Topical Vancomycin for Neurosurgery Wound Prophylaxis

This study is a collaboration between NYP-Columbia and NYP-Cornell that seeks to evaluate
the use of topical vancomycin and its reduction on surgical site infection (SSI) in
neurosurgical procedures. Adult patients undergoing neurosurgery at either institution will
be eligible for participation in this randomized control trial. Patients randomized to the
treatment group will receive 2g of vancomycin applied as a powder or paste to the wound site
and/or bone flap. Subjects in the control group will receive the current standard of care
without topical vancomycin. All subjects will undergo swabbing of the anterior nares and the
surgical site prior to surgery, once 10-14 days following the operation and 90 days
following the operation. The primary outcome measure will be surgical site infection,
assessed daily throughout the hospital stay, at the first follow-up visit, and by telephone
at 30 days. Secondary outcomes will include length of hospital stay, length of intensive
care stay, rate of reoperation and patient mortality. In addition, systemic vancomycin
levels will be assessed at 6 hours and 24 hours postoperatively in each patient. Patients
who have an external ventricular drain in place will have vancomycin levels assessed daily.
In patients who have cranial drains placed, vancomycin concentrations will be analyzed from
daily in wound drainage. Skin and nasal flora will be analyzed to assess the impact of
topical vancomycin on the patient microbiome. Although there has been a decrease in the
incidence of infections following craniotomy secondary to prophylactic intravenous
antibiotics, proper sterile techniques, and other interventions, SSIs continue to
significantly impact morbidity, mortality, and cost burden. Although never studied in
neurosurgical procedures other than instrumented spine, the application of topical
vancomycin to the surgical site prior to wound closure has demonstrated a reduction in SSIs
in spine, cardiac and ophthalmologic procedures. The benefits of using prophylactic
vancomycin topically, as opposed to intravenously, include reduced systemic levels of the
drug, and therefore, a decreased probability of adverse events related to the drug, such as
inducing resistance among native flora. The investigators propose a randomized control trial
to evaluate the effectiveness of topical vancomycin in reducing SSIs rates following
neurosurgical procedures.