5/9/2014 Disclosure I have no relevant disclosures The Local - - PowerPoint PPT Presentation

5/9/2014 1

The Local Application of Vancomycin in Spine Surgery: Changes to Bacterial Resistance Profiles

UCSF Orthopaedic Surgery Inman Abbott Lecture

Frank Valone, III M.D. Resident Department of Orthopaedic Surgery

May 9, 2014 2

Disclosure

I have no relevant disclosures

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Infections in Spinal Surgery

• Berven et al.:

– 6628 Hospital Visits Identified – Cumulative Incidence of SSI was 2.9%

• Scoliosis Research Society

– 108,419 Procedures – SSI rate of 2.1%

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Vancomycin Powder in Spine Surgery

• Sweet et al.:

– 1732 Consecutive Thoracic and Lumbar Posterior Instrumented Fusions

• 821 received standard 24 hours of perioperative

cephalexin

• 911 received standard perioperative cephalexin + 2

grams of Vancomycin

– Standard Cephalexin: 21 infections (2.6%) – Cephalexin + Vancomycin: 2 infections (0.2%)

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Vancomycin in Spine Surgery

• Molonari:

– 1512 Consecutive Spinal Surgeries – All received 1 gram Vancomycin beneath the fascia – 15 patients (0.99%) infection rate

• Sweet et al:

– 1001 posterior cervical spine surgical procedures from1995 to 2010 retrospectively reviewed – Infection rate of 0% in group with the addition of 500mg of Vancomycin

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Determining Resistance to Vancomycin in Spinal Surgery

• Research within the Department of

Orthopaedic Spine Surgery

• Two part:
• 1. Global changes to bacterial resistance patterns at a

tertiary academic spine center

• 2. Retrospective Data Analysis of all patients from 2011

to current

• Statistical correlation between Vancomycin use and

Vancomyci resistant microbe development

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Part 1: Global Changes to Microbial Resistance Profiles

• 126 bacteria were isolated from 81 surgical site

infections from 2007-2013

• Bacterial Resistance profiles were analyzed by

epoch

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Determining Microbial Resistance Patterns to Vancomycin in Spine Surgery

Microbiologic Profile of SSI in Spine Surgery 2007 (No Vancomycin resistance isolates)

Staph Aureus (MSSA) Staph Aureus (MRSA) Ent erobacter Cloacae Psuedomonas Eschericia Coli Klebsiella pneumonia

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Determining Microbial Resistance Patterns to Vancomycin in Spine Surgery

Microbiologic Profile of SSI in Spine Surgery 2008 (One Vancomycin Resistant iIsolate - Enterococcus Faecium)

St aph Aureus (MSSA) St aph Aureus (MRSA) St aph Epidermidis (MSSE) St aph Epidermidis (MRSE) Ent erobact er Cloacae Proprionobact erium Acnes Eschericia Coli Klebsiella pneumonia Klebsiella Oxyt oca Corynebact erium Acinet obact er lwof f i Cit robact er f reundii Ent erococcus f aecalis Prot eus Mirabelis Ent erococcus Faecium (Vanc Resist ant ) Cit robact er Koserii

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Determining Microbial Resistance Patterns to Vancomycin in Spine Surgery

Microbiologic Profile of SSI in Spine Surgery 2009 (No Vancomycin Resistant iIsolates) Staph Aureus (MSSA) Staph Aureus (MRSA) Proprionobacterium Acnes Staph Epidermidis (MRSE) Eschericia Coli Pseudomonas Corynebacterium Enterococcus faecalis Proteus Mirabelis

Sweet’s Article Presented

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Determining Microbial Resistance Patterns to Vancomycin in Spine Surgery

M icro bio lo gic Prof ile of SSI in Sp ine Surgery 2 0 10 ( N o V ancomycin R esist ant iIsolat es)

S taph Aur eus (MSS A) Pr opr ionobacter ium Acnes Escher icia Coli S taph Epider m idis (MRS E) Enter ococcus f aecium Cor ynebacter ium Enter ococcus f aecalis Pr oteus Mir abelis Enter obacter Cloacae Peptostr eptococcus Klebsiella Pneum

• nia

Pseudom

• nas

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Determining Microbial Resistance Patterns to Vancomycin in Spine Surgery

M i c r obi ol ogi c P r of i l e of S S I i n S pi ne S ur ge r y 2 0 11 ( No Va nc omy c i n Re si st a nt i I sol a t e s)

St aph Aur eus (M SSA) St aph Aur eus (M RSA) Ci tr obacter Fr eundi i St aph Epi der mi di s (M RSE) Escher i chi a Col i

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Determining Microbial Resistance Patterns to Vancomycin in Spine Surgery

M i c r obi ol ogi c P r of i l e of S S I i n S pi ne S ur ge r y 2 0 12 ( One Va nc om y c i n R e si st a nt i I sol a t e - Ent e r oc oc c us Fa e c i um)

Staph A ur eus (M SSA ) Str ept ococcus angi nosus E s cher i c hi a Col i Staph E pi der mi di s (M RSE ) Staph E pi der mi di s (M SSE ) P s eudomonas Cor ynebacter i um E nter ococcus Faeci um (V anco Resi s tant) P r opr i onobacter i um A cnes M or ganel l a M or gani K l ebsi el l a P neumoni a

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Determining Microbial Resistance Patterns to Vancomycin in Spine Surgery

Microbiologic Profile of SSI in Spine Surgery 2013 (No Vancomycin Resistant iIsolates) Pseudomonas Citrobacter Freundii Staph Epidermidis (MSSE) Staph Epidermidis (MRSE) Escherichia Coli

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Bacterial Resistance Patterns

Figure 1: Microbiologic changes in Spinal Surgery Infection (2007 - 2013)

2 4 6 8 10 12 2007 2008 2009 2010 2011 2012 2013 Year Number of Bacteria isolated per year

Staph Aureus (MSSA) Staph Aureus (MRSA) Staph Epidermidis (MSSE) Staph Epidermidis (MRSE) Enterobacter Cloacae Proprionobacterium Acnes Eschericia Coli Klebsiella pneumonia Klebsiella Oxytoca Corynebacterium Acinetobacter lwoffi Citrobacter freundii Enterococcus faecalis Proteus Mirabelis Enterococcus Faecium (Vanc Resistant) Enterococcus Faecium (Vanc Sensitive) Citrobacter Koserii Pseudomonas Peptostreptococcus Streptococcus Anginosus Morganella Morgani

* *

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Part 2:

Retrospective Analysis of consecutive cases 2011

• Current:
• Number of Cases 1013
• Vancomycin 1 gram free 134
• Vancomycin 1 gram with bone graft

41

• Vancomycin 2 gram free 236
• Vancomycin 2 gram with bone graft

63

• None

538

• No patient given local application of

Vancomycin developed a vancomycin resistant microbe

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Conclusions

• Part 1:
• Vancomycin resistant Microbes are rare in spine

surgical site infections (2)

• There has not been a significant increase in

Vancomycin resistant surgical site infections since Sweet’s study was introduced

• Part 2:
• There was no significant correlation between

Vancomycin placed intra-operatively and Vancomycin resistant microbes

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Discussion

• 1. How do bacteria become resistant to

antibiotics:

• Preventing the antibiotic from getting to its

target

• Changing the target
• Destroying the antibiotic
• 2. Transformation, plasmid, transposons,

mutation

• 3. Antibiotic effects on resistance:
• 1. Bacteriostasis
• 2. Exposure of bacteria to subtherapeutic antibiotics
• 1. Selection for resistant bacteria

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Vancomycin Application

• 1. Produce high antibiotic levels at the site of the

possible infection, yet safe drug levels in the systemic circulation

• Vancomycin:

– BacterioCIDAL: when concentration is 4 x MIC – Example:

• 2 x MIC for common spine pathogen (MRSA)

– Trough of 32-40 – High Risk of Toxicity

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Limitations/Future

• Short term follow up

– Necessary step

• Continue follow up globally and for each patient

that receives Vancomycin application

• Thank you:

– Serena Hu, M.D. – Sigurd Berven, M.D. – Shane Burch, M.D. – Bobby Tay, M.D. – Vedat Deviren, M.D.