Effectiveness of topical vancomycin in the prevention of spinal surgical site infections: a retrospective cohort study

Assessment of the implementation of risk minimization measures for bosentan: a retrospective study

BACKGROUND

Bosentan is associated with adverse hepatic effects. To minimize such risk, regulators implemented risk minimization measures (RMMs), including testing for liver injury biomarkers (alanine and aspartate transaminase and bilirubin) prior to therapy initiation and monthly throughout therapy. This study aimed to examine the adherence to hepatic monitoring requirements.

RESEARCH DESIGN AND METHODS

This retrospective cohort study collected data about bosentan new-users from the Real-world Evidence Research Network from 2016 to 2022. We ascertained hepatic tests from laboratory files. Adherence to RMM definition was performing the required tests within 90 days before initiation and categorized adherence to monthly testing requirement based on the expected number of tests throughout therapy as low (<50%), moderate (50-74%), and high (≥75%).

RESULTS

One hundred patients entered the study cohort and 71% were females, with a median age of 25 years. Adherence to testing prior to bosentan initiation was 60%. Adherence to monthly testing was low in the majority of patients (58.2%).

CONCLUSIONS

Adherence to bosentan RMMs relevant to minimizing risk of hepatotoxicity either before starting or throughout therapy was low. Our findings could be used as a baseline for monitoring trends in implementation of RMMs over time or to compare performance of various minimization strategies.

Mortality associated with carbapenem resistance in Klebsiella pneumoniae bloodstream infection: A propensity score-matched study

OBJECTIVE

Klebsiella pneumoniae are common pathogens causing bloodstream infection (BSI) that increasingly express carbapenem resistance worldwide. To date, no study has precisely investigated the impact of carbapenem resistance in K. pneumoniae (CRKP) BSI on mortality.

METHODS

This retrospective study included 87 patients with CRKP BSI and 321 patients with carbapenem-susceptible K. pneumoniae (CSKP) BSI from 2015 to 2020. Propensity score analyses with stabilized inverse probability of treatment weighting (IPTW-S) was applied to balance covariates. The hazard ratio for 30-day mortality associated with carbapenem resistance was estimated using Cox regression and Kaplan-Meier curves.

RESULTS

The 30-day crude mortality rates were 43.7% in patients with CRKP BSI and 17.8% in patients with CSKP BSI (P < .001). Age ≥55 years, underlying hematological malignancies and hemodialysis were independently associated with mortality in CRKP BSI. A skin or soft-tissue infection source, urinary catheter, and underlying chronic obstructive pulmonary disease were predictors of mortality in CSKP BSI. The group characteristics were well balanced after IPTW-S. The adjusted hazard ratio for 30-day mortality for CRKP BSI was 1.607 (interquartile range, 0.814-3.171).

CONCLUSIONS

Carbapenem resistance was not associated with a significant increase in 30-day mortality in KP BSI; patient and disease factors were primary determinants of outcomes.

Can local application of vancomycin reduce surgical site infection rate after open lumbar fusion surgery?: A multicenter retrospective cohort study

Surgical site infection (SSI) after posterior open lumbar fusion (POLF) is a major concern for both surgeons and patients. We sought to explore whether local application of vancomycin could decrease the rate of SSI. We reviewed the clinical data of patients who underwent POLF between June 2015 and June 2022 at 3 spinal centers. Patients were divided into those who received local vancomycin (vancomycin group) and those who did not (non-vancomycin group). The SSI rates at 12 months postoperatively were compared between the 2 groups. Although a trend toward a lower infection rate was observed in the vancomycin group than in the non-vancomycin group; the difference was not statistically significant (3.6% vs 5.5%, P = .121). However, we found that the postoperative SSI rate was significantly lower in the vancomycin group than in the non-vancomycin group (4.9% vs 11.4%, P = .041) in patients ≥ 2 fused segments, while there was no significant difference in postoperative SSI rate in patients with single fusion segment (3.1% vs 3.6%, P = .706). The logistic regression analysis indicated that the SSI rate in the non-vancomycin group was approximately 2.498 times higher than that in the vancomycin group (P = .048, odds ratio: 2.498, 95% confidence interval: 1.011-6.617) in patients with ≥2 fused segments. In SSI patients with confirmed pathogens, the SSI rate of Gram-negative bacteria in the vancomycin group was significantly higher than that in the non-vancomycin group (10/14 [71.4%] vs 5/22 [31.8%]), whereas the SSI rate of Gram-positive bacteria in the vancomycin group was significantly lower than that in the non-vancomycin group (4/14 [28.6%] vs 15/22 [68.2%]). Local administration of vancomycin is recommended in patients with ≥2 fused segments as it may facilitate to reduce the postoperative rate of SSI after POLF. Additionally, the local use of vancomycin can decrease the Gram-positive bacterial infections but is not effective against Gram-negative infections, which indirectly leads to an increase in the proportion of Gram-negative infections in SSI patients with confirmed pathogens.

Intrawound vancomycin powder in orthopaedic surgery as surgical site wound infection prophylaxis: A meta-analysis

A meta-analysis research was executed to appraise the consequence of intrawound vancomycin powder (IWVP) in orthopaedic surgery (OPS) as surgical site wound infection (SSWI) prophylaxis. Inclusive literature research till March 2023 was carried out and 2756 interconnected researches were revised. Of the 18 picked researches enclosed 13 214 persons with OPS were in the used researches' starting point, 5798 of them were utilising IWVP, and 7416 were control. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to appraise the consequence of the IWVP in OPS as SSWI prophylaxis by the dichotomous approaches and a fixed or random model. IWVP had significantly lower SSWIs (OR, 0.61; 95% CI, 0.50-0.74, P < .001), deep SSWIs (OR, 0.57; 95% CI, 0.36-0.91, P = .02), and superficial SSWIs (OR, 0.67; 95% CI, 0.46-0.98, P = .04) compared with control in persons with OPS. IWVP had significantly lower SSWIs, deep SSWIs, and superficial SSWIs compared with control in persons with OPS. However, when interacting with its values, caution must be taken and more research is needed to confirm this finding.

Intraoperative Antibiotic Use in Patients With Early-onset Scoliosis: Current Practices and Trends

BACKGROUND

Best Practice Guidelines (BPGs) regarding antibiotic prophylaxis in early-onset scoliosis (EOS) patients were published in September 2019. Recommendations included using intravenous cefazolin and topical vancomycin for all index procedures, plus gram-negative coverage for neuromuscular patients. Guideline adherence is unknown. This study aimed to characterize antibiotic prophylaxis at the time of index growth-friendly procedures and assess changes in practice patterns over time.

MATERIALS AND METHODS

This retrospective review of data collected through a multicenter study group included EOS patients undergoing index growth-friendly procedures between January 2018 and March 2021, excluding revisions, lengthenings, and tetherings. Demographics, clinical measurements, intraoperative antibiotics, and 90-day complications were recorded. Descriptive and univariate statistics were utilized. Antibiotic prophylaxis from April 2018 through September 2019 and October 2019 through March 2021 were compared with evaluate change after BPG publication.

RESULTS

A total of 562 patients undergoing growth-friendly procedures were included. The most common scoliosis types included neuromuscular (167, 29.7%), syndromic (134, 23.8%), and congenital (97, 17.3%). Most index procedures involved magnetically controlled growing rods (417, 74%) followed by vertical expandable prosthetic titanium rib or traditional growing rods (105, 19%). Most patients received cefazolin alone at index procedure (310, 55.2%) or cefazolin with an aminoglycoside (113, 20.1%). Topical antibiotics were used in 327 patients (58.2%), with most receiving vancomycin powder. There was increased use of cefazolin with an aminoglycoside after BPG publication (16% vs. 25%) ( P =0.01). Surgical site infections occurred in 12 patients (2.1%) within 90 days of index procedure, 10 pre-BPGs (3%), and 2 post-BPGs (0.9%), with no significant difference in surgical site infection rate by type of antibiotic administered ( P >0.05).

CONCLUSIONS

Historical variability exists regarding antibiotic prophylaxis during index growth-friendly procedures for EOS. There continues to be variability following BPG publication; however, this study found a significant increase in antibiotic prophylaxis against gram-negative bacteria after BPG publication. Overall, greater emphasis is needed to decrease variability in practice, improve compliance with consensus guidelines, and evaluate BPG efficacy.

LEVEL OF EVIDENCE

Level III-retrospective.

Effect of powdered vancomycin on stopping surgical site wound infections in neurosurgery: A meta-analysis

We performed a meta-analysis to evaluate the effect of powdered vancomycin on stopping surgical site wound infections in neurosurgery. A systematic literature search up to July 2022 was performed and 24 137 subjects with neurosurgery at the baseline of the studies; 10 496 of them were using the powdered vancomycin, and 13 641 were not using the powdered vancomycin as a control. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of powdered vancomycin on stopping surgical site wound infections in neurosurgery using dichotomous methods with a random or fixed-effect model. The powdered vancomycin had significantly lower surgical site wound infections after spinal surgery (OR, 0.53; 95% CI, 0.41-0.70, P < .001), deep surgical site wound infections after spinal surgery (OR, 0.45; 95% CI, 0.35-0.57, P < .001), superficial surgical site wound infections after spinal surgery (OR, 0.60; 95% CI, 0.43-0.83, P = .002), and surgical site wound infections after cranial surgery (OR, 0.37; 95% CI, 0.22-0.61, P < .001) compared to control in subjects with neurosurgery. The powdered vancomycin had significantly lower surgical site wound infections after spinal surgery, deep surgical site wound infections after spinal surgery, superficial surgical site wound infections after spinal surgery, and surgical site wound infections after cranial surgery compared to control in subjects with neurosurgery. The analysis of outcomes should be done with caution even though the low number of studies with low sample size, 3 out of the 42 studies, in the meta-analysis, and a low number of studies in certain comparisons.

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.

The use of vancomycin powder in the compound depressed skull fractures

BACKGROUND/AIM

Compound or open depressed fractures (CDF) is one of the urgent operations of neurosurgery, as it can result in complications of infection. This study is reported to investigate the effect of topical vancomycin powder to the infection rates in the compound depressed skull fractures which have been operated on.

MATERIALS AND METHODS

This present study was conducted on 46 cases with compound depressed skull fractures which have been operated on. Cases were divided into two groups according to the use of subgaleal topical vancomycin powder during the operation. The preoperative and postoperative CRP levels, localization of the fracture, hospitalization time, operation length, dural injury, pneumocephalus, and mortality rates have been examined.

RESULTS

In cases with dural injury and pneumocephalus, a statistically significant relationship was found between the use of topical vancomycin powder and the frequency of post-op infection (p < 0.001). It was observed that the incidence of postoperative infection was significantly higher in 12 (85.7%) cases with pneumocephalus and dural injury when vancomycin powder was not used. Also, it was observed that the post-operative infection level was significantly higher in fractures in the frontal and parietal regions without vancomycin powder(p < 0.05).

CONCLUSIONS

The use of subgaleal topical vancomycin powder is an option to reduce the infection rates and mortality, especially in the cases of compound depressed fractures, which is considered as a dirty wound and prone to infection. It is especially recommended in the presence of dural injury and pneumocephalus.