CORR Insights®: Does the Application of Topical Vancomycin Reduce Surgical Site Infections in Spine Surgery? A Meta-analysis of Randomized Controlled Trials

Where Are We Now?

Despite improvements in antimicrobial pharmacologic regimens and surgical techniques, surgical site infections (SSIs) in spinal surgery remain a scourge. Although they are not common [1], when they occur, they can be devastating. The fallout may range from the mild (high fever, nausea, or wound erythema easily treated with oral antibiotics) to the life-ending. Risk factors that are associated with progression of SSI are generally well known and include diabetes, other medical comorbidities, cigarette smoking, and chronic use of steroids [3, 4, 8]. It is natural for surgeons to want to take more aggressive approaches to try to prevent this complication.

But among the concerns associated with aggressive prophylaxis against SSI is the risk of creating antimicrobial-resistant pathogens. Topical vancomycin is a treatment that surgeons often choose as part of a more aggressive prevention approach, and it’s a good example of one that should cause us to think carefully in terms of the risks of generating antimicrobial resistance. Moreover, controversy exists regarding its effectiveness, utilization, safety profile, and even regulatory concerns. As a result, there are legitimate concerns about whether the risks of topical vancomycin outweigh the benefits. In addition, there have been conflicting studies reporting on its use and effectiveness, which only makes the matter more difficult. For that reason, a meta-analysis of the best-available evidence on this topic would be especially helpful.

In this month’s issue of Clinical Orthopaedics and Related Research®, Daher et al. [2] conducted a meta-analysis of randomized controlled trials (RCTs) to explore the efficacy of topical vancomycin for preventing surgical infection after spinal surgery. Based on prespecified inclusion and exclusion criteria, the authors analyzed six RCTs (which included a total of 2140 patients). They found no benefit in terms of reduced overall SSI risk between the vancomycin and the control groups (3.0% [32 of 1053] versus 3.9% [42 of 1087], respectively; relative risk 0.74 [95% CI 0.35 to 1.57]; p = 0.43). Likewise, in terms of deep SSI, there was no difference in risk between the vancomycin and control groups (1.8% [15 of 812] versus 2.7% [23 of 860], respectively; relative risk 0.69 [95% CI 0.24 to 2.00]; p = 0.50) nor in terms of superficial SSI (1.0% [6 of 620] versus 1.4% [9 of 662], respectively; relative risk 0.68 [95% CI 0.25 to 1.89]; p = 0.46). Given their results, the authors advised avoidance of the routine use of topical vancomycin for spine surgery, and I stand in agreement with them on this.

Where Do We Need To Go?

A major concern of complications from postsurgical infection is that they place a heavy burden not only on the patient and surgeon, but also on the patients’ family and other healthcare personal. As mentioned, the emergence of multidrug resistance can make recovery more difficult [5]. It would be interesting if future studies would explore different regimen modalities that would be best suited for microbial prevention and its alternatives in situations where contraindications are present (for example, pregnancy, drug allergies, and drug-drug interaction).

Further studies are needed to determine the effectiveness of topical vancomycin not only in the setting of spine surgery but also, potentially, for patients having major surgery who have the risk factors that I mentioned earlier. In addition, larger studies—perhaps from insurance or national registries—might help us determine whether usage of topical vancomycin is associated with risks, including the increased emergence of antimicrobial resistance.

How Do We Get There?

While we might be interested in determining whether topical vancomycin is useful as a preventative measure in patients undergoing spinal surgery who have particular risk factors for infection, randomized trials on this topic face two challenges: (1) identifying which patient groups might most benefit and (2) accruing large enough numbers of patients with those specific risk factors on whom to run an adequately powered RCT. Because prior studies have been inconsistent in reporting on the effectiveness and use of topical vancomycin, cohort studies that look into different subgroups and populations that might benefit from this regimen are needed. They are less resource intensive than RCTs, and so they make sense as a next step in this direction. In terms of the second challenge, it’s clear that multicenter collaboration will be required.

Read This Next

• This review article presents a comprehensive overview of the concept of SSI [6].

• This systematic review addresses the measures that can be taken for the prevention of SSI before, during, and after surgery [1].

• This study demonstrates the effects that SSIs have in areas of orthopaedics other than spine surgery [6, 7].