Use of intraoperative vancomycin powder and its effects on the incidence of surgical site infection in orthopaedic trauma: a systematic review with meta-analysis.

Introduction: Surgical site infection (SSI) in orthopaedic trauma can have devastating consequences. The use of intraoperative powdered vancomycin is one strategy used in orthopaedic trauma surgery to reduce SSI; however, evidence and guidelines remain unclear. The aim of this systematic review is to evaluate the evidence for the use of powdered vancomycin in orthopaedic trauma surgery for the prevention of SSI.

Methods: A search was conducted across PubMed/Medline, Cochrane, and Embase databases to evaluate the use of powdered vancomycin in orthopaedic trauma surgery for the prevention of SSIs. The search used a combination of keywords and MeSH terms. Titles and abstracts were screened for inclusion criteria eligibility. Full texts were screened and included if they met eligibility criteria. A meta-analysis was completed to evaluate the effects of vancomycin in orthopaedic trauma surgery for the prevention of SSIs. Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) standards were followed.

Results: Seven studies met final inclusion criteria. Four of 7 studies found a statistically significant reduction in either surgical site/fracture-related infection or reduction in gram-positive SSIs. No studies found any effect on the rate of gram-negative infections. Meta-analysis of 7 studies demonstrated a decrease in overall SSI when powdered vancomycin was used (odds ratio = 0.49; 95% confidence interval: 0.33-0.72, P = 0.0003) and a decrease in the incidence of gram-positive SSI (odds ratio = 0.35 [95% confidence interval: 0.14-0.84], P = 0.0185).

Conclusion: Powdered vancomycin may be a safe and effective treatment option that reduces the rate of overall SSI and gram-positive SSI in orthopaedic trauma surgery patients. However, these findings are tempered by the included studies heterogeneous populations and vancomycin dosing. Further large-scale trials stratified by fracture type, gram-negative risk, and cost-effectiveness studies, along with investigations into resistance patterns, biofilm prevention strategies, and local delivery systems, are essential for refining and optimizing the use of intraoperative powdered vancomycin in orthopaedic trauma care.

Level of evidence: Level III; Therapeutic.