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Intrawound use of vancomycin powder may reduce spine surgical site infections
Researchers found the antibiotic powder helped stave off infections for posterior cervical fusion performed for CSM.
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A retrospective comparative study of prospectively collected data produced evidence suggesting the use of vancomycin powder during the placement of posterior cervical instrumentation for patients with cervical spondylotic myelopathy can significantly reduce the risk of surgical site infections.
Although surgical site infection (SSI) can be reduced with local delivery of antibiotics, Cyrus Caroom, MD, of Lubbock, Texas, and colleagues who conducted the study said no such study had been done before to address this problem in patients undergoing posterior cervical instrumentation and decompression for cervical spondylotic myelopathy (CSM).
Postoperative fluid collection is shown on CT in a patient with class 3 obesity 2 weeks after posterior decompression and instrumented fusion for progressive hemiplegia. This patient’s infection is typical of those seen in the control group of the study.
Image: Chaput CD
“We changed the kind of prep we used in the operating room, but the big thing changed was we added vancomycin powder to our wounds before we closed them. It is something that has been going on in spine surgery for the past 10 years. It has been gaining more and more popularity because it is so effective,” Caroom told Spine Surgery Today.
This practice is one that cardiac surgeons have used for 25 years with good results, but over the last decade most of the related research has been in spine surgery, he said. Postoperative fluid collection is shown on CT in a patient with class 3 obesity 2 weeks after posterior decompression and instrumented fusion for progressive hemiplegia. This patient’s infection is typical of those seen in the control group of the study.
“Nearly all of the studies show that it is effective at reducing your rates of postoperative infection. We have not had any complications from it so far,” Caroom said.
Effective at reducing infection
Caroom and colleagues included in the study 112 patients who underwent multilevel posterior decompression and instrumentation for CSM performed by a single surgeon from 2003 to 2011. The prospectively collected data were analyzed and results in 72 patients treated with this technique without the use of vancomycin powder were compared to results in 40 patients who underwent the same surgery but also had local delivery of the vancomycin powder.
From the univariate analysis the investigators performed they found a 0% infection rate in the group that received the powder and this rate was significantly decreased compared to the 15% infection rate in the group that did not receive the powder.
“The local application of vancomycin was associated with a significant reduction in the risk of SSI in multilevel posterior cervical-instrumented fusions for CSM. This study supports the growing body of evidence that vancomycin powder placed in the wound can reduce the incidence of postoperative wound infections,” Caroom and colleagues wrote in the study.
Cost-effective method
Caroom told Spine Surgery Today vancomycin powder is also cost effective to use. A typical 1 gram dose of the powder costs about $3. The only potential downside, he said, is this type of use of vancomycin powder is not an indication that is approved by the FDA.
“It is cheap, but it is off-label. It is not FDA-indicated for this use; that is one downside. We list that as a disclosure every time we publish or present this material. The powder form of the drug is designed to be dissolved into solution and given intravenously. It is not FDA approved to be used in this manner, but that does not mean it is not safe or effective,” Caroom said. “One of the difficulties is that it is an expensive process and this is a drug that is now generic. Basically, nobody has gone forward with the investment that would be required to have this indication approved by the FDA.”
Christopher D. Chaput
Christopher D. Chaput, MD, one of the investigators, said the study showed an excellent decrease in infection at the site after use of the powder.
“This study showed a robust decrease in the rate of surgical site infection in a patient population that is known to be high risk for infection in cervical surgery. This supports multiple other studies in the thoracolumbar spine that report similar results. While high quality randomized studies sometimes fail to show the same degree of efficacy suggested by less well controlled trials, the available animal and clinical data suggest there is a significant decrease in the rate of SSIs when topical vancomycin is applied in the setting of multilevel instrumentation and fusion in the posterior spine,” Chaput told Spine Surgery Today.– by Robert Linnehan
Reference:
Caroom C. Spine. 2013; doi:10.1097/BRS.0b013e31828fcfb5.For more information:
Cyrus Caroom, MD, can be reached at Texas Tech University Health Science Center, Department of Orthopaedics, 3601 4th St., 4th Floor, Lubbock, TX, 79430; email: cyrus.caroom@ttuhsc.edu.Christopher D. Chaput, MD, can be reached at Scott and White Healthcare, 2401 South 31st St. Temple, TX 76504; email: cchaput@sw.org. .