Topical vancomycin for surgical site infection prophylaxis in craniotomies and noninstrumented spinal procedures: a randomized controlled trial

OBJECTIVE The objective of this study was to determine the efficacy of topical vancomycin application on the rates of surgical site infection (SSI) in craniotomy and noninstrumented spinal procedures. METHODS In total, 1103 patients randomly received either topical vancomycin at the surgical site in addition to standard systemic antibiotic prophylaxis (n = 552) or standard antibiotic prophylaxis alone (n = 551). Symptoms of SSI were assessed via standardized patient surveys for SSI symptoms at postoperative day 30. Univariate, multivariate, and sensitivity analyses were used to determine the effect of topical vancomycin on SSI rate while accounting for demographic and procedural characteristics. RESULTS Likely SSI rates did not vary between the treatment and control groups overall (3.94% vs 4.10%; risk difference −0.0016 [95% CI −0.027 to 0.024]; p = 0.90), nor when adjusted for known confounders. Stratification by procedure type showed different baseline rates of SSI, but in no group did topical vancomycin significantly reduce SSI rates. Sensitivity analysis based on various SSI classification schemes also showed no significant reduction due to topical vancomycin. Topical vancomycin use was not associated with significant systemic absorption or significant adverse events. CONCLUSIONS Topical vancomycin did not result in any significant reduction in SSI compared to the current standard of care. The authors believe that further research is needed to determine the role of topical vancomycin in neurosurgery, and that its use should not be established as the standard of care in the absence of clear evidence of its superiority over current prophylactic treatments.