Vancomycin for Surgical Prophylaxis?
Tonya Crawford
1
2
Keith A. Rodvold
1
2
Joseph S. Solomkin
0
1
0
Department of Surgery, University of Cincinnati College of Medicine
,
Ohio
1
Received 8 June 2011; accepted 22 December 2011; electronically published 10 February 2012. Practice, University of Illinois at Chicago
,
833 South Wood St, Room 164 (M/C 886), Chicago, IL, 60612-7230
2
Department of Pharmacy Practice, University of Illinois at Chicago
The increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) has resulted in a reevaluation of the role of vancomycin for surgical prophylaxis. Two systematic reviews of randomized control studies have concluded that cephalosporins are as effective as vancomycin for the prevention of surgical site infections (SSIs). However, most of these studies were conducted more than 10 years ago and cannot be generalized to the current rates of MRSA. Several time-series analyses have recently evaluated the effectiveness of vancomycin for surgical prophylaxis in institutions with a high prevalence of MRSA. Decision analysis models have also been used to estimate thresholds of MRSA prevalence for which vancomycin would minimize the incidence and cost of SSIs. Combination therapy and the emergence of resistant pathogens following vancomycin prophylaxis are reviewed. Vancomycin is not recommended for routine use in surgical prophylaxis but may be considered as a component of a MRSA prevention bundle for SSIs in selective circumstances.
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The prevention of surgical site infections (SSIs) remains
a major focus of attention due to the increased risks
of morbidity and mortality, and large economic costs
[1, 2]. In the United States, SSIs are considered the
second most common healthcare-associated infection
and occur as a serious complication of an estimated
300 000500 000 surgical procedures each year [3, 4].
Methicillin-resistant Staphylococcus aureus (MRSA) and
coagulase-negative staphylococci have become the
primary pathogens associated with SSIs in cardiothoracic,
vascular, orthopedic, and neurosurgical operations.
MRSA SSIs have been associated with increased
mortality, length of hospital stay, and costs compared with
SSIs due to other organisms, including
methicillinsusceptible S. aureus (MSSA) [57].
Communityacquired MRSA (CA-MRSA) strains have noticeably
increased in the United States during the past decade
and are becoming prevalent among MRSA strains in
hospitals [810]. In some hospitals, CA-MRSA strains
are now responsible for a significant proportion of
SSIs [10, 11]. These concerns are very much focused on
prosthetic joint insertion and any procedure involving
sternotomy or insertion of vascular grafts and other
devices because of the unique consequences of deep
infections in these settings.
The appropriate use of perioperative antibiotic
prophylaxis is a key intervention for preventing SSIs in
clean and clean-contaminated surgery. However, the
evolving epidemiology and increasing prevalence of
MRSA are challenging current guidelines for antibiotic
prophylaxis and the role of vancomycin in the United
States. The purpose of this review is to summarize the
available data regarding pharmacological properties and
efficacy of vancomycin for surgical prophylaxis.
SURGICAL PROPHYLAXIS GUIDELINES
AND PHARMACOLOGICAL PROPERTIES
OF VANCOMYCIN
Vancomycin has been available clinically for more than
50 years and has demonstrated a steady increase in use
with the resurgence of MRSA infections since the 1980s
[12]. As early as the 1990s, the use of vancomycin in
some United States hospitals had been equally divided
among 3 indications: empiric therapy, treatment of
culture-proven infections, and surgical prophylaxis [13].
First- or second-generation cephalosporins (eg, cefazolin,
cefuroxime) are generally considered the preferred
agents in patients receiving perioperative antibiotic
prophylaxis for most surgical procedures [1418]. Vancomycin
has been commonly recommended as an alternative agent for
patients with a life-threatening b-lactam allergy. Depending on
the specific guideline and/or type of surgical patient (eg,
cardiac), vancomycin has also been recommended as either a
primary or as an adjuvant agent (combined with cefazolin or an
aminoglycoside) for patients who are presumed or known to
have S. aureus colonization, in institutions where a high
prevalence of MRSA exists, and when a surgical procedure
involves a prosthetic joint insertion, sternotomy or vascular
graft insertion [1417]. The recommended dose of vancomycin
in these guidelines is a fixed dose of 10001500 mg or a
weightadjusted dose of 1015 mg/kg.
The pharmacological properties of vancomycin are limited
when compared with cephalosporins. In terms of
microbiological and pharmacodynamics features, vancomycin has slower
bactericidal activity, a narrow antimicrobial spectrum that does
not include gram-negative pathogens, uncertainty regarding
increasing minimum inhibitory concentration (MIC) values
of S. aureus, gives poor clinical ou (...truncated)