Safety of topical vancomycin for pediatric spinal deformity: nontoxic serum levels with supratherapeutic drain levels.

Study Design: Retrospective cohort analysis.

Objective: To establish if drain levels exceed the minimum inhibitory concentrations for common pathogens (methicillin-resistant Staphylococcus aureus, methicillin-sensitive Staphylococcus aureus, and Propionibacterium acnes-2 μg/mL; Staphylococcus epidermidis, Enterococcus faecalis-4 μg/mL). Evaluate the safety of topical vancomycin in pediatric patients undergoing spinal deformity surgery and determine if postoperative serum levels approach toxicity (25 μg/mL).

Summary Of Background Data: The application of topical vancomycin powder has decreased postoperative wound infections in retrospective analyses in the adult population with minimal local and systemic risks. The safety and efficacy of vancomycin powder has not been completely evaluated in the pediatric population after deformity surgery.

Methods: Topical vancomycin powder (1 g) was applied during wound closure after instrumented posterior spinal fusion. All patients received intravenous perioperative antibiotics and a subfascial drain was used. Serum and drain vancomycin levels were collected immediately postoperatively and during the first 2 postoperative days (PODs). Complications were recorded.

Results: The study population consisted of 25 patients with a mean age of 13.5 years (9.5-17.1 yr) and mean ± standard deviation body weight of 44.5 ± 18 kg. Underlying diagnoses included: adolescent idiopathic scoliosis (12), neuromuscular scoliosis (10), and kyphosis (3). Mean serum vancomycin levels trended downward from 2.5 μg/mL (POD 0) to 1.9 μg/mL (POD 1) to 1.1 μg/mL (POD 2). Mean drain levels also trended downward from 403 μg/mL (POD 0) to 251 μg/mL (POD 1) to 115 μg/mL (POD 2). No vancomycin toxicity or deep wound infections were observed. One patient with neuromuscular scoliosis developed a superficial wound dehiscence that was managed with dressing changes.

Conclusion: Topical application of vancomycin powder in pediatric spinal deformity surgery produced local levels well above the minimum inhibitory concentration for common pathogens and serum levels below the toxicity threshold (25 μg/mL). There were no deep wound or antibiotic related complications.

Level Of Evidence: 3.