1. SHEA 2019: Controversy in SSI Prevention
Does Vancomycin powder belong in the incision?
Presented by:
Jerrie Hammons, RN, CIC
Infection Preventionist, St. Luke’s
6/12/19

2. “That doesn’t look right, does it
“That doesn’t look right, does it? Let’s pour some Vanco powder in there and stitch him up. That’ll take care of it.”

3. Conundrums in Surgical Antibiotic Prophylaxis Tom Talbot, MD, MPH

4. Should we put Vanco powder into the incision?
Yes! It is effective in reducing spine SSIs.
Yes. It does not impact gram negative SSIs.
No! The appropriate dose is not known.
No. The only data we have is for spine surgery.
No. The data shows an increase in wound dehiscence
No. It increases the MIC level in patients.
No. The pH of Vanco is about 3; it may inhibit healing.
No. Surgeons at Vanderbilt tried it and then stopped.

5. systematic review includes 21 studies with control groups
Vancomycin powder significantly reduced the relative risk of developing an SSI (RR 0.55, 95% CI , p < )
the use of vancomycin powder did not significantly increase the risk of infection by gram-negative pathogens (RR 1.11, 95% CI , p = 0.701)
further studies are required to investigate whether rates of infection due to gram-negative pathogens are affected by the use of vancomycin powder

6. Behind closed doors: Controversies in surgical site infection prevention
Ms. Yokoe said, “All conclusions reflect my personal opinions. Some of my most trusted friends and advisors are surgeons.”

7. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update (Compendium) Approaches that should not be considered a routine part of SSI prevention:
Do not routinely use vancomycin for antimicrobial prophylaxis (quality of evidence: II).75,76,155
Vancomycin should not routinely be used for antimicrobial prophylaxis, but it can be an appropriate agent for specific scenarios.
Reserve vancomycin for specific clinical circumstances
Anderson D., et al; Infect Control Hosp Epidemiol Jun; 35(6): 605–627

8. CDC Guideline for the Prevention of Surgical Site Infection, 2017
Published: JAMA Surg. 2017;152(8): doi: /jamasurg
2B.1. Do not apply antimicrobial agents (ie, ointments, solutions, or powders) to the surgical incision for the prevention of SSI. (Category IB–strong recommendation; low-quality evidence.)

9. Topical vancomycin powder/paste
Does it work?
Spinal surgery: Many retrospective before-after studies showing reductions in SSI rates. Many studies had very high SSI rates (>10%) pre-intervention. One prospective RCT (907 spinal surgery procedures) had OR 0.96 (no difference).
Other ortho surgery: Single retrospective studies of THA, foot/ankle, and elbow surgeries suggest benefit; very limited data.

10. Topical vancomycin powder/paste
Does it work?
Cardiac surgery: Small single center RCT 1989 compared vancomycin thrombin-powdered gelatin paste vs. thrombin-powdered gelatin paste and found significantly lower SSI rates. Single center observational study from 2017 showed no significant difference in multivariate analysis.
Xie L, et al. Orth Surg 2017;9:350; Tubaki VR, et al. Spine 2013;8: 2149; Vander Salm TJ, et al. J Thorac Cardiovasc Surg 1989;98:619; Lander HL, et al. Ann Thorac Surg 2017;103:497; Fleischman AN, et al. J Bone Jt Infect 2017;2:23

11. Topical vancomycin powder/paste
Does it harm?
Case reports suggesting potential for systemic absorption leading to adverse events (renal insufficiency, hearing loss, circulatory collapse)
Theoretical risk of encouraging emergence of vancomycin resistance
Variable practices used to prepare and administer

12. Topical vancomycin powder/paste
The evidence says…

13. Topical vancomycin powder/paste
Conclusion

14. Guidance for IPs
2017 HICPAC Guidelines

15. Published in Prevention strategist, Fall 2017

16. 2017 HICPAC-CDC Guideline for Prevention of Surgical Site Infection: What the infection preventionist needs to know
Consider incorporating the following into your regular practice:
Round regularly in the operating room. Observation provides an excellent opportunity for assessing staff adherence to best practice.
Plan what you want to accomplish before you start; round with a purpose and define your goals in advance.
Provide regular and constructive feedback on your observations. Share this information with perioperative and surgical leaders and encourage them to join you in any future rounds.

17. 2017 HICPAC-CDC Guideline for Prevention of Surgical Site Infection: What the infection preventionist needs to know
Consider incorporating the following into your regular practice:
Use rounds as an opportunity to collaborate and educate. Reinforce best practices, whether these are the updated recommendations or those that have not changed.
Where there are those who do not feel that the evidence is sufficient or where there are “nonbelievers,” arrange smaller meetings to review the evidence and attempt to find common ground.
Be aware of guidelines from other societies (e.g., surgical specialty guidelines) and how they may support or be different from infection prevention guidelines.

18. Questions?

19. Articles

20. Results. The overall rate of SSI was 4
Results. The overall rate of SSI was 4.7% with a decrease in infection rate found in the treatment group (0.9% vs. 6.3%). This was statistically significant (P¼0.049) with an odds ratio of 0.13 (95% confidence interval 0.02–0.99). The treatment group had a significantly shorter onset of infection (5 vs days;
P<0.001) and shorter duration of infection (8.5 vs days; P<0.001). The most common causative organism was Pseudomonas aeruginosa (35.2%). Patient diagnosis, surgical approach, and intraoperative blood loss were significant risk factors for SSI after multivariable analysis.

21. RESULTS: 5,909 procedures performed; 115 SSIs identified, resulting in a 1.9% infection rate. Prophylactic vancomycin powder was used in the index procedure for 42 of those cases. 23.8% of cultures in the vancomycin group were polymicrobial and 16.7% were gram-negative compared with 9.6% (p=0.039) and 4.1% (p=0.021) in the untreated group, respectively. In the vancomycin-treated group, 26.1% of patients underwent repeat irrigation and debridement compared with 38.4% in the untreated group (p=0.184). The percentage of patients in the treatment and untreated group who required more than 1 antibiotic was 26.0% and 26.1%, respectively (p=0.984). Mean LOS in the treatment group was 8.0 versus 7.9 for the untreated group (p=0.945)

22. RESULTS: A total of 1200 consecutive spine operations were performed for deformity between 2011 and Review of records demonstrated 34 cases of SSI, an SSI rate of 2.83%. The patients' mean age (± SD) was ± years; mean body mass index was ± 7.15 kg/m2 and 29.41% had history of diabetes. The average dose of vancomycin powder was 1.41 ± 2.77 g (range 1-7 g). Subfascial drains were placed in 88% of patients. All SSIs occurred within 30 days of surgery, with deep wound infections accounting for 50%. In 74% of the SSIs cultures were positive, with about half the organisms being gram negative, such as Citrobacter freundii, Proteus mirabilis, Morganella morgani, and Pseudomonas aeruginosa. There were no adverse clinical outcomes related to the local application of vancomycin.