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Vancomycin Powder Use in Fractures at High Risk of Surgical Site Infection

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Vancomycin Powder Use in Fractures at High Risk of Surgical Site Infection ORIGINAL ARTICLE Vancomycin Powder Use in Fractures at High Risk of Surgical Site Infection Rabah Qadir, MD,a Timothy Costales, MD,a Max Coale, BA,a Alexandra Mulliken, BS,a Timothy Zerhusen, Jr, BS,a Manjari Joshi, MBBS,b Renan C. Castillo, PhD,c Anthony R. Carlini, MS,c and Robert V. O’Toole, MDa Results: Compared with a control group of fractures treated during Objectives: To determine if the use of intrawound vancomycin the same time period without vancomycin powder, the infection rate powder reduces surgical-site infection after open reduction and with vancomycin powder was significantly lower [0% (0/35) vs. fi internal xation of bicondylar tibial plateau, tibial pilon, and 10.6% (58/548), P = 0.04]. Compared with our previously published calcaneus fractures. historical infection rate of 13% for these injuries, vancomycin pow- fi Design: Retrospective analysis. der was also associated with signi cantly decreased deep surgical- site infection (0% vs. 13%, P = 0.02). These results agreed with the Setting: Level I trauma center. matched analyses, which also showed lower infection in the vanco- mycin powder group (0% vs. 11%–16%, P # 0.05). Patients: All fractures operatively treated from January 2011 to February 2015 were reviewed; 583 high-risk fractures were included, Conclusions: Vancomycin powder may play a role in lowering of which 35 received topical vancomycin powder. A previously surgical-site infection rates after fracture fixation. A larger random- published prospectively collected cohort of 235 similar high-risk ized controlled trial is needed to validate our findings. fractures treated at our center from 2007 through 2010 served as a Key Words: vancomycin powder, deep infection, surgical-site second comparison group. infection, tibial plateau fracture, tibial pilon fracture, calcaneus frac- Intervention: Topical vancomycin powder at wound closure. ture Main Outcome Measurements: Deep surgical-site infection. Level of Evidence: Therapeutic Level III. See Instructions for Analyses used both univariate comparison of all patients and 1:2 matching Authors for a complete description of levels of evidence. analysis using both nearest neighbor and propensity-based matching. (J Orthop Trauma 2021;35:23–28) INTRODUCTION Accepted for publication June 10, 2020. Deep infection after treatment of high-energy fractures From the aDepartment of Orthopaedics, R Adams Cowley Shock Trauma is a devastating complication, with incidence reported to be as Center, University of Maryland School of Medicine, Baltimore, MD; high as 67%.1 Certain high-risk injury patterns, such as tibial bDivision of Infectious Disease, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD; and cJohns plateau, tibial pilon, and calcaneus fractures, have been re- 2–5 Hopkins Center for Injury Research and Policy, Johns Hopkins Bloomberg ported to have infection rates higher than 50%. More mod- School of Public Health, Baltimore, MD. ern series have lower values, but large prospective trials still R. Qadir and his institution received research support funding for this work report infection rates of 11%–16% for these injury patterns, from AO North America. No other outside source of funding was even with planned delayed definitive fracture treatment and obtained for this study. R. V. O’Toole is a paid consultant for CoorsTek, fi Imagen, and Smith & Nephew, receives stock options from Imagen, and modern interventions that are speci cally geared toward receives royalties from CoorsTek, unrelated to this study. He is currently decreasing infection.6,7 Prevention of surgical-site infection the Principal Investigator on Department of Defense–funded randomized after fracture fixation is paramount, considering that infec- controlled trial on the same topic. M. Joshi has received payment for tions can result in substantial morbidity, health care resource consultancy and development of educational presentations from Pfizer, – Forest, and Atox. Her institution has current grants from Atox. The re- utilization, and costs as high as $55,000 $270,000 per case in 8–10 maining authors report no conflict of interest. the United States. Presented in part at the Annual Meeting of the AAOS, March 1, 2016, Recently, intrawound application of vancomycin pow- Orlando, FL. der has been shown to be effective in decreasing post- Supplemental digital content is available for this article. Direct URL citations operative infection by multiple retrospective spine surgery appear in the printed text and are provided in the HTML and PDF 11–19 versions of this article on the journal’s Web site (www.jorthotrauma. studies and a study of surgical site infection in patients com). with diabetes undergoing foot and ankle surgery.20 In the Reprints: Robert V. O’Toole, MD, Department of Orthopaedics, R Adams setting of 1 study in spine trauma surgery, the use of intra- Cowley Shock Trauma Center, University of Maryland School of wound vancomycin powder substantially decreased infection Medicine, 22 South Greene St, T3R62, Baltimore, MD 21201 (e-mail: 18 [email protected]). rates from 13% to 0%. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. Despite the promise of this technique as shown in spine DOI: 10.1097/BOT.0000000000001863 surgery, few data exist examining the use of intrawound J Orthop Trauma Volume 35, Number 1, January 2021 www.jorthotrauma.com | 23 Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Qadir et al J Orthop Trauma Volume 35, Number 1, January 2021 vancomycin powder to reduce infection after open reduction vancomycin powder, all 35 patients were followed for at least and internal fixation of bicondylar tibial plateau, tibial pilon, 6 months and included in the study group; 23 were treated by and calcaneus fractures.21 We therefore explored whether 1 surgeon, and the remaining 12 were treated by 3 other vancomycin powder decreases the incidence of deep surgeons. In this cohort, 1 g of vancomycin powder was surgical-site infection in these high-risk operatively treated applied topically to the surgical site directly in contact with fractures. the fixation device at the time of wound closure. The powder was not typically mixed with normal saline or any other material and was applied directly as a powder at the time of PATIENTS AND METHODS wound closure. We verified patients who received vancomy- After receiving institutional review board approval of cin powder by reviewing each operative note, intraoperative the study protocol, we conducted a retrospective cohort study documentation, and pharmacy records. We were careful to of all orthopaedic trauma surgery performed at a single level I distinguish those patients from patients who received vanco- trauma center from January 2011 to February 2015. We mycin through antibiotic spacers or beads. No patients who initially screened our trauma registry for the following injury received vancomycin powder were lost to follow-up. patterns: OTA/AO type 41C tibial plateau, OTA/AO type Our primary control group consisted of the remaining 43B or 43C tibial pilon, and OTA/AO type 81A, 81B, or 81C 548 fractures that did not receive vancomycin powder during calcaneus fractures. the study time period. For further comparison, we additionally We then individually reviewed each chart to screen for used a second previously published control group that had the inclusion as an injury at high risk of sustaining a surgical-site same definition of high-risk plateau, pilon, and calcaneus infection. For the purpose of this study, we defined “high- fractures and was from the same institution (n = 235).6 That risk” fractures as fractures requiring planned surgical delay group had been treated from April 2007 to November 2010 as and staged fracture fixation because of soft-tissue concerns. part of a prospective randomized controlled trial investigating We included all closed and open injuries, including those the effect of supplemental perioperative oxygen on surgical- requiring soft-tissue coverage and/or fasciotomies for com- site infection. The data represent high-quality prospectively partment syndrome. collected data on surgical-site infection from a few years For plateau fractures, we excluded injuries not requiring before the time point of this study. Because this study is initial external fixation and planned surgical delay to allow for not a randomized trial, we used both control cohorts as esti- swelling to resolve before fixation and for those that did not mates of the baseline rate of surgical-site infection at this require fixation across both condyles. For pilon fractures, we institution. The characteristics of all 3 cohorts are presented excluded any injury that did not require initial ankle-spanning in Table 1. external fixation. For calcaneus fractures, we excluded any Our primary outcome measure was deep surgical-site injury that was amenable to early (,10 days) fixation and any infection, which we defined in keeping with the Centers for injury that could be fixed by percutaneous means not involv- Disease Control and Prevention (CDC) definition as post- ing plate fixation. operative infection requiring operative débridement with in- Patients younger than 18 years and those who did not traoperative identification that infection was deep to the have a minimum follow-up duration of 6 months were also subcutaneous layer. Superficial infections that required only excluded. Six months were chosen as the minimum follow-up antibiotic treatment or local wound therapy were not included period because the previous work has shown that 85% of in our outcome measure. We considered deep infection to be open fractures and 95% of closed fractures that presented with present regardless of the time after surgery, although the CDC infection did so within that time frame.22 Initially, 598 definition has varied over time on this issue and considered patients older than 18 years of age were eligible for the study. surgical-site infection to be either within 90 days or 1 year of Fifteen were lost before attaining the required minimum of 6 surgery depending on the version of the CDC guidelines.
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