Intraoperative vancomycin powder and post-operative infection after spinal surgery: a systematic review and meta-analysis

Joaquim, Andrei Fernandes; Milano, Jerônimo Buzetti; Daniel, Jefferson Walter; Dantas, Fernando Rolemberg; Onishi, Franz; Russafa, Eloy; Bertolini, Eduardo de Freitas; Borgueresi, Marcelo Duva; Mudo, Marcelo L.; Botelho, Ricardo Vieira

doi:10.1590/1806-9282.65.2.253

Andrei Fernandes Joaquim CORRESPONDING AUTHOR: Andrei F. Joaquim, Cidade Universitaria Zeferino Vaz – Campinas – SP Brasil – 13090-610 E-mail: andjoaquim@yahoo.com

Neurosurgeon – State University of Campinas (UNICAMP), Campinas-SP, Brasil

https://orcid.org/0000-0003-2645-0483

Jerônimo Buzetti Milano

Neurosurgeon – Neurological Institute of Curitiba, Curitiba-PR, Brasil

https://orcid.org/0000-0002-7758-9058

Jefferson Walter Daniel

Professor of Neurosurgery – Santa Casa de São Paulo, São Paulo-SP, Brasil

https://orcid.org/0000-0001-6222-6708

Fernando Rolemberg Dantas

Neurosurgeon - Hospital Biocor – Belo Horizonte-MG, and Post-Graduation Program, Hospital do Servidor Público Estadual, São Paulo-SP, Brasil

Instituto de Assistência Médica ao Servidor Público Estadual, Hospital do Servidor Público Estadual, São Paulo, SP, Brasil

https://orcid.org/0000-0003-2710-8700

Franz Onishi

Neurosurgeon – Federal University of São Paulo (UNIFESP) – São Paulo-SP, Brasil

https://orcid.org/0000-0002-5641-5104

Eloy Russafa Neto

Neurosurgeon – University of São Paulo (USP), São Paulo-SP, Brasil

https://orcid.org/0000-0003-3186-2159

Eduardo de Freitas Bertolini

Neurosurgeon – Hospital do Servidor Público Estadual, São Paulo-SP, Brasil

https://orcid.org/0000-0001-9604-7978

Marcelo Duva Borgueresi

Neurosurgeon – Hospital do Servidor Público Estadual, São Paulo-SP, Brasil

https://orcid.org/0000-0001-7870-1956

Marcelo L. Mudo

Neurosurgeon – Hospital São Camilo – Itu-SP, Brasil

https://orcid.org/0000-0002-8367-3299

Ricardo Vieira Botelho

Neurosurgeon – Hospital do Servidor Público Estadual, São Paulo-SP, Brasil

https://orcid.org/0000-0002-9018-2746

CORRESPONDING AUTHOR: Andrei F. Joaquim, Cidade Universitaria Zeferino Vaz – Campinas – SP Brasil – 13090-610 E-mail: andjoaquim@yahoo.com

Author/year	Groups appraisals	Surgical site infection rate (N patients/Infections%); Comparisons between control (non-SSVP) and treatment groups (with SSVP)	Follow–up and general considerations
1. O’Neil et al.¹⁴14. O’Neill KR, Smith JG, Abtahi AM, Archer KR, Spengler DM, McGirt MJ, et al. Reduced surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powder. Spine J. 2011;11(7):641-6., 2011	Posterior spine instrumented fusions in traumatic aliments; All spinal segments	Control group: 54/13%; Treatment group: 1 g SSVP, 56/zero (p=0.02)	Median: 25 weeks; No adverse effects
2. Sweet et al.⁷7. Sweet FA, Roh M, Sliva C. Intrawound application of vancomycin for prophylaxis in instrumented thoracolumbar fusions: efficacy, drug levels, and patient outcomes. Spine (Phila Pa 1976). 2011;36(24):2084-8., 2011	Posterior spine instrumented fusions in deformity, traumatic, neoplastic aliments; Lumbar and thoracic spinal segments	Control group: 821/2.6%; Treatment group: 2 g SSVP, 911/0.2% (p<0.0001)	Average: 2.5 years; No adverse effects
3. Pahys et al.¹⁵15. Pahys JM, Pahys JR, Cho SK, Kang MM, Zebala LP, Hawasli AH, et al. Methods to decrease postoperative infections following posterior cervical spine surgery. J Bone Joint Surg Am. 2013;95(6):549-54., 2013	Posterior spine instrumented fusions in degenerative, deformity, traumatic, neoplastic, congenital aliments; Cervical spine	1. Control group: IV ATB, 483/1.86%; 2. Control group: IV ATB+Skin alcohol foam + drain, 323/0.3% (p=0.047); 3. Treatment group: IV ATB+ Skin alcohol foam + drain + 500 mg SSVP, 195/zero (p=0.048)	Minimum: 3 months; Risk factors: A BMI* of>30 kg/m² and rheumatoid arthritis had the strongest association with acute postoperative infections No adverse effects
4. Strom et al.¹⁶16. Strom RG, Pacione D, Kalhorn SP, Frempong-Boadu AK. Decreased risk of wound infection after posterior cervical fusion with routine local application of vancomycin powder. Spine (Phila PA 1976). 2013;38(12):991-4., 2013	Posterior spine instrumented fusions in degenerative, infectious, traumatic, neoplastic aliments; Cervical spine, occipitocervical and cervicothoracic spinal segments	Control group: 92/10.9%; Treatment group: 1 g SSVP, 79/2.5% (p=0.0384)	Control group: Mean 4.5 years; Treatment group: Mean 2.2 years; Absence of complications; Adverse effect: pseudarthrosis: Control group 92/5.4%; Treatment group 79/5.1% (p=1.000)
5. Strom et al.¹⁷17. Strom RG, Pacione D, Kalhorn SP, Frempong-Boadu AK. Lumbar laminectomy and fusion with routine local application of vancomycin powder: decreased infection rate in instrumented and non-instrumented cases. Clin Neurol Neurosurg. 2013;115(9):1766-9., 2013	Posterior spine instrumented and non instrumented fusions in degenerative, infectious, traumatic, neoplastic aliments; Thoracic and lumbar spinal segments	Control group: 97/11% overall rate (non instrumented 20/10%, instrumented 77/12%, p=0.0008); Treatment group: 1 g SSVP, 156/zero overall rate (non-instrumented 68/zero, instrumented 88/zero (p=0.049)	Control group: Mean 4.5 years; Treatment group: Mean 1.9 years; Absence of complications and no adverse effects
6. Caroom et al.¹⁸18. Caroom C, Tullar JM, Benton EG Jr, Jones JR, Chaput CD. Intrawound vancomycin powder reduces surgical site infections in posterior cervical fusion. Spine (Phila Pa 1976), 2013;38(14):1183-7., 2013	Posterior cervical decompression Instrumented in multilevel cervical spondylotic myelopathy (CSM); Cervical spine	Control group: 72/15%; Treatment group: 1 g SSVP, 40/zero (p=0.007)	Control group: Follow-up NI; Treatment group: Minimum of 6 months, average 18 months; No adverse effects
7. Kim et al.¹⁹19. Kim HS, Lee SG, Kim WK, Park CW, Son S. Prophylactic intrawound application of vancomycin powder in instrumented spinal fusion surgery. Korean J Spine. 2013;10(3):121-5., 2013	Posterior, anterior and lateral approaches instrumented in degenerative, traumatic and neoplastic aliments; All spinal segments	Control group: 40/12.5%, all in posterior approaches: Treatment group: 1 g SSVP, 34/zero (p=0.033)	Follow-up: NI; Risk factor: Elderly patients No adverse effects;
8. Godil et al.²⁰20. Godil SS, Parker SL, O’Neill KR, Devin CJ, McGirt MJ. Comparative effectiveness and cost-benefit analysis of local application of vancomycin powder in posterior spinal fusion for spine trauma: clinical article. J Neurosurg Spine. 2013;19(3):331-5., 2013	Posterior cervical approach instrumented in traumatic aliments; Cervical spine	Control group: 54/13% Treatment group: 1 g SSVP, 56/zero (p=0.02)	Control and treatment groups: median 25 weeks; No adverse effects
9. Tubaki et al.¹³13. Tubaki VR, Rajasekaran S, Shetty AP. Effects of using intravenous antibiotic only versus local intrawound vancomycin antibiotic powder application in addition to intravenous antibiotics on postoperative infection in spine surgery in 907 patients. Spine (Phila Pa 1976). 2013;38(25):2149-55., 2013	Open instrumented and non instrumented spine surgery; Aliment types: NI; All spinal segments	Control group: 474/1.68% Treatment group: 1 g SSVP, 433/1.61% (p>0.05)	Control and treatment groups: minimum of 12 weeks; No adverse effects
10. Martin et al.⁶6. Martin JR, Adogwa O, Brown CR, Bagley CA, Richardson WJ, Lad SP, et al. Experience with intrawound vancomycin powder for spinal deformity surgery. Spine (Phila Pa 1976). 2014;39(2):177-84., 2014	Open instrumented spine surgery in deformity; Thoracolumbar and lumbar spinal segments	Control group: 150/5.3%; Treatment group: 2 g SSVP, 156/5.1% (p=0.936)	Control and treatment groups: 30 days; No adverse effects
11. Emohare et al.²¹21. Emohare O, Ledonio CG, Hill BW, Davis RA, Polly DW Jr, Kang MM. Cost savings analysis of intrawound vancomycin powder in posterior spinal surgery. Spine J. 2014;14(11):2710-5., 2014	Open instrumented and non- instrumented spine surgery; Thoracic, thoracolumbar and lumbar spinal segments	Control group: 207/NI, return-to-surgery for infection = 6.71%; Treatment group: 1 g SSVP, 96/NI, return-to-surgery = zero (p=0.0841)	Follow-up: NI; Adverse effects: NI
12. Theologis et al.²²22. Theologis AA, Demirkiran G, Callahan M, Pekmezci M, Ames C, Deviren V. Local intrawound vancomycin powder decreases the risk of surgical site infections in complex adult deformity reconstruction: a cost analysis. Spine (Phila Pa 1976). 2014;39(22):1875-80., 2014	Open instrumented spine surgery in deformity; Thoracic, thoracolumbar and lumbar spinal segments	Control group: 64/NI, readmissions within 90 days for SSI = 10.9%; Treatment group: 2 g SSVP, 151/NI, readmissions within 90 days for SSI = 2.6% (p=0.01)	Control group: median 34 months; Treatment group: 18 months; No adverse effects
13. Martin et al.³3. Martin JR, Adogwa O, Brown CR, Kuchibhatla M, Bagley CA, Lad SP, et al. Experience with intrawound vancomycin powder for posterior cervical fusion surgery. J Neurosurg Spine. 2015;22(1):26-33., 2015	Open posterior instrumented spine surgery in degenerative, deformity, neoplastic and traumatic aliments; Occipitocervi cal, cervical only, and cervicothoracic spinal segments	Control group: 174/6.9%; Treatment group: 2 g SSVP, 115/5.2% (p=0.053)	Control and treatment groups: 30 days; No adverse effects
14. Scheverin et al.²³23. Scheverin N, Steverlynck A, Castelli R, Sobrero D, Kopp NV, Dinelli D, et al. Prophylaxis of surgical site infection with vancomycin in 513 patients that underwent to lumbar fusion. Coluna/Columna. 2015;14(3):177-80., 2015	Open posterior instrumented spine surgery in degenerative aliments; Lumbar spine	Control group: 281/4.98%; Treatment group: 1 g SSVP, 232/1.29% (p=0.0245)	Control and treatment groups: mean 10 months; Risks for SSI: age > 65 years, obesity, prolonged surgery, surgical blood lose; No adverse effects
15. Tomov et al.²⁴24. Tomov M, Mitsunaga L, Durbin-Johnson B, Nallur D, Roberto R. Reducing surgical site infection in spinal surgery with betadine irrigation and intrawound vancomycin powder. Spine (Phila Pa 1976). 2015;40(7):491-9., 2015	Open and percutaneous, anterior and posterior, instrumented and non instrumented spine surgery in deformity, degenerative, traumatic, neoplastic aliments; All spinal segments	Control group: NI; Treatment group: 1 g SSVP, NI; SSI rates were reduced by 50% after the intervention with SSVP (p=0.042)	Follow-up: NI; Risks for SSI: anemia, prior operation, vertebral fracture; Adverse effects: NI
16. Liu et al.²⁵25. Liu N, Wood KB, Schwab JH, Cha TD, Puhkan RD, Osler PM, et al. Comparison of intrawound vancomycin utility in posterior instrumented spine surgeries between patients with tumor and nontumor patients. Spine (Phila Pa 1976). 2015;40(20):1586-92., 2015	Open posterior spine surgery in degenerative, deformity, neoplastic aliments; Cervical, thoracic, lumbar spinal segments	Control group: Non-tumor, non-SSVP, 129/7%; Tumor, non-SSVP, 25/8% (p=0.011). Treatment group: Non-tumor, 0.5 mg – 2 g SSVP, 153/0.7%; Tumor, 0.5 mg – 2 g SSVP, 27/14.8% (p=0.442).	Control and treatment groups: 3 months; Preoperative radiotherapy may contribute to the increase of SSI; No adverse effects
17. Heller et al.²⁶26. Heller A, McIff TE, Lai SM, Burton DC. Intrawound vancomycin powder decreases staphylococcal surgical site infections after posterior instrumented spinal arthrodesis. J Spinal Disord Tech. 2015;28(10):E584-9., 2015	Open posterior spine surgery in degenerative, deformity, neoplastic; traumatic aliments; Cervical, thoracic, lumbar spinal segments	Control group: 341/3.89%; Treatment group: 0.5 mg-2 g SSVP, 342/1.1%; (p=0.029)	Control and treatment groups: 90 days. Risk factors for SSI: Discharge to skilled nursing or rehabilitation facilities; No adverse effects
18. Schroeder et al.²⁷27. Schroeder JE, Girardi FP, Sandhu H, Weinstein J, Cammisa FP, Sama A. The use of local vancomycin powder in degenerative spine surgery. Eur Spine J. 2016;25(4):1029-33., 2016	Open posterior or anterior, non instrumented and instrumented cervical, thoracic, lumbar spine surgery (anterior cervical excluded); Spinal aliments: NI	Control group: 2253/1.33%; Treatment group: 1-1.5 g SSVP, 1224/0.40% (p=0.04)	Control and treatment groups: 12 months; Adverse effects: NI
19. Lee et al.²⁸28. Lee GI, Bak KH, Chun HJ, Choi KS. Effect of using local intrawound vancomycin powder in addition to intravenous antibiotics in posterior lumbar surgery: midterm result in a single-center study. Korean J Spine. 2016;13(2):47-52., 2016	Open posterior lumbar spine surgery; Spinal aliments: NI (excluded traumatic)	Control group: 296/10.5%; Treatment group: 1 g SSVP, 275/5.5%	Control group: mean 11 months; Treatment group: mean 8 months; Risk factors: Diabetes mellitus, cardiovascular disease, and longer hospital stay; No adverse effects
20. Hey et al.²⁹29. Hey HW, Thiam DW, Koh ZS, Thambiah JS, Kumar N, Lau LL, et al. Is intraoperative local vancomycin powder the answer to surgical site infections in spine surgery? Spine (Phila Pa 1976). 2017;42(4):267-74., 2017	Open posterior, lateral spinal surgery; Degenerative, developmental, traumatic, infectious, neoplastic, revision; Non-instrumented and instrumented; Cervical, thoracic, lumbar	Control group: 272/6.3%; Treatment group: 1 g SSVP, 117/0,9%;	Control and treatment groups: 3 months; Adverse effects: NI
21. Van Hal et al.³⁰30. Van Hal M, Lee J, Laudermilch D, Nwasike C, Kang J. Vancomycin powder regimen for prevention of surgical site infection in complex spine surgeries. Clin Spine Surg. 2017;30(8):E1062-5., 2017	Spinal surgery (laminectomies and arthrodesis)	Control group: 652/NI; Treatment group: SSVP dose NI, 496/5.6%	Follow-up:NI
22. Chotai et al.³¹31. Chotai S, Wright PW, Hale AT, Jones WA, McGirt MJ, Patt JC, et al. Does intrawound vancomycin application during spine surgery create vancomycin-resistant organism? Neurosurgery. 2017;80(5):746-53., 2017	Open posterior and anterior spinal surgery: Degenerative, deformity, neoplastic; With and without instrumentation	Control group: 1587/2.5%; Treatment group: 1 g SSVP, 1.6%	Control and treatment groups: 1 year; No adverse effects

Study	Selection	Comparability	Exposition
Van Hal et al.³⁰30. Van Hal M, Lee J, Laudermilch D, Nwasike C, Kang J. Vancomycin powder regimen for prevention of surgical site infection in complex spine surgeries. Clin Spine Surg. 2017;30(8):E1062-5., 2017	****	*	**	Current vs. previous
Martin et al.⁶6. Martin JR, Adogwa O, Brown CR, Bagley CA, Richardson WJ, Lad SP, et al. Experience with intrawound vancomycin powder for spinal deformity surgery. Spine (Phila Pa 1976). 2014;39(2):177-84., 2014	****	*	**	Current vs. previous. Use of propensity score adjustment.
Liu et al.²⁵25. Liu N, Wood KB, Schwab JH, Cha TD, Puhkan RD, Osler PM, et al. Comparison of intrawound vancomycin utility in posterior instrumented spine surgeries between patients with tumor and nontumor patients. Spine (Phila Pa 1976). 2015;40(20):1586-92., 2015	****	*	**	Current vs. previous. Significant differences between samples.
Tomov et al.²⁴24. Tomov M, Mitsunaga L, Durbin-Johnson B, Nallur D, Roberto R. Reducing surgical site infection in spinal surgery with betadine irrigation and intrawound vancomycin powder. Spine (Phila Pa 1976). 2015;40(7):491-9., 2015	****	*	**	Current vs. previous. Data from the Healthcare Infection Management and Infection.
Martin et al.³3. Martin JR, Adogwa O, Brown CR, Kuchibhatla M, Bagley CA, Lad SP, et al. Experience with intrawound vancomycin powder for posterior cervical fusion surgery. J Neurosurg Spine. 2015;22(1):26-33., 2015	****	*	**	Current vs. previous. Significant differences between samples.
Theologis et al.²²22. Theologis AA, Demirkiran G, Callahan M, Pekmezci M, Ames C, Deviren V. Local intrawound vancomycin powder decreases the risk of surgical site infections in complex adult deformity reconstruction: a cost analysis. Spine (Phila Pa 1976). 2014;39(22):1875-80., 2014	****	*	**	Current vs. previous. Significant differences between samples.
Kim et al.¹⁹19. Kim HS, Lee SG, Kim WK, Park CW, Son S. Prophylactic intrawound application of vancomycin powder in instrumented spinal fusion surgery. Korean J Spine. 2013;10(3):121-5., 2013	****	*	**	Current vs. previous.
Strom et al.¹⁷17. Strom RG, Pacione D, Kalhorn SP, Frempong-Boadu AK. Lumbar laminectomy and fusion with routine local application of vancomycin powder: decreased infection rate in instrumented and non-instrumented cases. Clin Neurol Neurosurg. 2013;115(9):1766-9., 2013	****	*	**	Current vs. previous. Imbalanced for instrumentation.
Heller et al.²⁶26. Heller A, McIff TE, Lai SM, Burton DC. Intrawound vancomycin powder decreases staphylococcal surgical site infections after posterior instrumented spinal arthrodesis. J Spinal Disord Tech. 2015;28(10):E584-9., 2015	****	*	**	Current vs. previous. Only 8%follow-up losses Imbalanced for age, arterial hypertension and use of hair cut.
Schroeder et al.²⁷27. Schroeder JE, Girardi FP, Sandhu H, Weinstein J, Cammisa FP, Sama A. The use of local vancomycin powder in degenerative spine surgery. Eur Spine J. 2016;25(4):1029-33., 2016	****	*	**	Current vs. previous. Significant differences between samples.
Lee et al.²⁸28. Lee GI, Bak KH, Chun HJ, Choi KS. Effect of using local intrawound vancomycin powder in addition to intravenous antibiotics in posterior lumbar surgery: midterm result in a single-center study. Korean J Spine. 2016;13(2):47-52., 2016	****	*	**	Current vs. previous. Uni and multivariate analysis for covariates.
Pahys et al.¹⁵15. Pahys JM, Pahys JR, Cho SK, Kang MM, Zebala LP, Hawasli AH, et al. Methods to decrease postoperative infections following posterior cervical spine surgery. J Bone Joint Surg Am. 2013;95(6):549-54., 2013	****	*	**	Data collected and analyzed by three independent reviewers. Significant differences between samples.
Hey et al.²⁹29. Hey HW, Thiam DW, Koh ZS, Thambiah JS, Kumar N, Lau LL, et al. Is intraoperative local vancomycin powder the answer to surgical site infections in spine surgery? Spine (Phila Pa 1976). 2017;42(4):267-74., 2017	****	*	**	Significant differences between samples
Scheverin et al.²³23. Scheverin N, Steverlynck A, Castelli R, Sobrero D, Kopp NV, Dinelli D, et al. Prophylaxis of surgical site infection with vancomycin in 513 patients that underwent to lumbar fusion. Coluna/Columna. 2015;14(3):177-80., 2015	****	*	**	Vancomycin indicated according to the surgeon's preference. Significant differences between samples
Godil et al.¹⁸18. Caroom C, Tullar JM, Benton EG Jr, Jones JR, Chaput CD. Intrawound vancomycin powder reduces surgical site infections in posterior cervical fusion. Spine (Phila Pa 1976), 2013;38(14):1183-7., 2013	****	*	**	Samples based on surgeon preferences. Non controlled for confounders but without differences between samples.
Chotai et al.³¹31. Chotai S, Wright PW, Hale AT, Jones WA, McGirt MJ, Patt JC, et al. Does intrawound vancomycin application during spine surgery create vancomycin-resistant organism? Neurosurgery. 2017;80(5):746-53., 2017	****	*	**	Not controlled for confounders but without differences between samples.
Carrom et al.¹⁸18. Caroom C, Tullar JM, Benton EG Jr, Jones JR, Chaput CD. Intrawound vancomycin powder reduces surgical site infections in posterior cervical fusion. Spine (Phila Pa 1976), 2013;38(14):1183-7., 2013	****	*	**	Current vs. previous. The intervention group trended toward slightly more complex procedures.
Sweet et al.⁷7. Sweet FA, Roh M, Sliva C. Intrawound application of vancomycin for prophylaxis in instrumented thoracolumbar fusions: efficacy, drug levels, and patient outcomes. Spine (Phila Pa 1976). 2011;36(24):2084-8., 2011	****	*	**	Current vs. previous. No significant differences between samples
Emohare et al.²¹21. Emohare O, Ledonio CG, Hill BW, Davis RA, Polly DW Jr, Kang MM. Cost savings analysis of intrawound vancomycin powder in posterior spinal surgery. Spine J. 2014;14(11):2710-5., 2014	****	*	**	Patient allocation-specific surgeon or on-call admission. Significant differences between samples.
O’Neil et al.¹⁴14. O’Neill KR, Smith JG, Abtahi AM, Archer KR, Spengler DM, McGirt MJ, et al. Reduced surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powder. Spine J. 2011;11(7):641-6., 2011	****	**	**	The treatment and control groups were statistically similar.
Strom et al.¹⁶16. Strom RG, Pacione D, Kalhorn SP, Frempong-Boadu AK. Decreased risk of wound infection after posterior cervical fusion with routine local application of vancomycin powder. Spine (Phila PA 1976). 2013;38(12):991-4., 2013	****		**	Current vs. previous. No significant difference between samples.

Results for subgroups (random effects model):
	k	OR	95% - CI	Q	tau^2	I^2
IR = low	3	0.4499	[0.2139; 0.9461]	2.26	0.056	11.5%
IR = medium	5	0.3612	[0.1918; 0.6800]	8.32	0.2367	51.9%
IR = high	14	0.3484	[0.2252; 0.5391]	19.99	0.2039	35.0%

[1] CORRESPONDING AUTHOR: Andrei F. Joaquim, Cidade Universitaria Zeferino Vaz – Campinas – SP Brasil – 13090-610 E-mail: andjoaquim@yahoo.com

Brasil

Brasil

Intraoperative vancomycin powder and post-operative infection after spinal surgery: a systematic review and meta-analysis

SUMMARY