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Hiroki Ushirozako, Tomohiko Hasegawa, Yu Yamato, Go Yoshida, Tatsuya Yasuda, Tomohiro Banno, Hideyuki Arima, Shin Oe, Yuki Mihara, Tomohiro Yamada, Koichiro Ide, Yuh Watanabe, Keichi Nakai, Takaaki Imada, and Yukihiro Matsuyama

side effects. 10 However, the use of intrawound vancomycin powder has shown good efficacy in reducing SSI occurrence owing to the adequately maintained drug concentration at the surgical site and the fact that fewer systemic side effects are associated with vancomycin than with other antibiotics. 11–13 Prophylactic application of intrawound vancomycin powder to the surgical site has been demonstrated to decrease SSI rates after posterior instrumented spinal fusion. 14 Most retrospective studies have reported that vancomycin powder is beneficial in reducing SSI

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Joel R. Martin, Owoicho Adogwa, Christopher R. Brown, Maragatha Kuchibhatla, Carlos A. Bagley, Shivanand P. Lad, and Oren N. Gottfried

112 Control 15%; treated 0% (p = 0.007) Gans et al., 2013 Thoracic, lumbar Pediatric deformity cases 87 Treated 3.4% Pahys et al., 2013 Cervical All posterior cases 576 Control 1.73%; treated 0% (vancomycin + alcohol foam + drain) Tubaki et al., 2013 Cervical, thoracic, lumbar All spine cases 606 Control 1.98%; treated 1.99% Conversely, 2 groups reported no significant change in postoperative deep wound infection. Mohammed et al. compared open vascular procedures with and without intrawound vancomycin powder. 13 In the 454

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Nickalus R. Khan, Clinton J. Thompson, Michael DeCuypere, Jonathan M. Angotti, Erick Kalobwe, Michael S. Muhlbauer, Francis X. Camillo, and Paul Klimo Jr.

, 43 and reporting was performed according to the guidelines defined by Meta-analysis Of Observational Studies in Epidemiology (MOOSE) 48 and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). 31 The research question for this study was: “Does intrawound vancomycin powder reduce the rate of SSIs in spine surgery?” Search Strategy The systematic search strategy involved a search using multiple electronic databases, bibliographies of relevant articles, and consultation with the senior author (P.K.). In April 2014, we electronically

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Vincent Dodson, Neil Majmundar, Vanessa Swantic, and Rachid Assina

and PubMed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were selected to answer 2 research questions: “Does intrawound vancomycin powder decrease the risk of SSI?” and “Is the risk of infection by gram-negative pathogens greater in patients who receive intrawound vancomycin powder?” A variety of combinations of the search terms “vancomycin powder,” “infection,” “spine,” “gram-negative,” “prophylaxis,” and “surgical site” were used. Inclusion criteria for the first research question were

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Shoichi Haimoto, Ralph T. Schär, Yusuke Nishimura, Masahito Hara, Toshihiko Wakabayashi, and Howard J. Ginsberg

D espite the use of perioperative systemic antibiotic prophylaxis, surgical site infections (SSIs) remain a serious complication in spine surgery, particularly in instrumented spinal fusion. SSIs can have a profound negative impact on patient outcomes and burden the health care system by leading to revision surgery, lengthy use of systemic antibiotics, and prolonged hospitalization. 11 , 18 , 25 , 26 In recent years the use of intrawound vancomycin powder in spine surgery has emerged as a promising method to address these concerns. Many, mainly retrospective

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Kingsley O. Abode-Iyamah, Hsiu-Yin Chiang, Nolan Winslow, Brian Park, Mario Zanaty, Brian J. Dlouhy, Oliver E. Flouty, Zachary D. Rasmussen, Loreen A. Herwaldt, and Jeremy D. Greenlee

.e., prosthetic implants) during cranioplasty, and general medical debilitation after significant trauma. SSIs after cranioplasty can cause significant morbidity, and treatment often involves removing the bone or prosthetic flap followed by long-term antibiotic therapy. Subsequent reoperation to correct the cranial defect is delayed several months to reduce the risk of a second infection. 15 Given the morbidity associated with SSIs after neurosurgical and orthopedic procedures, several groups have assessed the use of intrawound vancomycin powder (VP) for preventing SSIs. Most

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Kingsley O. Abode-Iyamah, Hsiu-Yin Chiang, Royce W. Woodroffe, Brian Park, Francis J. Jareczek, Yasunori Nagahama, Nolan Winslow, Loreen A. Herwaldt, and Jeremy D. W. Greenlee

OBJECTIVE

Deep brain stimulation is an effective surgical treatment for managing some neurological and psychiatric disorders. Infection related to the deep brain stimulator (DBS) hardware causes significant morbidity: hardware explantation may be required; initial disease symptoms such as tremor, rigidity, and bradykinesia may recur; and the medication requirements for adequate disease management may increase. These morbidities are of particular concern given that published DBS-related infection rates have been as high as 23%. To date, however, the key risk factors for and the potential preventive measures against these infections remain largely uncharacterized. In this study, the authors endeavored to identify possible risk factors for DBS-related infection and analyze the efficacy of prophylactic intrawound vancomycin powder (VP).

METHODS

The authors performed a retrospective cohort study of patients who had undergone primary DBS implantation at a single institution in the period from December 2005 through September 2015 to identify possible risk factors for surgical site infection (SSI) and to assess the impact of perioperative (before, during, and after surgery) prophylactic antibiotics on the SSI rate. They also evaluated the effect of a change in the National Healthcare Safety Network’s definition of SSI on the number of infections detected. Statistical analyses were performed using the 2-sample t-test, the Wilcoxon rank-sum test, the chi-square test, Fisher’s exact test, or logistic regression, as appropriate for the variables examined.

RESULTS

Four hundred sixty-four electrodes were placed in 242 adults during 245 primary procedures over approximately 10.5 years; most patients underwent bilateral electrode implantation. Among the 245 procedures, 9 SSIs (3.7%) occurred within 90 days and 16 (6.5%) occurred within 1 year of DBS placement. Gram-positive bacteria were the most common etiological agents. Most patient- and procedure-related characteristics did not differ between those who had acquired an SSI and those who had not. The rate of SSIs among patients who had received intrawound VP was only 3.3% compared with 9.7% among those who had not received topical VP (OR 0.32, 95% CI 0.10–1.02, p = 0.04). After controlling for patient sex, the association between VP and decreased SSI risk did not reach the predetermined level of significance (adjusted OR 0.32, 95% CI 0.10–1.03, p = 0.06). The SSI rates were similar after staged and unstaged implantations.

CONCLUSIONS

While most patient-related and procedure-related factors assessed in this study were not associated with the risk for an SSI, the data did suggest that intrawound VP may help to reduce the SSI risk after DBS implantation. Furthermore, given the implications of SSI after DBS surgery and the frequency of infections occurring more than 90 days after implantation, continued follow-up for at least 1 year after such a procedure is prudent to establish the true burden of these infections and to properly treat them when they do occur.

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Paul M. Arnold, Zoher Ghogawala, and Candan Tamerler

infections . Surg Infect (Larchmt) 13 : 234 – 237 , 2002 2 Devin CJ , Chotai S , McGirt MJ , Vaccaro AR , Youssef JA , Orndorff DG , : Intrawound vancomycin decreases the risk of surgical site infection after posterior spine surgery—a multicenter analysis . Spine (Phila Pa 1976) [epub ahead of print] 2015 3 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 14 : 2710 – 2715 , 2014 4 Ghobrial GM , Cadotte

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George M. Ghobrial, David W. Cadotte, Kim Williams Jr., Michael G. Fehlings, and James S. Harrop

, Benton EG Jr , Jones JR , Chaput CD : Intrawound vancomycin powder reduces surgical site infections in posterior cervical fusion . Spine (Phila Pa 1976) 38 : 1183 – 1187 , 2013 5 Eder C , Schenk S , Trifinopoulos J , Külekci B , Kienzl M , Schildböck S , : Does intrawound application of vancomycin influence bone healing in spinal surgery? . Eur Spine J epub ahead of print 2015 6 Emohare O , Ledonio CG , Hill BW , Davis RA , Polly DW Jr , Kang MM : Cost savings analysis of intrawound vancomycin powder in

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University of Rochester, Rochester, NY 4 2017 42 4 New Technologies for Ischemic Stroke A2 A2 Copyright held by the American Association of Neurological Surgeons. You may not sell, republish, or systematically distribute any published materials without written permission from JNSPG. 2017 Background/Introduction: Surgical management of metastatic and primary spine tumors is associated with wound complication (infection, dehiscence) rates of up to 30%. The role of concurrent intrawound vancomycin powder (IVP) and betadine irrigation (BI) has not