Application Of Vancomycin Powder To Reduce Surgical Site Infection In Spinal Surgery A Meta-analysis

Objective:The surgical site infection(SSI)is a potential and devastating complication after spinal surgery.Local application of vancomycin powder is an attractive adjunctive therapy to reduce SSI in spinal surgery.It is of low cost,easy to use,has high local concentration,and less systemic adverse reactions.However,there are differences in the prophylactic programs used for various spinal surgeries.A meta-analysis is conducted to assess whether topical application of vancomycin powder could reduce SSI and deep SSI during spinal surgery and to explore the effect of dose-dependence and the method of administration in a subgroup analysis.Methods:We searched the electronic databases such as PubMed,The Cochrane Library,AMED,Web of Science,Scopus,Ovid,EMBASE,and Ebsco Medline for relevant articles with no time frame restrictions,with selection of studies published or in-press before January 2018.The language was limited to English.We used a combination of the following search terms:“topical vancomycin powder”,“local vancomycin powder”,“vancomycin powder”,“spine surgery”,“spinal surgery”,“surgical wound”,“surgical wound infection”,and“surgical site infection”.The relative risk(RR)and 95%confidence interval(CI)were computed from the rate of SSI data for each study.The contents of the statistical analysis were displayed by the forest plot.The heterogeneity tests were primarily carried out the Q statistic,P-values and I~2 statistics.Subgroup analysis was performed to determine if vancomycin powder was beneficial for reducing the SSI in spinal surgery according to the type of surgery,the site of surgery,the dosage used,and the method of administration.The quality of included studies was,respectively,evaluated by applying the Newcastle–Ottawa Scale(NOS)and Jada for retrospective studies and prospective randomized controlled trials.Publication bias was explored by funnel plot.We used the Stata/SE version 12.1 software to analyze the data.Results:A total of 21 studies involving 9480 patients were included in the final analysis which included 1 prospective randomized control trial,1 prospective multicenter observational study,and 19 retrospective studies.The treatment group with vancomycin powder treatment included 4517 patients and the control group included 4963 patients.Pooling the results from these studies demonstrated that the SSI with vancomycin powder treatment was 0.36 times higher than those SSI without vancomycin powder treatment(95%CI:0.27-0.47;P=0.000);Moreover,vancomycin powder can effectively prevent deep SSI(RR:0.28;95%CI:0.18–0.44).The analysis results showed that the combined RR of SSI in the instrumented group was 0.35(95%CI:0.25-0.49);SSI in the non-instrumented group was 0.39(95%CI:0.24-0.65,P=0.000).In the cervical region,the SSI incidence in vancomycin group was 0.15times as high as control group(95%CI:0.05-0.43).In the thoracic and lumbar regions,the SSI incidence in vancomycin group was 0.35 times as high as control group(95%CI:0.25-0.49),and this difference was also significant(P<0.001).The value of I~2 in the 1-g group was 35.5%(P=0.099),which was much lower than in the2-g group(I~2=66.7%,P=0.017).At the same time,there was high heterogeneity(52.4%,P=0.05)when vancomycin powder was directly sprinkled into all layers of the wound;the value of I~2 was 44.5%(P=0.055)when vancomycin powder was not exposed to the bone graft and instrumentation.The pseudoarthrosis treated with vancomycin powder was 0.88 times higher than the control group(95%CI:0.35–2.21),but showed no statistical significance(P=0.784).Conclusion:The application of vancomycin powder could decrease the SSI and deep SSI in spinal surgery.In the subgroup,vancomycin powder was beneficial to the SSI in the instrumented group.The administration of topical vancomycin powder would become a future topic in relation to the dose-dependent effectiveness of decreasing the incidence of surgical site infection.The available evidence was too limited to make the conclusion that the use of vancomycin powder causes pseudoarthrosis in spinal surgery,we needed to pay more attention on the length of follow-up time,and imaging evaluation of pseudoarthrosis.Further high-quality investigations should use standardized protocols to confirm these findings.