The effectiveness of pedicle screw immersion in vancomycin and ceftriaxone solution for the prevention of postoperative spinal infection: A prospective comparative study

Prophylactic Application of Vancomycin Powder in Preventing Surgical Site Infections After Spinal Surgery

OBJECTIVE

We sought to analyze the preventive effect of local vancomycin powder application on surgical site infection (SSI) in spinal surgeries and provide the basis for future clinical practice.

METHODS

Through PubMed, Medline, Elsevier, and the Cochrane Library, with MeSH words "vancomycin powder," "local/intraoperative/topical/intra-wound," "spine/spinal/lumbar/cervical/thoracolumbar," "surgery," "infection," and "SSI," we searched for case-control research papers on the impact of prophylactic application of vancomycin powder on the incidence of SSI and compared the rate of infection using RevMan 5.3 meta-analysis software.

RESULTS

A total of 1950 publications were found using the mesh words, and 50 of those studies were selected for final analysis. There were 34,301 cases in total, including 14,793 cases in vancomycin group and 19,508 cases in the control group. Results of meta-analysis showed that the incidence of SSI was significantly lower in the prophylactic vancomycin powder group than the control group (P < 0.001). Further subgroup analysis showed that the incidence of SSI was significantly lower in the prophylactic vancomycin powder group than the control group in spine surgeries with internal fixation, deformity correction, and deep tissue infections (P < 0.001). Meanwhile, there were no significant differences between the 2 groups concerning patients undergoing noninstrumented spine surgeries and the incidence of superficial tissue infection.

CONCLUSIONS

Overall, prophylactic application of vancomycin powder in spinal surgery can significantly reduce the incidence of SSI in deep tissues, and this effect is more prominent in patients undergoing internal fixation and deformity correction surgeries.

Plant-derived nanotherapeutic systems to counter the overgrowing threat of resistant microbes and biofilms

Since antiquity, the survival of human civilization has always been threatened by the microbial infections. An alarming surge in the resistant microbial strains against the conventional drugs is quite evident in the preceding years. Furthermore, failure of currently available regimens of antibiotics has been highlighted by the emerging threat of biofilms in the community and hospital settings. Biofilms are complex dynamic composites rich in extracellular polysaccharides and DNA, supporting plethora of symbiotic microbial life forms, that can grow on both living and non-living surfaces. These enforced structures are impervious to the drugs and lead to spread of recurrent and non-treatable infections. There is a strong realization among the scientists and healthcare providers to work out alternative strategies to combat the issue of drug resistance and biofilms. Plants are a traditional but rich source of effective antimicrobials with wider spectrum due to presence of multiple constituents in perfect synergy. Other than the biocompatibility and the safety profile, these phytochemicals have been repeatedly proven to overcome the non-responsiveness of resistant microbes and films via multiple pathways such as blocking the efflux pumps, better penetration across the cell membranes or biofilms, and anti-adhesive properties. However, the unfavorable physicochemical attributes and stability issues of these phytochemicals have hampered their commercialization. These issues of the phytochemicals can be solved by designing suitably constructed nanoscaled structures. Nanosized systems can not only improve the physicochemical features of the encapsulated payloads but can also enhance their pharmacokinetic and therapeutic profile. This review encompasses why and how various types of phytochemicals and their nanosized preparations counter the microbial resistance and the biofouling. We believe that phytochemical in tandem with nanotechnological innovations can be employed to defeat the microbial resistance and biofilms. This review will help in better understanding of the challenges associated with developing such platforms and their future prospects.

A meta-analysis of the local application of vancomycin powder to prevent surgical site infection after spinal surgeries

Objective

This study aimed to systematically analyze the effectiveness and safety of the local application of vancomycin powder to prevent surgical site infection (SSI) after spinal surgeries and provide guidance for clinical practice.

Methods

Two researchers independently searched PubMed, Web of Science, Elsevier, and China National Knowledge Infrastructure using the MeSH terms “spinal surgery,” “vancomycin,” “local,” “topical,” “prophylactic,” “surgical site infection,” and “SSI” to identify studies published between January 2010 and January 2020 on the local application of vancomycin powder for preventing SSI after spinal surgeries. The outcome assessment indicators were analyzed using RevMan 5.3 software.

Results

Three randomized controlled trials, two prospective studies, and 26 retrospective studies were included in the current research. The results of the meta-analysis revealed significant differences between the vancomycin and control groups (non-vancomycin group) concerning the incidence of SSI (risk ratio = 0.39, 95% confidence interval = 0.28–0.55, Z = 5.46), indicating that local application of vancomycin powder can significantly reduce the incidence of SSI.

Conclusion

Local application of vancomycin powder is an effective and safe method to prevent SSI after spinal surgeries.

Local antibiotics in posterior lumbar fusion procedures for neuromuscular scoliosis: a case for their use

BACKGROUND CONTEXT

Surgical site infections (SSIs) are medically devastating and financially costly complications after posterior spinal fusion (PSF) for neuromuscular scoliosis (NMS). Many strategies exist to reduce their occurrence. The efficacy of intraoperative antibiotics in the wound or bone graft is gaining in popularity, but this practice has not been well-studied in the PSF NMS population.

PURPOSE

To assess the potential utility of intraoperative local antibiotics in patients with NMS undergoing PSF.

STUDY DESIGN/SETTING

Retrospective review of prospectively collected data.

PATIENT SAMPLE

Pediatric patients who underwent PSF for NMS were identified from the 2016-2018 National Surgical Quality Improvement Program (NSQIP) pediatric spinal fusion datasets.

OUTCOME MEASURES

Perioperative adverse outcome variables assed included the occurrence of SSI, renal complications, and adverse hospital metrics.

METHODS

Patient demographic factors, comorbidities, and the use of intraoperative antibiotics in the wound were recorded (a specifically assessed variable in the dataset). The association between the use of intraoperative antibiotics and the occurrence of adverse outcomes/infection was assessed for the entire study population and higher risk sub-populations.

RESULTS

In total, 1,990 patients met the inclusion criteria, of which 87% received local antibiotics. Higher risk patients were more likely to receive local antibiotics in the wound as part of their procedure. When controlling for potentially confounding factors, the use of local antibiotics was not statistically significantly associated with any of the studied adverse outcomes for the overall study population. Subgroup analysis of higher risk patient populations (≥13 levels fused, osteotomy performed, prior deformity surgery, nonasthma lung condition) revealed a significantly decreased risk of SSI in patients undergoing ≥13 level fusions (relative risk: 0.48, 95% confidence interval: 0.25-0.91).

CONCLUSIONS

With no increased overall risks and reduced SSIs in higher risk NMS patients undergoing PSF, the use of intrawound antibiotics appears to be supported by this dataset.

Vancomycin prophylaxis for revision hip arthroplasty in penicillin and cephalosporin sensitive patients: Is dose adjustment necessary in accordance with blood loss and fluid replacement?

OBJECTIVE

The aims of this study were (1) to investigate the changes in the serum concentration of prophylactically administrated vancomycin in the perioperative period of revision hip arthroplasty in penicillin/cephalosporin-allergic patients, (2) to assess whether the postoperative re-administration of vancomycin is needed, and (3) to determine the relationships of vancomycin serum concentration with blood loss, body weight, and fluid replacement in such patients.

METHODS

This study consisted of 29 patients (20 females, 9 males; mean age=63.3 years; age range=45-79 years) with a history of penicillin/cephalosporin allergy undergoing revision hip arthroplasty secondary to aseptic loosening or periprosthetic fractures. Serum vancomycin levels were measured (1) before administration of vancomycin, (2) at the time of skin incision, (3) every 1,5 hours thereafter until the end of the operation, (4) during the skin closure, and (5) after three and 12 hours from the initial dosage. Data regarding body weight, amounts of intraoperative blood loss, fluid and blood replacements and postoperative wound drainage were recorded.

RESULTS

The average blood loss, fluid replacement, and drain volume were 1280.3±575.8 (500-2700) mL, 2922.6±768.8 (1700-4600) mL, and 480.2±163.7 (200-850) mL, respectively. The mean levels of serum vancomycin were 46.3±21.8 (14.1-80.7) mg/L at the time of skin incision, 17.9±4.7 (9.4-30.9) and 9.8±2.2 (4.3-13.8) mg/L after 1.5 and 3 hours from the beginning of the surgery and 5.1±1.1 (2.9-6.8)mg/L after 12th hour postoperatively. The measured vancomycin levels were below the effective serum concentrations (< 5 mg/L) for 18 patients at 12 hours the administration of the first dose. A moderate level negative correlation between the blood loss/body weight ratio and vancomycin levels was found (p=0.004, r=-0.493). Predictive ROC curve analysis resulted in determining a blood loss volume higher than 1150 ml and a blood loss/body weight ratio higher than 18,5 is significant to estimate the vancomycin level below the minimum effective serum level at 12th hour postoperatively (AUC=0.793±0.16, p=0.009, AUC=0.753) 26±0.12, p=0.025, respectively).

CONCLUSION

Evidence from this study has indicated vancomycin concentration at 12th hour is below the effective level in most patients. Thus, earlier repetitive infusion of vancomycin seems to be necessary in penicillin/cephalosporin-allergic patients undergoing revision hip arthroplasty, especially in those with high blood loss.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

Efficacy of prophylactic application of vancomycin powder in preventing surgical site infections after instrumented spinal surgery: A retrospective analysis of patients with high-risk conditions

OBJECTIVE

This study aimed to determine the efficacy of prophylactic use of vancomycin powder against surgical site infections in patients with high-risk conditions who underwent posterior spinal instrumentation.

METHODS

Data obtained from 209 patients who underwent posterior spinal instrumentation at a single institution from 2014 to 2017 were retrospectively reviewed. Patients were then divided into two groups: control group, including 107 patients (61 females, 46 males; mean age=54 years; age range=16-85 years), and treatment group, including 102 patients (63 females, 39 males; mean age=53 years; age range=14-90 years). All patients received the same standard prophylactic antibiotic regimen. In addition to the prophylactic antibiotic, vancomycin powder was applied locally to the surgical site in the treatment group. All patients were followed up for at least 90 days postoperatively. Infections were categorized as superficial and deep infections. Subgroup analysis of high-risk patients (Syrian refugees) was also performed.

RESULTS

The infection rates were 1.96% (two patients) in the treatment group and 6.54% (seven patients) in the control group. A significant decrease in the infection rates was observed with local vancomycin powder application. Advanced age (>46 years) and prolonged surgical duration (>140 min) were found to be the main risk factors for surgical site infections (p=0.004 and p=0.028, respectively). The infection rates were 3.22% and 8.11% in the treatment and control groups of refugees, respectively. There were three superficial and four deep infections in the control group and one superficial and one deep infection in the treatment group. A dominance of staphylococcus infections was observed in the control group, whereas no significant dominance was observed in the treatment group. Three patients in the control group and one patient in the treatment group received implant removal.

CONCLUSION

Evidence from this study has revealed that local application of vancomycin powder reduces the rate of surgical site infections after instrumented spinal surgery. The benefit of vancomycin application may be most appreciated in higher risk populations or in clinics with high baseline rates of infection.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

Implant Retention or Removal for Management of Surgical Site Infection After Spinal Surgery

STUDY DESIGN

A literature review.

OBJECTIVE

To summarize the implant removal rate, common bacterial organisms found, time of onset, ratio of superficial to deep infection, and regurgitating the prevalence among all the retrospective and prospective studies on management and characterization of surgical site infections (SSIs).

METHODS

PubMed was searched for articles published between 2000 and 2018 on the management or characterization of SSIs after spinal surgery. Only prospective and retrospective studies were included.

RESULTS

A total of 49 articles were found relevant to the objective. These studies highlighted the importance of implant removal to avoid recurrence of SSI. The common organisms detected were methicillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus epidermis, Staphylococcus epidermis, Staphylococcus aureus, and Propionibacterium acnes, with prevalence of 1% to 15%. A major proportion of all were deep SSI, with minority reporting on late-onset SSI.

CONCLUSION

Long-term antibiotics administration, and continuous irrigation and debridement were common suggestion among the authors; however, the key measure undertaken or implied by most authors to avoid risk of recurrence was removal or replacement of implants for late-onset SSI.

Spinal Fusion Surgery and Local Antibiotic Administration: A Systematic Review on Key Points From Preclinical and Clinical Data

STUDY DESIGN

Systematic review.

OBJECTIVE

The present review of clinical and preclinical in vivo studies focused on the local antibiotic administration for surgical site infection (SSI) in spinal fusion procedures and identifying new approaches or research direction able to release antibiotics in the infected environment.

SUMMARY OF BACKGROUND DATA

SSI is a severe complication of spinal fusion procedures that represents a challenging issue for orthopedic surgeons. SSIs can range from 0.7% to 2.3% without instrumentation up to 6.7% with the use of instrumentation with significant implications in health care costs and patient management.

METHOD

A systematic search was carried out by two independent researchers according to the PRISMA statement in three databases (www.pubmed.com, www.scopus.com and www.webofknowledge.com) to identify preclinical in vivo and clinical reports in the last 10 years. Additionally, to evaluate ongoing clinical trials, three of the major clinical registry websites were also checked (www.clinicaltrials.gov, www.who.int/ictrp, https://www.clinicaltrialsregister.eu).

RESULTS

After screening, a total of 43 articles were considered eligible for the review: 36 clinical studies and seven preclinical studies. In addition, six clinical trials were selected from the clinical registry websites.

CONCLUSION

The results reported that the topical vancomycin application seem to represent a strategy to reduce SSI incidence in spine surgery. However, the use of local vancomycin as a preventive approach for SSIs in spine surgery is mostly based on retrospective studies with low levels of evidence and moderate/severe risk of bias that do not allow to draw a clear conclusion. This review also underlines that several key points concerning the local use of antibiotics in spinal fusion still remains to be defined to allow this field to make a leap forward that would lead to the identification of specific approaches to counteract the onset of SSIs.

LEVEL OF EVIDENCE

4.

Incidence of Surgical Site Infection After Spine Surgery: A Systematic Review and Meta-analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

The objective of this study was to investigate the incidence of surgical site infection (SSI) in patients following spine surgery and the rate of microorganisms in these cases.

SUMMARY OF BACKGROUND DATA

Many studies have investigated the incidence and risk factors of SSI following spinal surgery, whereas no meta-analysis studies have been conducted regarding the comprehensive epidemiological incidence of SSI after spine surgery.

METHODS

We searched the PubMed, Embase, and Cochrane Library databases for relevant studies that reported the incidence of SSI after spine surgery, and manually screened reference lists for additional studies. Relevant incidence estimates were calculated. Subgroup analysis, sensitivity analysis, and publication bias assessment were also performed.

RESULTS

Our meta-analysis included 27 studies, with 603 SSI cases in 22,475 patients. The pooled SSI incidence was 3.1%. Subgroup analysis revealed that the incidence of superficial SSI was 1.4% and the incidence of deep SSI was 1.7%. Highest incidence (13.0%) was found in patients with neuromuscular scoliosis among the different indications. The incidences of SSI in cervical, thoracic, and lumbar spine were 3.4%, 3.7%, and 2.7%, respectively. Compared with posterior approach surgery (5.0%), anterior approach showed a lower incidence (2.3%) of SSI. Instrumented surgery had a higher incidence of SSI than noninstrumented surgery (4.4% vs. 1.4%). Patients with minimally invasive surgery (1.5%) had a lower SSI incidence than open surgery (3.8%). Lower incidence of SSI was found when vancomycin powder was applied locally during the surgery (1.9%) compared with those not used (4.8%). In addition, the rates of Staphylococcus aureus, Staphylococcus epidermidis, and methicillin-resistant Staphylococci in microbiological culture results were 37.9%, 22.7%, and 23.1%, respectively.

CONCLUSION

The pooled incidence of SSI following spine surgery was 3.1%. These figures may be useful in the estimation of the probability of SSI following spine surgery.

LEVEL OF EVIDENCE

3.

Evaluation of Cumulative and Conditional Antibiotic Release from Vancomycin-Embedded Fibrin Sealant and Its Antibacterial Activity : An In Vitro Study

Objective

Fibrin sealants have been used for hemostasis, sealant for cerebrospinal fluid leakage, and adhesive barrier in neurosurgery. Further, as its clinical use and role of an effective drug delivery vehicle have been proposed. This study was performed to measure antibacterial activity and continuous local antibiotic release from different concentrations of vancomycin-impregnated fibrin sealant in vitro.

Methods

Antibacterial activity was investigated by disk diffusion test by measuring the diameter of the growth inhibition zone of bacteria (methicillin-resistant Staphylococcus aureus, ATCC29213) from vancomycin-embedded fibrin sealant disc diluted at five different concentrations (C1–C5; 8.33, 4.167, 0.83, 0.083, and 0.0083 mg/disc, respectively). Continuous and conditioned release of vancomycin concentration (for 2 weeks and for 5 days, respectively) were also measured using high-performance liquid chromatography (HPLC) method. To mimic the physiologic wound conditions with in vitro, conditioned vancomycin release in phosphate buffer solution (PBS) was measured and replaced PBS for five consecutive days, half a day or completely daily.

Results

In the disk diffusion test, the mean diameters of bacterial inhibition zone were 2.54±0.07 cm, 2.61±0.12 cm, and 2.13±0.15 cm (C1, C2, and C3 respectively) but 1.67±0.06 cm and 1.23±0.15 cm in C4 and C5, respectively. Continuous elution test elicited the peak release of vancomycin from the fibrin sealant at 48 hours, with continued release until 2 weeks. However, conditioned vancomycin release decreased to half or more on day 2, however, the sustainable release was measured over the therapeutic dose (10–20 μg/mL) for 5 days and 4 days in assays of half and total exchange of PBS.

Conclusion

This study suggests that fibrin sealant can provide an efficient vehicle for antibiotic drug release in a wide range of neurosurgical procedures and the safe and effective therapeutic dose will be at the concentration embedded of 4.167 mg/disc or more of vancomycin.

Outcomes of an Intraoperative Povidone-Iodine Irrigation Protocol in Spinal Surgery for Surgical Site Infection Prevention

STUDY DESIGN

This was a retrospective observational study.

OBJECTIVE

The aim of this study was to evaluate the efficacy of our new protocol for preventing postoperative surgical site infection (SSI) following spinal surgery.

SUMMARY OF BACKGROUND DATA

SSI following spinal surgery is a serious postoperative complication. Several studies have recently assessed the effectiveness of wound irrigation with povidone-iodine (PVP-I) for SSI prevention, but no consensus has been reached as to how PVP-I should be used in clinical practice. We formed a PVP-I irrigation protocol focusing on the pharmacological properties of PVP-I. This study aimed to evaluate the efficacy and safety of our protocol for preventing SSI.

MATERIALS AND METHODS

All cases of spinal surgery at our hospital between October 2011 and September 2016 were retrospectively reviewed. The exclusion criteria were PVP-I allergy, prior surgical debridement for infection, and implant removal surgery. The patients were subdivided into those who had received normal saline irrigation after 90 seconds of 1% PVP-I pooling every 1.5 hours (study group) or only routine saline irrigation every 1.5 hours (control group). The study and control groups comprised of 177 and 146 patients, respectively. This study compared the rate of SSI with and without the use of the PVP-I irrigation protocol.

RESULTS

The SSI rates were 1.7% for the study group (3/177 patients) and 3.4% for the control group (5/146 patients), showing no significant statistical difference (P=0.32). There were no cases of deep SSI in the study group, whereas there were 4 cases in the control group. The deep SSI rate significantly decreased in the study group (P=0.027). No adverse events occurred in the study group.

CONCLUSION

In this study, 90 seconds of 1% PVP-I pooling every 1.5 hours followed by saline irrigation demonstrated the effectiveness of our protocol for the prevention of postoperative deep SSI after spinal surgery.

Gentamicin loading of calcium phosphate implants: implications for cranioplasty

Background

Surgical site infections (SSI) are a significant risk in cranioplasty, with reported rates of around 8–9%. The most common bacteria associated with these nosocomial infections are of the Staphylococcus species, which have the ability to form biofilm. The possibility to deliver antibiotics, such as gentamicin, locally rather than systemically could potentially lower the early postoperative SSI. Various antibiotic dosages are being applied clinically, without any true consensus on the effectiveness.

Methods

Drug release from calcium phosphate (CaP), polyetheretherketone (PEEK), and titanium (Ti) samples was evaluated. Microbiological studies with Staphylococcus aureus (SA) and Staphylococcus epidermidis (SE) including strains from clinical infection were used to establish clinically relevant concentrations.

Results

The CaP samples were able to retain and release gentamicin overtime, whereas the Ti and PEEK samples did not show any drug uptake or release. A gentamicin loading concentration of 400 μg/ml was shown to be effective in in vitro microbiological studies with both SA and SE.

Conclusions

Out of the three materials studied, only CaP could be loaded with gentamicin. An initial loading concentration of 400 μg/ml appears to establish an effective gentamicin concentration, possibly translating into a clinical benefit in cranioplasty.