Vakayil Victor, Atkinson Jeremiah, Puram Vikram, Glover James J, Harmon James V, Statz Catherine L, Polly David W, Bulander Robert E
1Department of Surgery.
2School of Public Health.
J Neurosurg Spine. 2021 Mar 5;34(5):788-798. doi: 10.3171/2020.8.SPINE201129. Print 2021 May 1.
Surgical site infection (SSI) following spine surgery is associated with increased morbidity and healthcare costs. In an effort to reduce SSI rates, the application of intrawound vancomycin powder has gained popularity. However, there is limited high-quality evidence to support the safety and efficacy of this practice. The authors sought to determine if intrawound application of vancomycin powder improves 90-day overall SSI rates.
The authors performed a retrospective, vancomycin exposure-matched cohort study at a single tertiary care hospital over 21 months. They included all patients undergoing elective spinal surgery and stratified the patients into two groups: those who received intrawound vancomycin powder application and those who received no application of vancomycin powder. The primary outcome of interest was the 90-day overall SSI rate. Secondary outcomes included rates of superficial SSI, deep SSI, wound disruption, and a post hoc analysis of the microbiology and minimum inhibitory concentrations. Baseline patient demographics, clinical presentation, comorbidities, perioperative factors, and 90-day postoperative outcomes were manually abstracted from patient charts. To mitigate bias, we performed 1:1 matching after calculating propensity scores and identified 1 patient from the no-vancomycin cohort for each patient in the vancomycin cohort.
A total of 997 patients met our inclusion criteria (473 patients receiving vancomycin and 524 patients not receiving vancomycin). Propensity score matching produced 221 matched pairs. Risk-adjusted analysis demonstrated similar overall SSI rates between the groups (OR 1.9, p = 0.329). On unadjusted analysis, the overall 90-day SSI rate was greater in the vancomycin group (n = 10 [4.5%]) than in the no-vancomycin group (n = 5 [2.3%]) (p < 0.001), as were the superficial SSI rate (7 [3.2%] vs 4 [1.8%], p < 0.001), deep SSI rate (3 [1.4%] vs 1 [0.5%], p < 0.001), and wound disruption rate (5 [2.3%] vs 1 [0.5%], p < 0.001). No cultured isolate demonstrated vancomycin resistance.
The authors observed no difference in SSI rates after the intrawound application of vancomycin powder during spine surgery. Vancomycin use did not contribute to antimicrobial resistance; however, it may select out gram-negative bacteria and increase rates of wound disruption.
脊柱手术后手术部位感染（SSI）与发病率增加及医疗费用上升相关。为降低SSI发生率，伤口内应用万古霉素粉末的做法已逐渐流行。然而，支持这种做法安全性和有效性的高质量证据有限。作者试图确定伤口内应用万古霉素粉末是否能提高90天总体SSI发生率。
作者在一家三级医疗中心进行了一项为期21个月的回顾性、万古霉素暴露匹配队列研究。纳入所有接受择期脊柱手术的患者，并将患者分为两组：接受伤口内万古霉素粉末应用的患者和未接受万古霉素粉末应用的患者。主要关注的结局是90天总体SSI发生率。次要结局包括浅表SSI、深部SSI、伤口裂开发生率，以及微生物学和最低抑菌浓度的事后分析。从患者病历中人工提取基线患者人口统计学、临床表现、合并症、围手术期因素和术后90天结局。为减轻偏倚，我们在计算倾向得分后进行1:1匹配，为万古霉素队列中的每位患者从无万古霉素队列中确定1名患者。
共有997例患者符合纳入标准（473例接受万古霉素治疗，524例未接受万古霉素治疗）。倾向得分匹配产生221对匹配病例。风险调整分析显示两组总体SSI发生率相似（OR 1.9，p = 0.329）。未经调整分析时，万古霉素组90天总体SSI发生率（n = 10 [4.5%]）高于无万古霉素组（n = 5 [2.3%]）（p < 0.001），浅表SSI发生率（7 [3.2%] 对4 [1.8%]，p < 0.001）、深部SSI发生率（3 [1.4%] 对1 [0.5%]，p < 0.001）和伤口裂开发生率（5 [2.3%] 对1 [0.5%]，p < 0.001）也是如此。培养的分离株均未显示对万古霉素耐药。
作者观察到脊柱手术期间伤口内应用万古霉素粉末后SSI发生率无差异。使用万古霉素不会导致抗菌药物耐药；然而，它可能会筛选出革兰氏阴性菌并增加伤口裂开发生率。
