Analysis of a ten step protocol to decrease postoperative spinal wound infections

Table 2 Studies evaluating the use of vancomycin powder intraoperatively

Ref.	Study design (level of evidence)	Surgery performed	Groups	Main outcome	Significance
Ghobrial et al[56] (2014)	Retrospective case series (IV)	Spinal procedures for degenerative disease, trauma, pain and scoliosis	Vancomycin powder(range from 1-6 g) applied to subfascial and epifascial layers but not to bone graft (n = 981)	66 infections identified (6.7%) A number of gram-negative infections were encountered	Vancomycin may increase the incidence of gram-negative or polymicrobial spinal infections
Hill et al[55] (2014)	Retrospective cohort (III)	Instrumented or non-instrumented posterior spine surgery in adults	Patients receiving 1-2 g vancomycin powder in surgical bed (n = 150), No vancomycin powder (n = 150)	5 superficial infections in vancomycin powder group (3.3%), 5 superficial and 6 deep infections in control group (7.3%)	Significantly fewer deep infections in patients treated with vancomycin powder (P = 0.0297)
Theologis et al[59] (2014)	Retrospective cohort (III)	Complex adult spinal deformity reconstruction	Patients receiving 1-2 g vancomycin powder in subfascial space (n = 151), No vancomycin powder (n = 64)	4 infections in first 90 d in treatment group (2.6%), 7 infections in first 90 d in control (10.9%)	Significantly fewer hospital readmissions within 90 d of surgery when using vancomycin powder (P = 0.01)
Caroom et al[49] (2013)	Retrospective comparative study of prospectively collected data (II)	Multilevel posterior decompression and instrumentation for cervical spondylitic myelopathy	1 g vancomycin powder applied subfascially along bone graft and instrumentation (n = 40), No vancomycin powder (n = 72)	Zero infections in vancomycin powder group (0%), 11 infections in control (15%)	Significant decrease in infection rate with use of vancomycin powder (P = 0.007)
Gans et al[58] (2013)	Therapeutic retrospective cohort (II)	Pediatric spinal deformity surgery (fusion, growing rods, vertical expandable prosthetic titanium rib)	Patients received 1g vancomycin powder in surgical wound (n = 87)	3 surgical site infections identified (3.4%) The postoperative systemic vancomycin levels remained undetectable. None of the patients experienced nephrotoxicity or red man syndrome	Local application of vancomycin powder is safe without significant changes in creatinine level or systemic vancomycin level
Kim et al[57] (2013)	Retrospective cohort (IV)	Instrumented spinal fusion	Patients receiving 1 g vancomycin powder in surgical wound (n = 34), No vancomycin powder (n = 40)	Zero infections in vancomycin powder group (0%) 5 infections in control (12.5%)	Significant decrease in infection rate with use of vancomycin powder (P < 0.033)
Martin et al[53] (2013)	Retrospective cohort (II)	Adult posterior thoracolumbar or lumbar instrumented fusion for spinal deformity	Patients receiving 2 g vancomycin powder in surgical wound (n = 156), No vancomycin powder (n = 150)	8 infections in vancomycin powder group (5.1%), 8 infections in control (5.3%)	No significant difference in infection rate with use of vancomycin powder (P = 0.944)
Pahys et al[50] (2013)	Therapeutic retrospective cohort (II)	Posterior cervical spine surgery	Group 1: Perioperative antibiotics alone (n = 483), Group 2: addition of alcohol foam prep and drain (n = 323), Group 3: group 2 plus vancomycin powder in wound (n = 195)	9 infections in group 1 (1.86%), 1 infection in group 2 (0.3%), No infections in group 3 (0%)	Significant decrease in infections in both group 2 (P = 0.047) and group 3 (P = 0.048) compared to group 1
Strom et al[48] (2013)	Retrospective cohort (IV)	Instrumented and non-instrumented posterior lumbar laminectomy and fusion	Patients receiving 1 g vancomycin powder in surgical wound (n = 156), No vancomycin powder (n = 97)	Zero infections in vancomycin powder group (0%), 11 infections in control (11%)	Significant decrease in infection rate with use of vancomycin powder (P = 0.000018)
Strom et al[51] (2013)	Retrospective cohort (IV)	Posterior cervical fusion	Patients receiving 1 g vancomycin powder in surgical wound (n = 79), No vancomycin powder (n = 92)	2 infections in vancomycin powder group (2.5%), 10 infections in control (10.9%)	Significant decrease in infection rate with use of vancomycin powder (P = 0.0384)
Tubaki et al[52] (2013)	Prospective randomized controlled trial (II)	Any primary spine surgery excluding biopsy or minimally invasive procedure	Patients receiving 1 g vancomycin powder in surgical wound (n = 433), No vancomycin powder (n = 474)	7 infections in vancomycin powder group (1.61%), 8 infections in control (1.68%)	No significant difference in infection rate with use of vancomycin powder
Molinari et al[54] (2012)	Retrospective case series (IV)	Any spine surgery	Patients receiving 1 g vancomycin powder in surgical wound (n = 1512)	Fifteen infections identified (0.99%)	Low rate of deep spinal wound infection for both instrumented and uninstrumented cases
Sweet et al[46] (2011)	Retrospective cohort (IV)	Thoracic or lumbar posterior instrumented fusion	Patients receiving 1 g vancomycin powder in bone graft and 1 g applied directly to deep and superficial wound (n = 911), No vancomycin powder (n = 821)	Two infections in vancomycin powder group (0.2%), Twenty-one infection in control (2.6%)	Significant decrease in infection rate with use of vancomycin powder (P < 0.0001)
O’Neill et al[47] (2011)	Retrospective cohort (IV)	Instrumented posterior spine fusion for traumatic injury	Patients receiving 1 g vancomycin powder in surgical wound (n = 54), No vancomycin powder (n = 56)	Zero infections in vancomycin powder group (0%), Seven infections in control (13%)	Significant decrease in infection rate with use of vancomycin powder (P = 0.02)