Intraoperative vancomycin for preventing infection after open spine surgery: a systematic review and meta-analysis of randomized controlled trials.

Objective: The use of prophylactic intrasite vancomycin powder in spine surgery has been described as a possible method for infection prevention. Despite clinical guidelines encouraging the use of intraoperative vancomycin for infection prophylaxis, the evidence in support of such recommendations remains unclear. The primary objective of this meta-analysis was to evaluate the effect of intrawound vancomycin on deep and superficial surgical site infections (SSIs) following open spine surgery.

Methods: The PubMed/MEDLINE, Embase, Scopus, and Google Scholar databases were searched from inception to October 2024 for randomized controlled trials that investigated the association between intrawound vancomycin use and infection following open spine surgery. The results were pooled using a restricted maximum-likelihood estimation random-effects model with inverse variance weighting and Hartung-Knapp adjustment to account for variation between studies.

Results: Seven randomized controlled trials with 2235 patients met the inclusion criteria. Of these, 1095 (49%) patients were randomized to receive intrawound vancomycin during open spine surgery. The overall rate of superficial and deep SSIs in the treatment group was 3.38%, compared with 4.08% in the control group. The overall rates of deep infection were 2.5% and 1.8% in the treatment and control groups, and the overall superficial infection rates were 0.9% and 1.8% in the treatment and control groups, respectively. In a random-effects model, intraoperative vancomycin was not associated with lower rates of SSI (risk ratio [RR] 0.89, 95% CI 0.47-1.67; p = 0.6; τ2 < 0.0001, I2 = 22%). In a subanalysis of patients who underwent instrumented spine surgery, vancomycin was also not significantly associated with decreased rates of SSI (RR 0.77, 95% CI 0.38-1.57; p = 0.47; τ2 = 0.2041, I2 = 33%), superficial infections (RR 0.59, 95% CI 0.22-1.57; p = 0.45; τ2 = 0, I2 = 0%), or deep infections (RR 1.37, 95% CI 0.78-2.40; τ2 = 0, I2 = 0%), nor was it associated with an increased risk of gram-negative/culture-negative infection (RR 0.99, 95% CI 0.47-2.06; τ2 = 0.107, I2 = 20%).

Conclusions: Intraoperative vancomycin may not be associated with significantly decreased rates of superficial or deep SSI in patients undergoing open spine surgery. The role of intraoperative vancomycin in open spine surgery warrants further study in larger randomized controlled trials.