, Volume 102, Issue 1, pp 35–39 | Cite as

Intrawound application of vancomycin changes the responsible germ in elective spine surgery without significant effect on the rate of infection: a randomized prospective study

  • B. Mirzashahi
  • M. Chehrassan
  • S. M. J. Mortazavi
Original Article



Surgical site infection (SSI) is a costly complication associated with spine surgery. The impact of intrawound vancomycin has not been strongly postulated to decrease the risk of surgical site infection. We designed study to determine whether intrawound vancomycin application reduces the risk of SSI in patients after spine surgery.


A prospective randomized control trial study to evaluate the patients with elective spine surgery in a period of 15 month was designed. Patients were divided into two groups based on whether intrawound vancomycin was applied or not. The relative risk of SSI within postoperative 30 days was evaluated.


Three hundred and eighty patients were included in this study: degenerative spine pathologies and tumor 80% (304), trauma 11% (42) and deformity 9% (34). Intrawound vancomycin was used in 51% of patients. Prevalence of SSI was 2.7% in the absence of vancomycin use versus 5.2% with intrawound vancomycin. In multivariable regression model, those with higher number of levels exposed, postoperative ICU admission and obesity and use of instrumentation more than two levels had higher risk of developing SSI. In the treatment group Acinetobacter and Pseudomonas aeruginosa (20%) were the most common pathogens. In control group, Staphylococcus aureus and Acinetobacter (40%) were the most common organisms.


Intrawound application of vancomycin after elective spine surgery was not associated with reduced risk of SSI and return to OR associated with SSI in our patients. However, the use of intrawound vancomycin changed the responsible infection germ.


Spine infection Intrawound vancomycin Elective spine surgery 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Levi AD, Dickman CA, Sonntag VK (1997) Management of postoperative infections after spinal instrumentation. J Neurosurg 86(6):975–980CrossRefPubMedGoogle Scholar
  2. 2.
    Rechtine GR et al (2001) Postoperative wound infection after instrumentation of thoracic and lumbar fractures. J Orthop Trauma 15(8):566–569CrossRefPubMedGoogle Scholar
  3. 3.
    Kirkland KB et al (1999) The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 20(11):725–730CrossRefPubMedGoogle Scholar
  4. 4.
    Picknell B, Mizen L, Sutherland R (1977) Antibacterial activity of antibiotics in acrylic bone cement. Bone Jt J 59(3):302–307CrossRefGoogle Scholar
  5. 5.
    Poelstra K, Vaccaro A, Albert T (2007) Gentamicin microspheres for infection prophylaxis in the rabbit spine. In: 53rd Orthopaedic Research Society (ORS) meeting, San Diego, CA, p 10–14Google Scholar
  6. 6.
    Dennis H et al (2016) Is intraoperative local vancomycin powder the answer to surgical site infections in spine surgery? Spine 42:267–274Google Scholar
  7. 7.
    Gaviola ML et al (2016) A retrospective study on the protective effects of topical vancomycin in patients undergoing multilevel spinal fusion. Pharmacother: J Hum Pharmacol Drug Ther 36(1):19–25CrossRefGoogle Scholar
  8. 8.
    Devin CJ, et al (2015) Intrawound vancomycin decreases the risk of surgical site infection after posterior spine surgery-A multicenter analysis. Spine. doi: 10.1097/BRS.0000000000001371 Google Scholar
  9. 9.
    De la Garza-Ramos R et al (2016) Provider volume and short-term outcomes following surgery for spinal metastases. J Clin Neurosci 24:43–46CrossRefPubMedGoogle Scholar
  10. 10.
    Kang DG et al (2015) Intrasite vancomycin powder for the prevention of surgical site infection in spine surgery: a systematic literature review. Spine J 15(4):762–770CrossRefPubMedGoogle Scholar
  11. 11.
    Godil SS et al (2013) Comparative effectiveness and cost-benefit analysis of local application of vancomycin powder in posterior spinal fusion for spine trauma: clinical article. J Neurosurg: Spine 19(3):331–335Google Scholar
  12. 12.
    Bakhsheshian J et al (2015) The use of vancomycin powder in modern spine surgery: systematic review and meta-analysis of the clinical evidence. World Neurosurg 83(5):816–823CrossRefPubMedGoogle Scholar
  13. 13.
    O’Neill KR et al (2011) Reduced surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powder. Spine J 11(7):641–646CrossRefPubMedGoogle Scholar
  14. 14.
    Evaniew N et al (2015) Intrawound vancomycin to prevent infections after spine surgery: a systematic review and meta-analysis. Eur Spine J 24(3):533–542CrossRefPubMedGoogle Scholar
  15. 15.
    Caroom C et al (2013) Intrawound vancomycin powder reduces surgical site infections in posterior cervical fusion. Spine 38(14):1183–1187CrossRefPubMedGoogle Scholar
  16. 16.
    Ehlers AP et al (2016) Intra-wound antibiotics and infection in spine fusion surgery: a report from Washington state’s SCOAP-CERTAIN collaborative. Surg Infect 17(2):179–186CrossRefGoogle Scholar
  17. 17.
    Watters W 3rd et al (2009) North American Spine Society: antibiotic prophylaxis in spine surgery: an evidence-based clinical guideline for the use of prophylactic antibiotics in spine surgery. Spine J 9(2):142–146CrossRefPubMedGoogle Scholar
  18. 18.
    Bratzler DW et al (2013) Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm 70(3):195–283CrossRefPubMedGoogle Scholar
  19. 19.
    Centers for Medicare and Medicaid Services (2007) Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 2008 rates. Fed Regist 72(162):47129Google Scholar
  20. 20.
    Kim HS et al (2013) Prophylactic intrawound application of vancomycin powder in instrumented spinal fusion surgery. Korean J Spine 10(3):121–125CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Strom RG et al (2013) Lumbar laminectomy and fusion with routine local application of vancomycin powder: decreased infection rate in instrumented and non-instrumented cases. Clin Neurol Neurosurg 115(9):1766–1769CrossRefPubMedGoogle Scholar
  22. 22.
    Vitale MG et al (2013) Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery. J Pediatr Orthop 33(5):471–478CrossRefPubMedGoogle Scholar
  23. 23.
    Glotzbecker MP et al (2013) Surgeon practices regarding infection prevention for pediatric spinal surgery. J Pediatr Orthop 33(7):694–699CrossRefPubMedGoogle Scholar
  24. 24.
    Gans I et al (2013) Adjunctive vancomycin powder in pediatric spine surgery is safe. Spine 38(19):1703–1707CrossRefPubMedGoogle Scholar
  25. 25.
    Bull AL, Worth LJ, Richards MJ (2012) Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive Staphylococcus aureus surgical site infections: report from Australian Surveillance Data (VICNISS). Ann Surg 256(6):1089–1092CrossRefPubMedGoogle Scholar
  26. 26.
    Khan NR et al (2014) A meta-analysis of spinal surgical site infection and vancomycin powder: a review. J Neurosurg: Spine 21(6):974–983Google Scholar
  27. 27.
    Anderson DJ, Kaye KS (2009) Staphylococcal surgical site infections. Infect Dis Clin N Am 23(1):53–72CrossRefGoogle Scholar
  28. 28.
    Armaghani SJ et al (2014) Safety of topical vancomycin for pediatric spinal deformity: nontoxic serum levels with supratherapeutic drain levels. Spine 39(20):1683–1687CrossRefPubMedGoogle Scholar
  29. 29.
    Bormann N et al (2014) Analysis of parameters influencing the release of antibiotics mixed with bone grafting material using a reliable mixing procedure. Bone 59:162–172CrossRefPubMedGoogle Scholar
  30. 30.
    Emohare O et al (2014) Cost savings analysis of intrawound vancomycin powder in posterior spinal surgery. Spine J 14(11):2710–2715CrossRefPubMedGoogle Scholar
  31. 31.
    Ghobrial GM et al (2015) Complications from the use of intrawound vancomycin in lumbar spinal surgery: a systematic review. Neurosurg Focus 39(4):E11CrossRefPubMedGoogle Scholar
  32. 32.
    Takahashi H et al (2009) Antimicrobial prophylaxis for spinal surgery. J Orthop Sci 14(1):40–44CrossRefPubMedGoogle Scholar
  33. 33.
    Finkelstein R et al (2002) Vancomycin versus cefazolin prophylaxis for cardiac surgery in the setting of a high prevalence of methicillin-resistant staphylococcal infections. J Thorac Cardiovasc Surg 123(2):326–332CrossRefPubMedGoogle Scholar
  34. 34.
    Moise PA et al (2008) Microbiological effects of prior vancomycin use in patients with methicillin-resistant Staphylococcus aureus bacteraemia. J Antimicrob Chemother 61(1):85–90CrossRefPubMedGoogle Scholar
  35. 35.
    Gibson M et al (1987) The penetration of antibiotics into the normal intervertebral disc. Bone Jt J 69(5):784–786CrossRefGoogle Scholar
  36. 36.
    Rhoten RP et al (1995) Antibiotic penetration into cervical discs. Neurosurgery 37(3):418–421CrossRefPubMedGoogle Scholar
  37. 37.
    Sweet FA, Roh M, Sliva C (2011) Intrawound application of vancomycin for prophylaxis in instrumented thoracolumbar fusions: efficacy, drug levels, and patient outcomes. Spine 36(24):2084–2088CrossRefPubMedGoogle Scholar
  38. 38.
    Molinari WJ, Khera O, Molinari RW (2011) Prophylactic operative site powdered vancomycin and postoperative deep spinal wound infection: 1,512 consecutive surgical cases during a six-year period: PAPER# 37. In: Spine journal meeting abstracts, LWWGoogle Scholar
  39. 39.
    Tubaki VR, Rajasekaran S, Shetty AP (2013) Effects of using intravenous antibiotic only versus local intrawound vancomycin antibiotic powder application in addition to intravenous antibiotics on postoperative infection in spine surgery in 907 patients. Spine 38(25):2149–2155CrossRefPubMedGoogle Scholar
  40. 40.
    Martin JR et al (2015) Experience with intrawound vancomycin powder for posterior cervical fusion surgery. J Neurosurg: Spine 22(1):26–33Google Scholar

Copyright information

© Istituto Ortopedico Rizzoli 2017

Authors and Affiliations

  1. 1.Orthopedic Department of Imam HospitalTehran University of Medical SciencesTehranIran
  2. 2.Rizzoli Orthopaedic InstituteBolognaItaly
  3. 3.Joint Reconstruction Research Center (JRRC), Orthopedic Department of Imam HospitalTehran University of Medical SciencesTehranIran

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