SLR - June 2019 - Katie Pettibone

Intrasite Antibiotic Powder for the Prevention of Surgical Site Infection in Extremity Surgery: A Systematic Review

Reference: Fernicola SD1, Elsenbeck MJ, Grimm PD, Pisano AJ, Wagner SC. Intrasite Antibiotic Powder for the Prevention of Surgical Site Infection in Extremity Surgery: A Systematic Review. J Am Acad Orthop Surg. 2019 Apr 16. doi: 10.5435/JAAOS-D-18-00475.

Scientific Literature Review

Reviewed By: Katie Pettibone, DPM
Residency Program: Kaiser Permanente Vallejo, North Bay Consortium, Vallejo, CA

Podiatric Relevance: Surgical site infections are of great concern in podiatric surgery, and surgeons should make every reasonable evidence-based effort to minimize postoperative infection rates. Surgical site infections resulting in revision surgeries and prolonged antibiotics are costly and detrimental to patients. This systematic review analyzes the use of intrasite antibiotic powder, for example, lyophilized vancomycin powder, to reduce surgical site infection in lower-extremity surgeries.  

Methods: A systematic review of studies involving vancomycin powder and local antibiotic usage in orthopaedic extremity and pelvic surgery was conducted. The electronic search ultimately yielded 11 retrospective studies, and all studies were level III evidence. Studies involving the use of antibiotic cement, beads and spacers were excluded. Most of the included studies involve the lower extremity, and surgeries included foot and ankle surgery in patients living with diabetes, lower-extremity amputations and open fractures among others. The antibiotic powders studied included vancomycin, tobramycin and gentamicin. The authors examined each study design and noted infection rates, quantity of antibiotic powder used, type of surgery and postoperative complications.  

Results: Eight of the 11 studies demonstrated a statistically significant decrease in surgical site infection rate with the use of local antibiotic powder. One study examined the use of vancomycin in diabetic foot and ankle procedures and demonstrated a statistically significant decrease in overall infection rate of 73 percent using 0.5–1g of antibiotic powder administered to deep and subcutaneous tissues. Of note, one study examined the use of tobramycin and gentamicin for open fractures in patients with known systemic infection or delayed time to surgery and found local antibiotics significantly decreased infection rates while having no effect on nonunion rates. One periprosthetic joint infection study demonstrated a decreased infection rate with use of antibiotic powder but an increase in wound complications. The authors draw attention to the fact that the infecting organisms in open fractures versus elective surgeries differ greatly, and thus, these categories should be considered separately.  

Conclusions: This systematic review indicates that not many studies are available that examine the use of local antibiotic powder in lower-extremity surgery. The studies included in the review are all level III evidence. The majority demonstrated a statistically significant decrease in surgical site infection rates and a few studies demonstrated good union rates in the setting of ORIF and open fracture surgery. Vancomycin was previously shown to be less cytotoxic to osteoblasts. Concern regarding wound complications in the setting of antibiotic powder utilization was identified by one study but not thoroughly explored by the remainder. This review encompassed a wide variety of elective and traumatic lower-extremity surgeries in a range of patients. Thus, there is much need for focused and larger prospective studies. 

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