SLR - March 2021 - Zach T. Laidley

Topical Vancomycin Powder Decreases the Proportion of Staphylococcus aureus Found in Culture of Surgical Site Infections in Operatively Treated Fractures

Reference: Qadir R, Costales T, Coale M, Zerhusen T Jr, Joshi M, O'Toole RV. Topical Vancomycin Powder Decreases the Proportion of Staphylococcus aureus Found in Culture of Surgical Site Infections in Operatively Treated Fractures. J Orthop Trauma. 2021 Jan 1;35(1):17-22.

Level of Evidence: 3

Scientific Literature Review

Reviewed By: Zach T. Laidley, DPM
Residency Program: Swedish Medical Center – Seattle, WA

Podiatric Relevance: Fracture related surgical site infection is a major complication that can occur in the orthopedic trauma patient. Local antibiotics in high concentrations can be an important adjunct to mitigate this complication. Research on use of vancomycin powder after orthopedic surgery has been limited on how it can change the bacterial composition of surgical site infections. 

Methods: They included all deep infections treated with surgical debridement after pelvic and extremity fracture and tibial and femoral nonunion surgeries. They defined deep surgical site infection as infection requiring operative debridement with intraoperative identification that the infection was deep to the subcutaneous layer and positive cultures obtained at the time of debridement. Closed and open fractures were treated with the same perioperative antibiotic protocol. All patients received preoperative intravenously administered cefazolin, which was continued postoperatively for 24 hours. Clindamycin was administered for penicillin-allergic patients. Penicillin was also administered for barnyard-type injuries. Within the study period, a subset of patients received vancomycin powder at the time of wound closure for their definitive fracture surgery. Vancomycin patients received 1 gram of powder applied topically to the surgical wound in contact with fracture fixation devices at the time of wound closure. In nonunion cases, vancomycin powder was mixed with bone graft and applied topically in the wound. They specifically assessed the culture results of deep infections in patients who received vancomycin powder versus those of deep infections in patients who had not received vancomycin powder. 

Results: The vancomycin powder cohort included 133 patients with 145 injuries with minimum of six months of postoperative follow-up. Ten of 133 patients who received vancomycin powder developed deep surgical site infection. The control group consisted of 175 deep infections after fracture fixation that were not treated with vancomycin powder during the same study time. The proportion of cultures positive for S. aureus was significantly lower in patients with surgical site infection who received vancomycin powder than in those who did not receive vancomycin powder (10 percent [1 of 10 patients in the treatment group] vs. 50 percent [87 of 175 patients in the control group]; P = 0.02). A trend was observed for a lower proportion of methicillin-resistant S. aureus (0 percent vs. 23 percent; P = 0.12).

Conclusions: They conclude that vancomycin powder may alter the bacteriology of surgical site infections and decrease the proportions of cultures with the most common organism in deep site surgical site infections following fracture fixation. Their findings provide support for use of vancomycin powder for prophylactic treatment of surgical site infections in the orthopedic trauma population. Future research should include larger patient populations, randomization and looking specifically at cohorts of foot and ankle surgery patients with deep space infection. 

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