Intrawound Antibiotic Powder in Acetabular Fracture Open Reduction Internal Fixation Does Not Reduce Surgical Site Infections

Local vancomycin administration in Orthopaedic Surgery - A systematic review of comparative studies

Background

There is still controversy surrounding the routine use of vancomycin locally in primary orthopaedic surgery procedures. Therefore, the aim of this review is to assess how local vancomycin impacts the rates and microbiology of surgical site infections.

Methods

A systematic electronic search of MEDLINE, EMBASE, and Web of Science was carried out for all comparative studies comparing locally applied vancomycin to control for primary orthopaedic surgery procedures published before August 14, 2022.

Results

A total of 61 studies with 65,671 patients were included for analysis. Forty-six studies used vancomycin powder, 12 studies with grafts soaked in vancomycin, two studies used vancomycin irrigation, and one study administered vancomycin interosseously. There were 15 studies (of 26) in spine surgery, five (of 14) in arthroplasty, ten (of 11) in sports medicine, and two (of five) in trauma surgery that found statistically significant decreases in overall infection rates when applying local vancomycin. Only one study (in spine surgery) found significant increases in infection rates with local vancomycin application. For spine surgery, local vancomycin application had the greatest proportion of gram-negative bacteria (40.7%) isolated compared to S. aureus (42.4%) in controls. In arthroplasty and trauma surgery, there were increases in the proportions of gram-negative bacteria when vancomycin was added. There were no reported systemic adverse reactions associated with local vancomycin use in any of the studies.

Conclusion

Applying local vancomycin during primary orthopaedic surgery procedures may reduce the rates of infections in multiple different orthopaedic specialties, particularly in spine surgery and sports medicine. However, careful consideration should be applied when administering local vancomycin during specific orthopaedic procedures given the heterogeneity of included studies and breadth of surgeries included in this review.

Level of evidence

Level III. A systematic review of level I - III studies.

The State of Local Antibiotic Use in Orthopedic Trauma

Fracture-related infections are a challenging complication in orthopedic trauma that often necessitates multiple surgeries. Early administration of systemic antibiotics and surgical intervention remains the gold standard of care, but despite these measures, treatment failures can be as high as 35%. For these reasons, the introduction of local antibiotics at the site of at-risk fractures has increased over the past decade. This review looks at the various measures being used clinically including local antibiotic powder, polymethylmethacrylate, biodegradable substances, antibiotic-coated implants, and novel methods such as hydrogels and nanoparticles that have the potential for use in the future.

A technique for introducing broad-spectrum topical antibiotics during open reduction and internal fixation of acetabular fractures

Postoperative surgical site infections remain a significant and prevalent complication after open reduction and internal fixation of acetabular fractures. Local antibiotics have been shown to decrease risk of postoperative infection, although recent evidence is conflicting. We provide a consistent and replicable technique for delivering intraoperative broad-spectrum antibiotics in the form of a putty applied directly to surgical implants. With this technique, systemic levels of those antibiotics remain safe and stable.

Does topical vancomycin prevent fracture-related infections in closed fractures undergoing open reduction and internal fixation? A randomised controlled trial

PURPOSE

The role of topical vancomycin in fracture-related infection (FRI) is debatable. Very few studies have reported their efficacy in open and high-risk extremity fractures. This study aimed to assess topical vancomycin's role in reducing FRI in closed fractures undergoing open surgical intervention with an implant.

METHODS

This prospective randomized cohort study was carried out between February 2021 to January 2022. Patients with isolated closed fractures, who were planned for open reduction and internal fixation within 2 weeks from the time of injury were included for this study. The data collected included age, gender, socioeconomic status, mechanism of injury, diagnosis, Tscherne classification, and time interval to take up for surgery. Patients were randomized into the intervention and control groups using the block randomization technique. The control group received only systemic antibiotic prophylaxis, whereas the intervention group received topical application of vancomycin powder in the surgical wound alongside systemic antibiotic prophylaxis. The primary outcome measure was the incidence of FRI among these individuals. Clinical and radiological findings and culture reports (in cases with infection) were recorded during the post-operative period and at 6 weeks of follow-up. All relevant statistical calculations were done using STATA statistical/data analysis-parallel edition version 16.0 (StataCorp LLC). The quantitative variables like age and duration of the surgery were assessed for normalcy by Shapiro-Wilk W test. An independent samples t-test with equal variances was applied to the age data. Fisher's exact test was used for the analysis of the primary outcome measure (presence of FRI following surgery), and "Risk of FRI" and "Risk difference" between the 2 groups was calculated. The strength of the association between qualitative variables was assessed using the Fisher's exact and Chi-square tests, respectively.

RESULTS

There were 88 patients included in this study. No statistical significance was found about FRI between both groups (p = 0.494). At 6 weeks following surgery, no incidence of infection was observed in the intervention group. Two infections (4.5%) were found in the control group, with positive cultures reported in one of them but none in the treatment group. Radiologically, 15.9% of patients in the control group showed lysis around the implant compared to 2.3% in the intervention group. Impaired fracture healing was observed in 22.7% of patients in the intervention group compared to 15.9% in the control group.

CONCLUSION

Applying topical vancomycin in closed fractures undergoing open reduction and internal fixation does not significantly reduce the incidence of FRI until the end of 6 weeks following surgery.

Prophylactic Intrawound Antibiotics Significantly Reduce the Risk of Deep Infections in Fracture Fixation: Subgroup Meta-analyses of the Type of Fracture, Antibiotics, and Organism

OBJECTIVES

To analyze the efficacy of subgroups of various intrawound local antibiotics in reducing the rate of fracture-related infections.

DATA SOURCES AND STUDY SELECTION

PubMed, MEDLINE via Ovid, Web of Science, Cochrane database, and Science Direct were searched for articles in English on July 5, 2022, and December 15, 2022.

STUDY SELECTION

All clinical studies comparing the incidence of fracture-related infection between the administration of prophylactic systemic and topical antibiotics in fracture repair were analyzed.

DATA EXTRACTION

Cochrane collaboration's assessment tool and the methodological bias and the methodological index for nonrandomized studies were used to detect bias and evaluate the quality of included studies, respectively.

DATA SYNTHESIS

RevMan 5.3 software (Nordic Cochrane Centre, Denmark) was used to conduct the meta-analyses and generate forest plots.

CONCLUSIONS

From 1990 to 2021, 13 studies included 5309 patients. Nonstratified meta-analysis showed that intrawound administration of antibiotics significantly decreased the overall incidence of infection in both open and closed fractures, regardless of the severity of open fracture and antibiotics class [OR = 0.58, ( P = 0.007)] [OR = 0.33, ( P < 0.00001)], respectively. The stratified analysis revealed that prophylactic intrawound antibiotics significantly lowered infection rate in open fracture patients with Gustilo-Anderson type I (OR = 0.13, P = 0.004), type II (OR = 0.29, P = 0.0002), type III (OR = 0.21, P < 0.00001), when either tobramycin PMMA beads (OR = 0.29, P < 0.00001) or vancomycin powder (OR = 0.51, P = 0.03) was applied. This study demonstrates prophylactic administration of intrawound antibiotics significantly decreases the overall incidence of infection in all subgroups of surgically fixated fractures but does not affect the patient's length of hospital stay.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Orthopaedic infections: what have we learned?

Orthopaedic infections remain challenging complications to treat, with profound economic impact in addition to patient morbidity. The overall estimates of infection after orthopaedic surgery with internal devices has been estimated at 5%, with hospital costs eight times that of those without fracture-related infections and with significantly poorer functional and pain interference PROMIS scores. Orthopaedic infection interventions have been focused on prevention and treatment options. The creation of new modalities for orthopaedic infection treatment can benefit from the understanding of the temporal relationship between bacterial colonization and host-cell integration, a concept referred to as "the race for the surface." Regarding prevention, host modulation and antibiotic powder use have been explored as viable options to lower infection rates. Orthopaedic infection treatment has additionally continued to evolve, with PO antibiotics demonstrating equivalent efficacy to IV antibiotics for the treatment of orthopaedic infections in recent studies. In conclusion, orthopaedic infections remain difficult clinical dilemmas, although evolving prevention and treatment modalities continue to emerge.

Predictors of Deep Infection After Distal Femur Fracture: A Multicenter Study

OBJECTIVES

To identify potentially modifiable risk factors for deep surgical site infection after distal femur fracture.

DESIGN

Multicenter retrospective cohort study.

SETTING

Ten Level-I trauma centers.

PATIENTS/PARTICIPANTS

Patients with OTA/AO 33A or C distal femur fractures (n = 1107).

INTERVENTION

Surgical fixation of distal femur fracture.

MAIN OUTCOME MEASUREMENT

The outcome of interest was deep surgical site infection.

RESULTS

There was a 7% rate (79/1107) of deep surgical site infection. In the multivariate analysis, predictive factors included alcohol abuse [odds ratio (OR) = 2.36; 95% confidence interval (CI), 1.17-4.46; P = 0.01], intra-articular injury (OR = 1.73; 95% CI, 1.01-3.00; P = 0.05), vascular injury (OR = 3.90; 95% CI, 1.63-8.61; P < 0.01), the use of topical antibiotics (OR = 0.50; 95% CI, 0.25-0.92; P = 0.03), and the duration of the surgery (OR = 1.15 per hour; 95% CI, 1.01-1.30; P = 0.04). There was a nonsignificant trend toward an association between infection and type III open fracture (OR = 1.73; 95% CI, 0.94-3.13; P = 0.07) and lateral approach (OR = 1.60; 95% CI, 0.95-2.69; P = 0.07). The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (22%), methicillin-sensitive Staphylococcus aureus (20%), and Enterobacter cloacae (11%).

CONCLUSIONS

Seven percent of distal femur fractures developed deep surgical site infections. Alcohol abuse, intra-articular fracture, vascular injury, and increased surgical duration were risk factors, while the use of topical antibiotics was protective.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Topical Antibiotic Powder and Nonunion Risk in Surgically Treated Tibial Plateau and Pilon Fractures

INTRODUCTION

High-energy periarticular tibia fractures are challenging injuries with a significant risk of complications. Postoperative infection rates, although improved, remain unacceptable. Intrawound topical antibiotic (TA) application has been popularized to reduce postoperative infections. Although TA may minimize infections, it remains unclear whether TAs have any impact on the development of nonunion. Recent investigations of TA use in fracture care have questioned its efficacy in vivo and suggested a potentially deleterious effect on fracture healing. This study investigates the impact of TA on nonunion rates in surgically treated high-energy periarticular tibia fractures.

METHODS

Retrospective analysis of surgically treated periarticular tibia fractures at a single Level 1 trauma center was conducted. Intervention in question was the clinical effect of intrawound TA powder application at definitive closure. A total of 222 high-energy periarticular tibia fractures were included, 114 with TA use and 108 without. The primary outcome was the occurrence of nonunion, with secondary outcomes being superficial and deep postoperative surgical site infections.

RESULTS

Twenty-seven patients (12.1%) were diagnosed with nonunions (14 pilons and 13 plateaus). There was no statistically significant difference in nonunion rates among patients who received topical antibiotics (15.8%) versus the group of patients who did not (8.3%) ( P = 0.23). Odds of developing nonunion was significant for open injuries (odds ratio 6.16, P < 0.001) and patients with a provisional external fixator (odds ratio 8.72, P = 0.03) before definitive fixation. No notable difference in the number of superficial and deep infections was identified between groups.

CONCLUSION

The use of TA in high-energy periarticular tibia fractures showed no statistically significant increase in nonunion rates but did not conclusively rule out nonunion as a possible effect of intrawound TA. Additional large-scale multicenter prospective studies are needed to confirm these findings. The current body of literature regarding high-energy periarticular tibia fractures does suggest that TAs lower the risk of postoperative infections, but the nonunion risk remains unclear.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Study.

Perioperative management of acetabular and pelvic fractures: evidence-based recommendations

PURPOSE

The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF.

METHODS

A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis.

RESULTS

A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic.

CONCLUSION

The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Local administration of vancomycin powder in orthopaedic fracture surgery: current practice and trends

Objectives

Surgical site infections in orthopaedic trauma are a significant problem with meaningful patient and health care system-level consequences. Direct application of antibiotics to the surgical field has many potential benefits in reducing surgical site infections. However, to date, the data regarding the local administration of antibiotics have been mixed. This study reports on the variability of prophylactic vancomycin powder use in orthopaedic trauma cases across 28 centers.

Methods

Intrawound topical antibiotic powder use was prospectively collected within three multicenter fracture fixation trials. Fracture location, Gustilo classification, recruiting center, and surgeon information were collected. Differences in practice patterns across recruiting center and injury characteristics were tested using chi-square statistic and logistic regression. Additional stratified analyses by recruiting center and individual surgeon were performed.

Results

A total of 4941 fractures were treated, and vancomycin powder was used in 1547 patients (31%) overall. Local administration of vancomycin powder was more frequent in open fractures 38.8% (738/1901) compared with closed fractures 26.6% (809/3040) (P < 0.001). However, the severity of the open fracture type did not affect the rate at which vancomycin powder was used (P = 0.11). Vancomycin powder use varied substantially across the clinical sites (P < 0.001). At the surgeon level, 75.0% used vancomycin powder in less than one-quarter of their cases.

Conclusions

Prophylactic intrawound vancomycin powder remains controversial with varied support throughout the literature. This study demonstrates wide variability in its use across institutions, fracture types, and surgeons. This study highlights the opportunity for increased practice standardization for infection prophylaxis interventions.

Level of Evidence

Prognostic-III.

Effect of Local Antibiotic Prophylaxis on Postoperative Deep Infection in Fracture Surgery: A Systematic Review and Meta-Analysis

OBJECTIVES

Despite the use of systemic antibiotic prophylaxis, postoperative infection after fracture surgery remains an issue. The purpose of this systematic review and meta-analysis was to evaluate the effect of locally applied antibiotics on deep infection in fracture surgery in both the open and closed fractures.

DATA SOURCES

A comprehensive search of MEDLINE, Embase, and PubMed was performed from the date of inception to April 15, 2021, and included studies in all languages.

STUDY SELECTION

Cohort studies were eligible if they investigated the effect on the infection rate of local antibiotic prophylaxis on deep infection after fracture surgery.

DATA EXTRACTION

This study was conducted according to the Cochrane Handbook for Systematic Reviews and reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias was assessed using version 2 of the Cochrane risk-of-bias tool for randomized trials and the Methodological Index for Nonrandomized Studies tool where applicable.

DATA SYNTHESIS

An inverse variance random-effects model was the primary analysis model because of the anticipated diversity in the evaluated populations. Univariate models were used when a single outcome was of interest.

CONCLUSIONS

The risk of deep infection was significantly reduced when local antibiotics were applied compared with the control group receiving systemic prophylaxis only. This beneficial effect was observed in open fractures but failed to reach statistical significance in closed fractures. This meta-analysis suggests that there may be a significant risk reduction in deep infection rate after fracture surgery when local antibiotics are added to standard systemic prophylaxis, particularly in open fractures. Further high-powered Level I studies are needed to support these findings.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Do Intrawound Antibiotics Reduce the Incidence of Surgical Site Infections in Pelvic and Lower-Limb Trauma Surgery? A Systematic Review and Meta-analysis

OBJECTIVES

To analyze the efficacy of intraoperative topical antibiotics in reducing the incidence of postoperative surgical site infections in pelvic and lower-limb trauma orthopaedic surgery.

DATA SOURCES

A search of Ovid MEDLINE, PubMed, and Embase was conducted for English language studies published from 1946 through September 3, 2021, using relevant keywords.

STUDY SELECTION

Included studies were randomized controlled trials, cohort studies, or case-control studies reporting on the rate of surgical site infections in adult patients (age 16 and older) who underwent surgical fixation of lower-limb or pelvic traumatic fractures, including both open and closed fractures, with topical intraoperative antibiotics applied to the surgical site before wound closure.

DATA EXTRACTION

Studies were evaluated using the Joanna Briggs Institute Critical Appraisal Checklist for analytical cross-sectional studies. The risk of bias was assessed using the ROBINS-I and Cochrane risk-of-bias tools.

DATA SYNTHESIS

A meta-analysis was conducted using the inverse variance method and random-effects model to assess effect significance and study heterogeneity.

CONCLUSIONS

Seven studies were included in the systematic review. Results of the meta-analysis suggested a potential 23% reduction in the odds of developing a deep surgical site infection in patients treated with intraoperative antibiotic powder compared with those managed with intravenous antibiotics alone (odds ratio 0.77, 95% confidence interval 0.52-1.13), although the results did not reach statistical significance. Further powered studies including randomized controlled trials would be of great value to validate the results suggested in this study and inform best practice intraoperative antibiotic prophylaxis in pelvic and lower-limb trauma surgery.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Rates of Antimicrobial Resistance With Extended Oral Antibiotic Prophylaxis After Total Joint Arthroplasty

Background

There is increased interest and utilization of extended oral antibiotic prophylaxis (EOAP) following primary and revision total hip arthroplasties (THAs) and total knee arthroplasties (TKAs). The purpose of this study was to look for potential associations between EOAP and differential rates of antimicrobial resistance or epidemiology of organisms causing periprosthetic joint infection (PJI) following primary and aseptic revision THAs/TKAs.

Methods

Patients who developed PJI following a primary or aseptic revision TKA/THA at a single institution from 2009 to 2020 were retrospectively identified. Patients who received at least 7 days of EOAP following the surgery were noted. Rates of antimicrobial resistance were compared between standard antibiotic prophylaxis and EOAP cohorts using the Fisher's exact test.

Results

One hundred twenty-eight cultures were obtained from 119 patients with PJI. Fourty-four cases (37%) developed PJI after EOAP. Staphylococcus aureus was the most frequently isolated organism (30% of all cultures; 78% were methicillin-sensitive). Rates of antimicrobial resistance were similar between standard antibiotic prophylaxis and EOAP cohorts in all but 2 instances: Increased resistance to erythromycin and trimethoprim-sulfamethoxazole was observed in coagulase-negative Staphylococci isolates in the EOAP cohort (89% vs 21%, P < .01; 44% vs 0%, P = .02). An increased frequency of gram-negative organisms was observed in the EOAP group (22% vs 8%, P = .03).

Conclusions

Rates of antimicrobial resistance were not significantly different between EOAP and standard antibiotic prophylaxis cohorts except in coagulase-negative Staphylococci. The increased frequency of gram-negative infections was present in the EOAP cohort. Larger, multicenter studies are needed to better understand the impact of EOAP on antimicrobial resistance and PJI epidemiology.

Level of Evidence

Level III; retrospective cohort study.

Supratherapeutic Antibiotic Levels and Acute Kidney Injury from Absorption of Topical Antibiotics: A Case Report

CASE

A 96-year-old woman with no baseline renal dysfunction presented with a distal femoral shaft fracture after a ground-level fall. Treatment was with a retrograde intramedullary nail and included placement of topical antibiotics. Postoperatively, she developed acute kidney injury and was found to have supratherapeutic antibiotic levels.

CONCLUSION

This case report demonstrates the risk of clinically relevant systemic absorption along with associated downstream end organ damage with the use of topical antibiotics in certain circumstances. We present this case as an illustration of a rare hazard associated with topical antibiotic use.

Biofilm Growth on Simulated Fracture Fixation Plates Using a Customized CDC Biofilm Reactor for a Sheep Model of Biofilm-Related Infection

Most animal models of infection utilize planktonic bacteria as initial inocula. However, this may not accurately mimic scenarios where bacteria in the biofilm phenotype contaminate a site at the point of injury. We developed a modified CDC biofilm reactor in which biofilms can be grown on the surface of simulated fracture fixation plates. Multiple reactor runs were performed and demonstrated that monomicrobial biofilms of a clinical strain of methicillin-resistant Staphylococcus aureus, S. aureus ATCC 6538, and Pseudomonas aeruginosa ATCC 27853 consistently developed on fixation plates. We also identified a method by which to successfully grow polymicrobial biofilms of S. aureus ATCC 6538 and P. aeruginosa ATCC 27853 on fixation plates. This customized reactor can be used to grow biofilms on simulated fracture fixation plates that can be inoculated in animal models of biofilm implant-related infection that, for example, mimic open fracture scenarios. The reactor provides a method for growing biofilms that can be used as initial inocula and potentially improve the testing and development of antibiofilm technologies.

Topical Vancomycin and Risk of Sternal Wound Infections: A Double-Blind Randomized Controlled Trial

BACKGROUND

The use of topical vancomycin in the reduction of sternal wound infection (SWI) risk has become a point of contention. Prior literature consists of only observational studies and one unblinded trial. Hence, our objective was to assess whether vancomycin reduces the incidence of SWI in a double-blind randomized controlled trial.

METHODS

Patients were randomized 1:1 to either vancomycin-soaked (vancomycin) or saline-soaked (control) sponges. The sponges were applied once the sternum was opened and were removed just prior to sternal closure. Patients were followed at three months and one-year post-operatively to determine the incidence of SWI in each group. Results were analyzed according to the modified intention-to-treat principle.

RESULTS

We assessed 1038 patients for eligibility and enrolled 1037 patients. There were 517 patients randomized to the vancomycin group, and 520 patients to the control group. Analysis was performed on 1021 patients. At three months post-operatively, there was no significant difference in the incidence of SWI between the vancomycin and control groups (2.7% vs 4.1%, p = 0.23). There was also no significant difference between the vancomycin and control groups in the risk of superficial, deep, and organ-space infections. Similar findings were observed one-year post-operatively. The most common organism isolated was Coagulase-negative Staphylococci.

CONCLUSIONS

The use of vancomycin applied to the sternum during cardiac surgery does not reduce the incidence of SWI. [NCT02374853].

Prophylactic Topical Antibiotics in Fracture Repair and Spinal Fusion

INTRODUCTION

The objective of this systematic review with meta-analysis is to determine whether prophylactic local antibiotics prevent surgical site infections (SSIs) in instrumented spinal fusions and traumatic fracture repair. A secondary objective is to investigate the effect of vancomycin, a common local antibiotic of choice, on the microbiology of SSIs.

METHODS

An electronic search of PubMed, EMBASE, and Web of Science databases and major orthopedic surgery conferences was conducted to identify studies that (1) were instrumented spinal fusions or fracture repair and (2) had a treatment group that received prophylactic local antibiotics. Both randomized controlled trials (RCTs) and comparative observational studies were included. Meta-analysis was performed separately for randomized and nonrandomized studies with subgroup analysis by study design and antibiotic.

RESULTS

Our review includes 44 articles (30 instrumented spinal fusions and 14 fracture repairs). Intrawound antibiotics significantly decreased the risk of developing SSIs in RCTs of fracture repair (RR 0.61, 95% CI: 0.40-0.93, I 2 = 32.5%) but not RCTs of instrumented spinal fusion. Among observational studies, topical antibiotics significantly reduced the risk of SSIs in instrumented spinal fusions (OR 0.34, 95% CI: 0.27-0.43, I 2 = 52.4%) and in fracture repair (OR 0.49, 95% CI: 0.37-0.65, I 2 = 43.8%). Vancomycin powder decreased the risk of Gram-positive SSIs (OR 0.37, 95% CI: 0.27-0.51, I 2 = 0.0%) and had no effect on Gram-negative SSIs (OR 0.95, 95% CI: 0.62-1.44, I 2 = 0.0%).

CONCLUSIONS

Prophylactic intrawound antibiotic administration decreases the risk of SSIs in fracture surgical fixation in randomized studies. Therapeutic efficacy in instrumented spinal fusion was seen in only nonrandomized studies. Vancomycin appears to be an effective agent against Gram-positive pathogens. There is no evidence that local vancomycin powder is associated with an increased risk for Gram-negative infection.