Effect of Intra-wound Vancomycin for Spinal Surgery: A Systematic Review and Meta-analysis

Abstract

Intra-site prophylactic vancomycin in spine surgery is an effective method of decreasing the incidence of postsurgical wound infection. However, there are differences in the prophylactic programs used for various spinal surgeries. Thus, this systematic review and meta-analysis aimed to evaluate the effectiveness of using intra-wound vancomycin during spinal surgery and to explore the effects of dose-dependence and the method of administration in a subgroup analysis. A total of 628 citations or studies were searched in PubMed, Ovid, Web of Science, and Google Scholar that were published before August 2016 with the terms "local vancomycin", "intra-wound vancomycin", "intraoperative vancomycin", "intra-site vancomycin", "topical vancomycin", "spine surgery", and "spinal surgery". Finally, 19 retrospective cohort studies and one prospective case study were eligible for inclusion in the systematic review and meta-analysis. The odds of developing postsurgical wound infection without prophylactic local vancomycin use were 2.83-fold higher than the odds of experiencing wound infection with the use of intra-wound vancomycin (95% confidence interval, 2.03-3.95; P = 0.083; I2 = 32.2%). The subgroup analysis including the dosage and the method of administration, revealed different results compared to previous research. The value of I2 in the 1-g group was 27.2%, which was much lower than in the 2-g group (I2 = 57.6%). At the same time, the value of I2 was 0.0% (P = 0.792, OR = 2.70) when vancomycin powder was directly sprinkled into all layers of the wound. However, there is high heterogenicity (I2 = 60.0%, P = 0.007, OR = 2.83) when vancomycin powder is not exposed to the bone graft and instrumentation. There are differences found with the method of local application of vancomycin for reducing postoperative wounds and further studies are necessary, including investigations focusing on the dose-dependent effects during spinal or the topical pharmacokinetic and other orthopaedic surgeries.

Keywords: Dose-dependent effects; Intra-wound vancomycin; Method of administration; Spinal surgery; Wound infection.

© 2017 Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.

Figures

Figure 1

Flow chart of study selection in this systematic review and meta‐analysis.

Figure 2

The Forest graph of the total included studies. This figure reveals the rate of postoperative wound infection in spine surgery for total included studies. The pooled odds ratio (OR) was 2.83 (95% CI: 2.03–3.95), I 2 = 32.2%, P = 0.083.

Figure 3

The subgroup analysis of the dosage of vancomycin powder used. The value of I 2 in the 1‐g group is 27.2%, which is much lower than for the 2‐g group (I 2 = 57.6%). The total I 2 = 35.5%, P = 0.079. CI, confidence interval; OR, odds ratio.

Figure 4

The subgroup analysis of the method of vancomycin powder administration. Method of administration: A, vancomycin was directly sprinkled into all layers of the wound (I 2 = 0.0%, P = 0.792, OR = 2.70). Method of administration B, vancomycin was directly sprinkled into the muscle, fascia, and subcutaneous layers, but the bone graft and instrumentation were not exposed to it (I 2 = 60.0%, P = 0.007, OR = 2.83).

Figure 5

Funnel plot diagram of the total included studies. This funnel plot diagram indicates that the bias was primarily attributed to many studies having small sample sizes, and negative results of the articles without publishing in the databases may become another factor.