Topical Vancomycin during Cardiac Surgery
Date First Published:
August 20, 2002
Last Updated:
May 6, 2003
Report by:
Joel Desmond, Research Fellow (Manchester Royal Infirmary)
Search checked by:
Tom Barker, Manchester Royal Infirmary
Three-Part Question:
In [patients undergoing cardiac surgery] does the [topical application of Vancomycin to the sternotomy wound] reduce [incidence of mediastinitis]?
Clinical Scenario:
While closing a 59 year old lady after elective mitral valve replacement, the theatre nurse hands you 500mg of vancomycin powder to apply to the sternotomy wound prior to closure. You have just completed a BET relating to resistant bacteria in surgical patients and you question whether there is any benefit to this method in addition to intravenous antibiotics.
Search Strategy:
Medline 1966-07/02 using the OVID interface.
Search Details:
[cardiac surgical procedures.mp OR Thoracic surgery.mp OR Coronary artery Bypass.mp OR Cardiopulmonary Bypass.mp OR Thoracic Surgical Procedures.mp OR Cardiovascular Surgical Procedures.mp] AND [Vancomycin.mp] OR [(mediastinitis.mp OR "sternal wound".mp OR "sternal infection".mp) AND Vancomycin.mp]
Outcome:
Out of 98 papers only one was found to be relevant. This paper is shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Reduction of sternal infection by application of topical vancomycin. Vander Salm TJ, Okike ON, Pasque MK, Pezzella AT, Lew R, Traina V et al. 1989, USA | 416 patients undergoing cardiac operations. All patients received prophylactic iv Cefazolin for 36 hrs (or iv vancomycin if allergies present – 42). 223 patients had 1g of topical vancomycin applied to the sternal edges with a haemostatic paste of thrombin and powdered absorbable gelatin. 193 patients had the haemostatic paste alone. All patients also had 2 days of prophylactic intravenous antibiotics. |
PRCT. Single blinded | Sternal infection (superficial wound infections not included). | Vancomycin group:1 out of 223 sternal infections(0.45%). Control group :7 out of 193 sternal infections(3.6%). P=0.013 | Flawed randomisation (odd/even hospital numbers) |
| Other factors that may cause sternal infection | Operative time was also correlated with sternal infection (P=0.014) |
Author Commentary:
Only 1 paper was found that supported the use of Topical Vancomycin in cardiac surgery, and this paper reports a reduction of 6 sternal wound infections (Number Needed to Treat is 1/ (0.036-0.0045) = 32). Also found in the search was a paper by Massias et al 1992 (2) That took 10 sternal biopsies intraoperatively after 48hrs of preoperative intravenous vancomycin prophylaxis and they found vancomycin concentrations of 9+/-3mcg/l which is well in the therapeutic range. A search was therefore also done for studies that looked at the addition of Vancomycin i.v. to standard prophylaxis. No studies were found, only studies comparing vancomycin as a replacement to standard prophylaxis.
Therefore it is unknown whether giving vancomycin i.v. instead of topically would be equally effective.
Therefore it is unknown whether giving vancomycin i.v. instead of topically would be equally effective.
Bottom Line:
Topical Vancomycin applied to the sternal edges with haemostatic paste is effective in reducing the incidence of sternal infection (NNT 32).
Level of Evidence:
Level 3: Small numbers of small studies or great heterogeneity or very different population
References:
- Vander Salm TJ, Okike ON, Pasque MK, Pezzella AT, Lew R, Traina V et al.. Reduction of sternal infection by application of topical vancomycin.
- Massias L, Dubois C, de Lentdecker P, Brodaty O, Fischler M, Farinotti R.. Penetration of vancomycin in uninfected sternal bone.