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Intraoperative Vancomycin Use in Spinal Surgery: Single Institution Experience and Microbial Trends

Ghobrial, George M. MD*; Thakkar, Vismay MD*; Andrews, Edward BS*; Lang, Michael MD*; Chitale, Ameet MD*; Oppenlander, Mark E. MD*,†; Maulucci, Christopher M. MD*; Sharan, Ashwini D. MD*; Heller, Joshua MD*; Harrop, James S. MD*; Jallo, Jack MD*; Prasad, Srinivas MD*

doi: 10.1097/BRS.0000000000000241
Clinical Case Series
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Study Design. Retrospective case series.

Objective. To demonstrate the microbial trends of spinal surgical site infections in patients who had previously received crystallized vancomycin in the operative bed.

Summary of Background Data. Prior large, case control series demonstrate the significant decrease in surgical site infection with the administration of vancomycin in the wound bed.

Methods. A single institution, electronic database search was conducted for all patients who underwent spinal surgery who had received prophylactic crystalline vancomycin powder in the wound bed. Patients with a prior history of wound infection, intrathecal pumps, or spinal stimulators were excluded.

Results. A total of 981 consecutive patients (494 males, 487 females; mean age, 59.4 yr; range, 16–95 yr) were identified from January 2011 to June 2013. The average dose of vancomycin powder was 1.13 g (range, 1–6 g). Sixty-six patients (6.71%) were diagnosed with a surgical site infection, of which 51 patients had positive wound cultures (5.2%). Of the 51 positive cultures, the most common organism was Staphylococcus aureus. The average dose of vancomycin was 1.3 g in the 38 cases where a gram-positive organism was cultured. A number of gram-negative infections were encountered such as Serratia marcescens, Enterobacter aerogenes, Bacteroides fragilis, Enterobacter cloacae, Citrobacter koseri, and Pseudomonas aeruginosa. The average dose of vancomycin was 1.2 g in 23 cases where a gram-negative infection was cultured. Fifteen of the 51 positive cultures (29.4%) were polymicrobial. Eight (53%) of these 15 polymicrobial cultures contained 3 or more distinct organisms.

Conclusion. Prophylactic intraoperative vancomycin use in the wound bed in spinal surgery may increase the incidence of gram-negative or polymicrobial spinal infections. The use of intraoperative vancomycin may correlate with postoperative seromas, due to the high incidence of nonpositive cultures. Large, randomized, prospective trials are needed to demonstrate causation and dose-response relationship.

Level of Evidence: 4

A total of 981 patients receiving intraoperative vancomycin were retrospectively reviewed, with 51 patients having positive cultures (5.2%). Many of these were infections were gram-negative and polymicrobial infections, giving credence to the concern that intraoperative vancomycin powder has a significant impact on microbial trends.

*Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA; and

Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ.

Address correspondence and reprint requests to Srinivas Prasad, MD, Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA; E-mail: Srinivas.prasad@jefferson.edu

Acknowledgment date: September 10, 2013. First revision date: December 16, 2013. Acceptance date: January 15, 2014.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

No relevant financial activities outside the submitted work.

© 2014 by Lippincott Williams & Wilkins