Topical Vancomycin Versus Standard Care in Diabetic CABG Patients: Effect on Sternal Wound Infection
DOI:
https://doi.org/10.47489/szmc.v39i4.868Keywords:
Coronary Artery Bypass, Diabetes Mellitus, Surgical Wound Infection, Vancomycin, Cardiac Surgical ProceduresAbstract
Background: Although surgical practice and prophylaxis have improved still sternum wound infection is an expensive and severe problem of coronary artery bypass (CABG). Diabetic patients are, however, a very high-risk group of this complication because they have a weakened immunity and a slow healing of wounds. Although systemic antibiotic prophylaxis has remained very popular, its shortcomings have created interest in the usage of topical methods. The effectiveness of topical vancomycin powder in high-risk diabetic patients needs to be studied to generate local evidence.
Objective: To determine the effectiveness of topical vancomycin application to the edges of the sternum in decreasing the sternal wound contamination rate in diabetic post-CABG patients.
Methods: This quasi-experiment was done in a tertiary cardiac care institution. 100 eligible diabetic post-elective CABG patients were randomly assigned to two groups. The Vancomycin group (n = 50) received topical application of 1 gram of vancomycin powder on sternum while comparison group (n = 50) received standard care without the topical vancomycin. The incidence of sternal wound infection in 30 days was determined through the criteria of Jones. Data was entered on SPSS v23.0. Multivariate analysis was done.
Results: Overall, the occurrence of sternal wound contamination was 8% in Vancomycin group and 26% in Control group with p=0.016 while Infection of deep sternal wound was present in 2% and 12% respectively. Vancomycin group had a significantly lesser median hospital stay associated to the comparison group, 7 and 8 days respectively (p=0.026). Topical vancomycin was found an independent protection on multivariate analysis with an adjusted odds ratio of 0.25 and 95% Confidence Interval [0.07-0.84, p=0.025).
Conclusion: Topical vancomycin use is effective in preventing the occurrence of sternal wound infection as well as in the reduction of hospital stay in diabetic patients after CABG.
References
Kowalewski M, Ko?odziejczak MM, Urbanowicz T, De Piero ME, Mariani S, Pasierski M, Makhoul M, Comanici M, D?browski EJ, Matteucci M, Massimi G. Regional antibiotic delivery for sternal wound infection prophylaxis a systematic review and meta-analysis of randomized controlled trials. Scientific Reports. 2024 Apr 27;14(1):9690. https://doi.org/10.1038/s41598-024-60242-z
Spampinato SF, Caruso GI, De Pasquale R, Sortino MA, Merlo S. The treatment of impaired wound healing in diabetes: looking among old drugs. Pharmaceuticals. 2020 Apr 1;13(4):60. https://doi.org/10.3390/ph13040060
Lazar HL, Ketchedjian A, Haime M, Karlson K, Cabral H. Topical vancomycin in combination with perioperative antibiotics and tight glycemic control helps to eliminate sternal wound infections. The Journal of thoracic and cardiovascular surgery. 2014 Sep 1;148(3):1035-40. https://doi.org/10.1016/j.jtcvs.2014.06.045
Vander Salm TJ, Okike ON, Pasque MK, Pezzella AT, Lew R, Traina V, Mathieu R. Reduction of sternal infection by application of topical vancomycin. The Journal of thoracic and cardiovascular surgery. 1989 Oct 1;98(4):618-
https://doi.org/10.1016/S0022-5223(19)34366-1
Graf K, Ott E, Vonberg RP, Kuehn C, Haverich A, Chaberny IF. Economic aspects of deep sternal wound infections. European Journal of Cardio-Thoracic Surgery. 2010 Apr 1;37(4):893-6. https://doi.org/10.1016/j.ejcts.2009.10.005
Servito M, Khani-Hanjani A, Smith KM, Tsuyuki RT, Mullen JC. Topical vancomycin and risk of sternal wound infections: a double-blind randomized controlled trial. The Annals of Thoracic Surgery. 2022 Nov 1;114(5):1555- 61https://doi.org/10.1016/j.athoracsur.2021.11.012.
Patel PM, Arrington RL, Jonsson A, Wei JW, Binongo J, Devireddy C, Nicholson W, Jaber W, Rinfret S, Halkos ME. Advancing the treatment paradigm for multivessel coronary artery disease: hybrid coronary revascularization. Innovations. 2025 Jan;20(1):57-64. https://doi.org/10.1177/15569845241311292
Shah SJ, Jadhav UE. Efficacy of topical vancomycin application in cardiac surgery to reduce deep sternal wound infection: a randomised control trial at tertiary cardiac care hospital. International Surgery Journal. 2022 Feb 28;9(3):601-5. https://dx.doi.org/10.18203/2349-2902.isj20220628
Elrggal ME, Haseeb A, AlGethamy M, Ahsan U, Saleem Z, Althaqafi AS, Alshuail SS, Alsiddiqi ZA, Iqbal MS, Alzahrani AF, AlQarni A. Dose optimization of vancomycin in obese patients: A systematic review. Frontiers in Pharmacology. 2023 Mar 24;14:965284. https://doi.org/10.3389/fphar.2023.965284
Blouin RA, Bauer LA, Miller DD, Record KE, Griffen Jr WO. Vancomycin pharmacokinetics in normal and morbidly obese subjects. Antimicrobial agents and chemotherapy. 1982 Apr;21(4):575-80. https://doi.org/10.1128/aac.21.4.575
Kowalewski M, Raffa GM, Szwed KA, Anisimowicz L. Meta-analysis to assess the effectiveness of topically used vancomycin in reducing sternal wound infections after cardiac surgery. The Journal of thoracic and cardiovascular surgery. 2017 Oct 1;154(4):1320-3. https://doi.org/10.1016/j.jtcvs.2017.06.004
Pan L, Mo R, Zhou Q, Wang D. Deep sternal wound infection after cardiac surgery in the Chinese population: a single-centre 15-year retrospective study. Journal of thoracic disease. 2017 Sep;9(9):3031. https://doi.org/10.21037/jtd.2017.08.41
Ozcan AV, Demir M, Onem G, Goksin I, Baltalarli A, Topkara VK, Kaleli I. Topical versus systemic vancomycin for deep sternal wound infection caused by methicillin-resistant Staphylococcus aureus in a rodent experimental model. Texas Heart Institute Journal. 2006;33(2):107. PMCID: PMC1524712 PMID: 16878608
Friberg Ö, Svedjeholm R, Söderquist B, Granfeldt H, Vikerfors T, Källman J. Local gentamicin reduces sternal wound infections after cardiac surgery: a randomized controlled trial. The Annals of thoracic surgery. 2005 Jan 1;79(1):153-61. https://doi.org/10.1016/j.athoracsur.2004.06.043
Bennett-Guerrero E, Ferguson TB, Lin M, Garg J, Mark DB, Scavo VA, Kouchoukos N, Richardson JB, Pridgen RL, Corey GR, SWIPE-1 Trial Group. Effect of an implantable gentamicin-collagen sponge on sternal wound infections following cardiac surgery: a randomized trial. Jama. 2010 Aug 18;304(7):755-62. https://doi.org/10.1001/jama.2010.1152
Speir AM, Kasirajan V, Barnett SD, Fonner Jr E. Additive costs of postoperative complications for isolated coronary artery bypass grafting patients in Virginia. The Annals of thoracic surgery. 2009 Jul 1;88(1):40-6. https://doi.org/10.1016/j.athoracsur.2009.03.076
Furnary AP, Wu Y. Clinical effects of hyperglycemia in the cardiac surgery population: the Portland Diabetic Project. Endocrine Practice. 2006 Jul 1;12:22-6. https://doi.org/10.4158/EP.12.S3.22
Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, Seley JJ, Van den Berghe
G. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism. 2012 Jan 1;97(1):16-38. https://doi.org/10.1210/jc.2011-2098
Lola I, Levidiotou S, Petrou A, Arnaoutoglou H, Apostolakis E, Papadopoulos GS. Are there independent predisposing factors for postoperative infections following open heart surgery?. Journal of cardiothoracic surgery. 2011 Nov 14;6(1):151. https://doi.org/10.1186/1749-8090-6-151
Filsoufi F, Castillo JG, Rahmanian PB, Broumand SR, Silvay G, Carpentier A, Adams DH. Epidemiology of deep sternal wound infection in cardiac surgery. Journal of cardiothoracic and vascular anesthesia. 2009 Aug 1;23(4):488-94. https://doi.org/10.1053/j.jvca.2009.02.007
Lwanga SK, Lemeshow S. Sample size determination in health studies: a practical manual. Geneva: World Health Organization; 1991. Available from: https://iris.who.int/handle/10665/40062
This work is licensed under a 