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Published on: March 14, 2019
Does Topical Vancomycin Powder Use in Fracture Surgery Change Bacteriology and Antibiotic Susceptibilities? An
Manjari Joshi1, Robert V O'Toole2, Anthony R Carlini3
1Division of Infectious Disease, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD.
Objective:
To determine whether intrawound vancomycin changes the bacteriology of surgical site infection pathogens and investigate the emergence of antibiotic-resistant pathogens.
Design:
Secondary analysis of phase III, prospective, randomized clinical trial.
Setting:
Thirty-six US trauma centers.
Patient Selection Criteria:
Patients who became infected after fixation of tibial plateau or pilon fracture.
Outcome Measures And Comparisons:
Pathogen types and bacterial susceptibilities as determined from routine clinical culture in the operating room.
Results:
Seventy-four patients were studied who were 67.5% male with a mean age of 48.6 years. A lower proportion of gram-positive cocci was observed in the vancomycin powder compared with the standard-of-care group (3.7% vs. 8.0%, P = 0.01). Methicillin-resistant Staphylococcus aureus infection incidence was comparable in both the vancomycin powder and the standard-of-care groups, but rates of methicillin-susceptible S. aureus infections were lower in the treatment group (1.4% vs. 4.8%, P = 0.01). The incidence of coagulase-negative Staphylococci and gram-negative rod infections were similar in both groups. There was no significant difference in susceptibilities between groups in rates of vancomycin-resistant enterococcus.
Conclusions:
Topical vancomycin powder decreases the likelihood of gram-positive infections consistent with the biologic activity of vancomycin. Fewer methicillin-susceptible S. aureus and coagulase-negative Staphylococci infections were observed in the group treated with vancomycin powder. An effect of vancomycin powder on methicillin-resistant S. aureus infection risk was not detected given the low incidence in both the intrawound vancomycin and the standard-of-care groups. There was no emergence of gram-negative rod infections or increased resistance patterns observed. Use of topical vancomycin powder does not seem to produce infections in these patients with greater antibiotic resistance than would have occurred without its use.
Level Of Evidence:
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Insights
Intrawound vancomycin powder reduced gram-positive infections, including methicillin-susceptible Staphylococcus aureus, in trauma patients. This study found no increased antibiotic resistance or emergence of resistant pathogens with vancomycin use.
Area of Science:
- Orthopedic Surgery
- Infectious Disease
- Pharmacology
Background:
- Surgical site infections (SSIs) are a significant complication in orthopedic trauma surgery.
- Antibiotic prophylaxis is crucial, but the emergence of resistant pathogens is a growing concern.
- Intrawound vancomycin has been explored to reduce SSIs, particularly those caused by Gram-positive bacteria.
Purpose of the Study:
- To evaluate the impact of intrawound vancomycin powder on the bacteriology of SSIs.
- To investigate the potential emergence of antibiotic-resistant pathogens following vancomycin application.
- To analyze pathogen types and antibiotic susceptibilities in patients with SSIs after tibial plateau or pilon fracture fixation.
Main Methods:
- Secondary analysis of a prospective, randomized clinical trial involving 74 patients across 36 US trauma centers.
- Patients with SSIs after tibial plateau or pilon fracture fixation were included.
- Pathogen identification and antibiotic susceptibility testing were performed on routine clinical cultures obtained during surgery.
Main Results:
- A lower proportion of Gram-positive cocci was observed in the vancomycin powder group compared to the standard-of-care group (3.7% vs. 8.0%, P=0.01).
- Incidence of methicillin-susceptible Staphylococcus aureus infections was significantly lower in the vancomycin group (1.4% vs. 4.8%, P=0.01).
- No significant difference was found in the incidence of methicillin-resistant Staphylococcus aureus, coagulase-negative Staphylococci, gram-negative rods, or vancomycin-resistant enterococci between groups.
Conclusions:
- Intrawound vancomycin powder effectively decreases the likelihood of Gram-positive SSIs.
- The use of vancomycin powder was associated with fewer methicillin-susceptible S. aureus and coagulase-negative Staphylococci infections.
- No evidence of increased antibiotic resistance or emergence of resistant pathogens was observed with intrawound vancomycin use.
