Letter to the Editor. Use of intraoperative vancomycin powder and postoperative infection

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  • 1 Tufts University School of Medicine, Boston, MA; and
  • | 2 University of Alabama at Birmingham, Birmingham, AL
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TO THE EDITOR: We read with great interest the article by Adogwa et al.1 (Adogwa O, Elsamadicy AA, Sergesketter A, et al: Prophylactic use of intraoperative vancomycin powder and postoperative infection: an analysis of microbiological patterns in 1200 consecutive surgical cases. J Neurosurg Spine 27:328–334, September 2017). The authors report on a large, 1200-patient study on vancomycin powder use in adults undergoing spinal deformity correction at their institution between 2011 and 2013 with a minimum 3-month follow-up. Surgical site infection (SSI) following spine surgery is a costly complication associated with significant morbidity and mortality. Topical vancomycin has emerged as a potential low-cost, low-toxicity tool to reduce the rates of infection. However, clinical results have varied, and the utility of topical vancomycin in spine surgery continues to be controversial.2,4–6 Given the higher risk of infection in spinal deformity patients,7 their paper adds much-needed data on vancomycin use in a population that may benefit from its application.

We had a few questions regarding the methodology in this paper. The patients in this study received 1–7 g of intraoperative crystalline vancomycin powder. This is a fairly wide range, with doses higher than those reported in the literature, which are typically around 1–2 g. Although dosing should ideally be based on body weight, the authors did not specify their dosing strategy. We would also appreciate a distribution for the dosing in their study population.

The authors mentioned that traumatic, infectious, and neoplastic cases were excluded, but they did not provide a breakdown of the indications for surgery. We wanted to clarify whether all 1200 cases were truly for deformity correction procedures, or if patients with deformity undergoing procedures such as decompression and fusion were included in this cohort. This number of cases would be in the upper limit of a normal range for adult spinal deformity correction at a single institution in the given time span. We would very much appreciate the authors stratifying their inclusion criteria, as it was not clearly defined in the paper.

Many spine surgeons have adopted the use of vancomycin powder. And although studies suggest that the use of vancomycin powder is a safe and efficacious practice, much of the existing literature is based on level III evidence.2,4–6 Additionally, the Centers for Disease Control and Prevention (CDC) Guideline for the Prevention of Surgical Site Infection states as follows: “2B.1. Do not apply antimicrobial agents (ie, ointments, solutions, or powders) to the surgical incision for the prevention of SSI. (Category 1B-strong recommendation; low-quality evidence.).”3 Given this recommendation and the concern for the development of antibiotic resistance, vancomycin powder should be utilized judiciously in multilevel spine surgeries until further robust evidence is established.

This article is a much-needed addition to the literature, and we congratulate the authors on a successful publication. As it stands, the role of vancomycin powder in spine surgery remains unclear and further high-quality studies are needed to investigate the safety and efficacy of this intervention in select populations.

Disclosures

The authors report no conflict of interest.

References

  • 1

    Adogwa O, Elsamadicy AA, Sergesketter A, Vuong VD, Mehta AI, Vasquez RA, et al. : Prophylactic use of intraoperative vancomycin powder and postoperative infection: an analysis of microbiological patterns in 1200 consecutive surgical cases. J Neurosurg Spine 27:328334, 2017

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  • 2

    Bakhsheshian J, Dahdaleh NS, Lam SK, Savage JW, Smith ZA: The use of vancomycin powder in modern spine surgery: systematic review and meta-analysis of the clinical evidence. World Neurosurg 83:816823, 2015

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  • 3

    Berrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. : Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 152:784791, 2017 (Erratum in JAMA Surg 152:803, 2017)

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  • 4

    Chiang HY, Herwaldt LA, Blevins AE, Cho E, Schweizer ML: Effectiveness of local vancomycin powder to decrease surgical site infections: a meta-analysis. Spine J 14:397407, 2014

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    • Export Citation
  • 5

    Kang DG, Holekamp TF, Wagner SC, Lehman RA Jr: Intrasite vancomycin powder for the prevention of surgical site infection in spine surgery: a systematic literature review. Spine J 15:762770, 2015

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    • PubMed
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    • Export Citation
  • 6

    Khan NR, Thompson CJ, DeCuypere M, Angotti JM, Kalobwe E, Muhlbauer MS, et al. : A meta-analysis of spinal surgical site infection and vancomycin powder. J Neurosurg Spine 21:974983, 2014

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    • Export Citation
  • 7

    Smith JS, Klineberg E, Lafage V, Shaffrey CI, Schwab F, Lafage R, et al. : Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery. J Neurosurg Spine 25:114, 2016

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    • Export Citation

Response

No response was received from the authors of the original article.

Contributor Notes

Correspondence Sakthivel R. Manoharan: srajaram@uabmc.edu.

INCLUDE WHEN CITING Published online May 25, 2018; DOI: 10.3171/2018.1.SPINE1867.

Disclosures The authors report no conflict of interest.

  • 1

    Adogwa O, Elsamadicy AA, Sergesketter A, Vuong VD, Mehta AI, Vasquez RA, et al. : Prophylactic use of intraoperative vancomycin powder and postoperative infection: an analysis of microbiological patterns in 1200 consecutive surgical cases. J Neurosurg Spine 27:328334, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Bakhsheshian J, Dahdaleh NS, Lam SK, Savage JW, Smith ZA: The use of vancomycin powder in modern spine surgery: systematic review and meta-analysis of the clinical evidence. World Neurosurg 83:816823, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Berrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. : Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 152:784791, 2017 (Erratum in JAMA Surg 152:803, 2017)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Chiang HY, Herwaldt LA, Blevins AE, Cho E, Schweizer ML: Effectiveness of local vancomycin powder to decrease surgical site infections: a meta-analysis. Spine J 14:397407, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Kang DG, Holekamp TF, Wagner SC, Lehman RA Jr: Intrasite vancomycin powder for the prevention of surgical site infection in spine surgery: a systematic literature review. Spine J 15:762770, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Khan NR, Thompson CJ, DeCuypere M, Angotti JM, Kalobwe E, Muhlbauer MS, et al. : A meta-analysis of spinal surgical site infection and vancomycin powder. J Neurosurg Spine 21:974983, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Smith JS, Klineberg E, Lafage V, Shaffrey CI, Schwab F, Lafage R, et al. : Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery. J Neurosurg Spine 25:114, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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