5, 4.5] versus 0.7% [0.2, 1.7], P < .01). The overall readmission rate (6.1 [4.2, 8.5] versus 2.8% [1.7, 4.4], P < .01), as well as readmission for suspected infection (2.1 [1.1, 3.7] versus 0.6% [0.02, 1.5], P = .03), were higher in the IVP group. ConclusionsThe use of IVP in primary THA was associated with a higher rate of PJI, overall reoperation, reoperation for wound complications, and readmission in a prospective quality control project. Until future prospective randomized studies determine the safety and efficacy of IVP in THA conclusively, we advocate against its utilization.

Is Topical Vancomycin an Option? A Randomized Controlled Trial to Determine the Safety of the Topical Use of Vancomycin Powder in Preventing Postoperative Infections in Total Knee Arthroplasty, as Compared With Standard Postoperative Antibiotics

BackgroundThe demand for total knee arthroplasties (TKAs) is expected to rise in the coming decades, increasing the burden of periprosthetic joint infections (PJIs). The use of intrawound vancomycin powder (VP) has proven to be effective in reducing the incidence of PJIs after spinal surgery. That said, its effectiveness in TKA remains unclear. This trial aims to examine the efficacy of intrawound vancomycin powder first versus standard postoperative antibiotics in preventing PJIs after TKA. MethodsThis study was a double-blinded, noninferiority, randomized controlled trial. All participants received standard preoperative intravenous (IV) antibiotics (Cefazolin/Vancomycin) within 60 minutes of skin incision. Patients in the treatment group received 1 gram of VP applied intraoperatively by the orthopedic surgeon (500 mg directly on the prosthesis, 500 mg above the closed joint capsule). These patients did not receive postoperative antibiotics. Patients in the control group received standard postoperative IV antibiotics. The primary outcome was the incidence of acute surgical site infection within 42 days of procedure. ResultsThere were 80 patients randomized to the treatment group and 85 patients randomized to the control. Groups were matched with respect to baseline characteristics, including average age (66 versus 64), BMI (35.7 versus 33.4), and diabetics (16 versus 13). The trial was halted at 1 year as a significantly greater proportion (P = .03) of patients in the treatment group (n = 3, 3.75%) were diagnosed with PJIs compared to the control (n = 0). ConclusionOur trial demonstrated the intrawound application of VP to be inferior to standard postoperative IV antibiotics in reducing the incidence of PJIs after TKA.

The inhibitory effects of vancomycin on rat bone marrow-derived mesenchymal stem cell differentiation.

The use of intrawound vancomycin powder in spine surgery has been shown to decrease the rate of surgical site infections; however, the optimal dose is unknown. High-dose vancomycin inhibits osteoblast proliferation in vitro and may decrease the rate of solid arthrodesis. Bone marrow-derived mesenchymal stem cells (BMSCs) are multipotent cells that are a source of osteogenesis in spine fusions. The purpose of this study was to determine the effects of vancomycin on rat BMSC viability and differentiation in vitro. BMSCs were isolated from the femurs of immature female rats, cultured, and then split into two equal groups; half were treated to stimulate osteoblastic differentiation and half were not. Osteogenesis was stimulated by the addition of 50 µg/mL l-ascorbic acid, 10 mM β-glycerol phosphate, and 0.1 µM dexamethasone. Vancomycin was added to cell culture medium at concentrations of 0, 0.04, 0.4, or 4 mg/mL. Early differentiation was determined by alkaline phosphatase activity (4 days posttreatment) and late differentiation by alizarin red staining for mineralization (9 days posttreatment). Cell viability was determined at both the early and late time points by measurement of formazan colorimetric product. Viability within the first 4 days decreased with high-dose vancomycin treatment, with cells receiving 4 mg/mL vancomycin having 40%-60% viability compared to the control. A gradual decrease in alizarin red staining and nodule formation was observed with increasing vancomycin doses. In the presence of the osteogenic factors, vancomycin did not have deleterious effects on alkaline phosphatase activity, whereas a trend toward reduced activity was seen in the absence of osteogenic factors when compared to osteogenically treated cells. Vancomycin reduced BMSC viability and impaired late osteogenic differentiation with high-dose treatment. Therefore, the inhibitory effects of high-dose vancomycin on spinal fusion may result from both reduced BMSC viability and some impairment of osteogenic differentiation.

Povidone-iodine irrigation combined with Vancomycin powder lowers infection rates in pediatric deformity surgery

BackgroundSurgical site infection is a morbid, devastating complication after spinal procedures. Studies have investigated the effect of wound lavage with 3.5% Povidone-iodine solution or the use of intrawound Vancomycin powder. We examined the effect of Povidone-iodine irrigation, intrawound Vancomycin powder, or a combination of both agents in a tertiary care Pediatric Hospital.MethodsWe queried our health system database for patients undergoing spinal surgery over an eight-year span between January 2008 and June 2016 and identified patient cohorts who received no intervention, intrawound Vancomycin alone, Povidone-iodine irrigation alone, or a combination of both agents. Infection rates were determined. The effect of treatment on outcome was analyzed using a logistic regression model.Results475 patients were identified who met study inclusion criteria. 88 non-neuromuscular patients received no intra-operative agent. The surgical site infection (SSI) rate in this group of patients was 10%. For the 194 non-neuromuscular scoliosis patients who received Povidone-iodine and Vancomycin powder, the infection rate was reduced to 0.7%. The SSI rate in the 180 non-neuromuscular patients who were treated with Vancomycin powder alone was 1.4%. 13 patients were treated with Povidone-iodine lavage only, with a small sample size precluding statistical comparison. Infection rate in the 132 neuromuscular disease patients decreased from 14 to 7% overall during this time span: while the odds ratio of infection was reduced in all neuromuscular treatment groups receiving intra-operative measures, statistical significance was not reached in any neuromuscular group studied.ConclusionsA protocol using combined 3.5% weight/volume Povidone-iodine and Vancomycin powder was associated with the lowest infection rate in our non-neuromuscular patient population and should be considered as a low cost intervention in pediatric patients undergoing spinal deformity procedures.Level of evidenceLevel II.

Impact of intrawound vancomycin powder on prevention of surgical site infection after posterior spinal surgery.

Surgical site infection (SSI) after posterior spinal surgery is one of the severe complications that may occur despite administration of prophylactic antibiotics and the use of intraoperative aseptic precautions. The use of intrawound vancomycin powder for SSI prevention is still controversial, with a lack of high-quality and large-scale studies. The purpose of this retrospective study using a propensity score-matched analysis was to clarify whether intrawound vancomycin powder prevents SSI occurrence after spinal surgery. The authors analyzed 1261 adult patients who underwent posterior spinal surgery between 2010 and 2018 (mean age 62.3 years; 506 men, 755 women; follow-up period at least 1 year). Baseline and surgical data were assessed. After a preliminary analysis, a propensity score model was established with adjustments for age, sex, type of disease, and previously reported risk factors for SSI. The SSI rates were compared between patients with intrawound vancomycin powder treatment (vancomycin group) and those without (control group). In a preliminary analysis of 1261 unmatched patients (623 patients in the vancomycin group and 638 patients in the control group), there were significant differences between the groups in age (p = 0.041), body mass index (p = 0.013), American Society of Anesthesiologists classification (p < 0.001), malnutrition (p = 0.001), revision status (p < 0.001), use of steroids (p = 0.019), use of anticoagulation (p = 0.033), length of surgery (p = 0.003), estimated blood loss (p < 0.001), and use of instrumentation (p < 0.001). There was no significant difference in SSI rates between the vancomycin and control groups (21 SSIs [3.4%] vs 33 SSIs [5.2%]; OR 0.640, 95% CI 0.368-1.111; p = 0.114). Using a one-to-one propensity score-matched analysis, 444 pairs of patients from the vancomycin and control groups were selected. There was no significant difference in the baseline and surgical data, except for height (p = 0.046), between both groups. The C-statistic for the propensity score model was 0.702. In the score-matched analysis, 12 (2.7%) and 24 (5.4%) patients in the vancomycin and control groups, respectively, developed SSIs (OR 0.486, 95% CI 0.243-0.972; p = 0.041). There were no systemic complications related to the use of vancomycin. The current study showed that intrawound vancomycin powder was useful in reducing the risk of SSI after posterior spinal surgery by half, without adverse events. Intrawound vancomycin powder use is a safe and effective procedure for SSI prevention.

Vancomycin Powder Use in Fractures at High Risk of Surgical Site Infection.

To determine if the use of intrawound vancomycin powder reduces surgical-site infection after open reduction and internal fixation of bicondylar tibial plateau, tibial pilon, and calcaneus fractures. Retrospective analysis. Level I trauma center. All fractures operatively treated from January 2011 to February 2015 were reviewed; 583 high-risk fractures were included, of which 35 received topical vancomycin powder. A previously published prospectively collected cohort of 235 similar high-risk fractures treated at our center from 2007 through 2010 served as a second comparison group. Topical vancomycin powder at wound closure. Deep surgical-site infection. Analyses used both univariate comparison of all patients and 1:2 matching analysis using both nearest neighbor and propensity-based matching. Compared with a control group of fractures treated during the same time period without vancomycin powder, the infection rate with vancomycin powder was significantly lower [0% (0/35) vs. 10.6% (58/548), P = 0.04]. Compared with our previously published historical infection rate of 13% for these injuries, vancomycin powder was also associated with significantly decreased deep surgical-site infection (0% vs. 13%, P = 0.02). These results agreed with the matched analyses, which also showed lower infection in the vancomycin powder group (0% vs. 11%-16%, P ≤ 0.05). Vancomycin powder may play a role in lowering surgical-site infection rates after fracture fixation. A larger randomized controlled trial is needed to validate our findings. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Use of intrawound vancomycin powder against postoperative infection after spine surgery.

Local application of vancomycin has recently become widely used in spine surgery. However, local application is not included in the indication and has not been approved by the US Food and Drug Administration (FDA). Thus, we searched for reports with “intra wound-vancomycin” and “SSI” as keywords in the MEDLINE database, and investigated the efficacy, problems with use, and future prospects based on these reports. Intrawound vancomycin was described as effective in most of the reports, but was found to have no effect or to aggravate the condition in some reports. A toxic effect on osteoblasts due to a high local concentration was described in some reports, whereas local application was found to be safe in other studies. The amount of vancomycin used and the administration method varied among the reports. Overall, the results suggest that intrawound vancomycin is clinically effective, but this has yet to be established in a randomized controlled trial. There is a need to identify cases that should be selected for this treatment and to investigate the dose and optimum concentration of vancomycin for clinical use.

In vitro susceptibility of Propionibacterium acnes to simulated intrawound vancomycin concentrations

BackgroundThere is convincing evidence supporting the prophylactic use of intrawound vancomycin powder in spinal fusion surgery and mounting evidence in the arthroplasty literature suggesting that it can reduce surgical site infections. As a result, a number of shoulder arthroplasty surgeons have adopted this practice, despite a paucity of evidence and the presence of a pathogen that is, for the most part, unique to this area of the body—Propionibacterium acnes. The purpose of this study was to evaluate the efficacy of vancomycin against planktonic P. acnes in vitro, using time-dependent concentrations one would expect in vivo after intra-articular application.MethodsIntrawound vancomycin concentrations were interpolated and extrapolated from existing in vivo data. Planktonic P. acnes was then subjected to a time-kill analysis during 96 hours. At each time point, the inoculum was centrifuged into pellet form and then reconstituted for serial drop counts onto blood agar plates. After anaerobic incubation, colony-forming units were counted, and log10 colony-forming units per milliliter were determined.ResultsEarly time points grew to confluence, and thus colony-forming units per milliliter were not calculated. However, at 12 hours of vancomycin treatment, distinct colonies were appreciated. Notably, there was a 3 × log10 reduction in colony-forming units per milliliter between 12 and 48 hours, denoting bactericidal activity. In addition, P. acnes was completely eradicated after 3 days of treatment.ConclusionWhen administered in a fashion meant to simulate time-dependent in vivo intrawound concentrations, vancomycin exhibited bactericidal activity against P. acnes. This may lend credence to the prophylactic use of vancomycin in shoulder surgery.

Intrawound Vancomycin Powder Associated With Reduced Surgical Site Infection in Rib-based Distraction Surgery.

Despite clinical reports of improved pulmonary function and reduced spinal deformity with rib-based distraction surgery in early-onset scoliosis (EOS) patients, infection remains a common complication, reported as high as 32% in some studies. The purpose of this study was to evaluate intrawound vancomycin powder in pediatric patients managed with rib-based distraction for EOS. This was a single institution retrospective cohort study of EOS patients treated with rib-based distraction. Patients treated with and without intrawound vancomycin were compared. Patients included were younger than 18 years of age, had undergone placement of a rib-based distraction construct, and had a minimum of 6 months' follow-up. For patients in the vancomycin group, 500 mg of vancomycin powder was placed before wound closure. Complications including infection and revision surgery were recorded. P-values and 95% confidence intervals (CIs) were reported for both unadjusted and adjusted complication rates for prevancomycin and postvancomycin powder. All P-values were calculated at a significance level of 0.05. In total, 118 patients were included, accounting for 1035 procedures in the nonvancomycin control group and 252 procedures in the vancomycin group. Both groups were similar with regard to age at initial implant, sex, diagnosis, ambulatory status, and bowel/bladder incontinence. There were 55 (5.3%; 95% CI, 4.1-7.6) postoperative infections in the control group and 3 (1.2%; 95% CI, 0.3-3.8) in the vancomycin group (P=0.008, unadjusted). After adjusting for surgery type and transfusions, the vancomycin group still had a significantly lower infection rate (1.4%; 95% CI, 0.3-3.7 vs. 5.5%; 95% CI, 3.04-6.5; P=0.022). We were unable to demonstrate a difference between the control (3.5%, 95% CI, 2.4-5.1) and vancomycin (1.8%, 95% CI, 0.5-5.7) groups for deep infection (P=0.27). Intrawound vancomycin powder significantly reduced the surgical site infection rates following rib-based distraction surgery for EOS. We therefore recommend the use of intrawound vancomycin powder as a standard of care for patients undergoing rib-based distraction surgery. Pre-post intervention, retrospective cohort study-therapeutic level III.

Has the Time For Vancomycin Powder Arrived?: Commentary on an article by Adam I. Edelstein, MD, et al.: "Intra-Articular Vancomycin Powder Eliminates Methicillin-Resistant S. aureus in a Rat Model of a Contaminated Intra-Articular Implant".

The role of intra-articular vancomycin powder to prevent periprosthetic joint infection (PJI) after total joint arthroplasty (TJA) is unclear. Although vigorous studies have shown a correlation between the use of intrawound vancomycin powder and a decreased rate of surgical site infection1-3, such studies were performed only in spine or trauma settings. Unfortunately, prospective randomized studies require a tremendous effort both financially and in terms of time …

A meta-analysis of spinal surgical site infection and vancomycin powder.

Surgical site infection (SSI) is a serious and costly complication of spinal surgery. There have been several conflicting reports on the use of intrawound vancomycin powder in decreasing SSI in spine surgery. The purpose of this study is to answer the question: "Does intrawound vancomycin powder reduce the rate of SSIs in spine surgery?" A comprehensive search of multiple electronic databases and bibliographies was conducted to identify clinical studies that evaluated the rates of SSI with and without the use of intrawound vancomycin powder in spine surgery. Independent reviewers extracted data and graded the quality of each paper that met inclusion criteria. A random effects meta-analysis was then performed. The search identified 9 retrospective cohort studies (Level III evidence) and 1 randomized controlled trial (Level II evidence). There were 2574 cases and 106 infections in the control group (4.1%) and 2518 cases and 33 infections (1.3%) in the treatment group, yielding a pooled absolute risk reduction and relative risk reduction of 2.8% and 68%, respectively. The meta-analysis revealed the use of vancomycin powder to be protective in preventing SSI (relative risk = 0.34, 95% confidence interval 0.17-0.66, p = 0.021). The number needed to treat to prevent 1 SSI was 36. A subgroup analysis found that patients who had implants had a reduced risk of SSI with vancomycin powder (p = 0.023), compared with those who had noninstrumented spinal operations (p = 0.226). This meta-analysis suggests that the use of vancomycin powder may be protective against SSI in open spinal surgery; however, the exact population in which it should be used is not clear. This benefit may be most appreciated in higher-risk populations or in facilities with a high baseline rate of infection.

Cost savings analysis of intrawound vancomycin powder in posterior spinal surgery

Background contextRecent studies have shown that prophylactic use of intrawound vancomycin in posterior instrumented spine surgery substantially decreases the incidence of wound infections requiring repeat surgery. Significant cost savings are thought to be associated with the use of vancomycin in this setting. PurposeTo elucidate cost savings associated with the use of intrawound vancomycin in posterior spinal surgeries using a budget-impact model. Study designRetrospective cohort study. Patient sampleData from a cohort of 303 patients who underwent spinal surgery (instrumented and noninstrumented) over 2 years were analyzed; 96 of these patients received prophylactic intrawound vancomycin powder in addition to normal intravenous (IV) antibiotic prophylaxis, and 207 received just routine IV antibiotic prophylaxis. Patients requiring repeat surgical procedures for infection were identified, and the costs of these additional procedures were elucidated. Outcome measureCost associated with the additional procedure to remediate infection in the absence of vancomycin prophylaxis. MethodsWe retrospectively reviewed the cost of return procedures for treatment of surgical site infection (SSI). The total reimbursement received by the health care facility was used to model the costs associated with repeat surgery, and this cost was compared with the cost of a single local application of vancomycin costing about $12. ResultsOf the 96 patients in the treatment group, the return-to-surgery rate for SSI was 0. In the group without vancomycin, seven patients required a total of 14 procedures. The mean cost per episode of surgery, based on the reimbursement, the health care facility received was $40,992 (range, $14,459–$114,763). A total of $573,897 was spent on 3% of the 207-patient cohort that did not receive intrawound vancomycin, whereas a total of $1,152 ($12×96 patients) was spent on the cohort treated with vancomycin. ConclusionsThis study shows a reduction in SSIs requiring a return-to-surgery—with large cost savings—with use of intrawound vancomycin powder. In our study population, the cost savings totaled more than half a million dollars.