title: Does Intrawound Vancomycin Application During Spine Surgery Create Vancomycin-Resistant Organism?
abstract: BACKGROUND
  Surgical site infection (SSI) following spine surgery is a morbid and expensive complication. The use of intrawound vancomycin is emerging as a solution to reduce SSI. The development of vancomycin-resistant pathogens is an understandable concern.
  
  
  OBJECTIVE
  To determine the occurrence of vancomycin-resistant SSI in patients with and without use of intrawound vancomycin.
  
  
  METHODS
  Patients undergoing elective spine surgery were dichotomized based on whether intrawound vancomycin was applied. Outcome was occurrence of SSI requiring return to the operating room within postoperative 90 days. The intrawound culture and vancomycin minimal inhibitory concentrations (MIC) were reviewed. Analyses were conducted to compare the pathogen profile and MIC for vancomycin in patients who received vancomycin and those who did not.
  
  
  RESULTS
  Of the total 2802 patients, 43% (n = 1215) had intrawound vancomycin application during the index surgery. The use of vancomycin was associated with significantly lower deep SSI rates (1.6% [n = 20] vs 2.5% [n = 40], P = .02). The occurrence of Staphylococcus aureus SSI was significantly lower in the patients who had application of intrawound vancomycin (32% vs 65%, P = .003). None of the patients who had application of intrawound vancomycin powder, and subsequently developed an S aureus SSI, demonstrated pathogens with resistance to vancomycin. All patients had MIC < 2 μg/mL, the vancomycin susceptibility threshold. The occurrence of gram-negative SSI (28% vs 7%) and culture negative fluid collection (16% vs 5%) was higher in the vancomycin cohort.
  
  
  CONCLUSIONS
  The use of intrawound vancomycin during the index spine surgery was protective against SSI following spine surgery. The application of intrawound vancomycin during index surgery does not appear to create vancomycin-resistant organisms in the event of an SSI.
authors.affiliation: Department of Orthopedics Surgery and Department of Neurological surgery, Vanderbilt University Medical Center, Nas-hville, Tennessee.
authors.forename: Silky
authors.initials: S
authors.lastname: Chotai
authors.affiliation: Division of Infections Disease, Department of Medicine, Vande-rbilt University Medical Center, Nashville, Tennessee.
authors.forename: Patty W
authors.initials: PW
authors.lastname: Wright
authors.affiliation: Department of Orthopedics Surgery and Department of Neurological surgery, Vanderbilt University Medical Center, Nas-hville, Tennessee.
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Hale
authors.affiliation: Division of Infections Disease, Department of Medicine, Vande-rbilt University Medical Center, Nashville, Tennessee.
authors.forename: Whitney A
authors.initials: WA
authors.lastname: Jones
authors.affiliation: Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: McGirt
authors.affiliation: Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina.
authors.forename: Joshua C
authors.initials: JC
authors.lastname: Patt
authors.affiliation: Department of Orthopedics Surgery and Department of Neurological surgery, Vanderbilt University Medical Center, Nas-hville, Tennessee.
authors.forename: Clinton J
authors.initials: CJ
authors.lastname: Devin
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000009:adverse effects; D019072:Antibiotic Prophylaxis / Q000009:adverse effects; D017558:Elective Surgical Procedures / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D013122:Spinal Diseases / Q000175:diagnosis / Q000601:surgery*; D013203:Staphylococcal Infections / Q000175:diagnosis / Q000188:drug therapy; D013211:Staphylococcus aureus / Q000187:drug effects / Q000302:isolation & purification; D013530:Surgical Wound Infection / Q000175:diagnosis / Q000188:drug therapy*; D014640:Vancomycin / Q000008:administration & dosage* / Q000009:adverse effects; D020713:Vancomycin Resistance / Q000187:drug effects* / Q000502:physiology
chemical_list: D000900:Anti-Bacterial Agents; D014640:Vancomycin
keywords: Intrawound; MIC; Resistance; SSI; Spine; Surgical site infection; Vancomycin