Page 81 - 2022 Spring JSOM

28
Pavey et al. sought to determine if the use of inexpensive van- anti-fibrinolytic effect of TXA was not affected. It is import-
comycin powder would reduce the risk of costly infections ant to note however that TXA is not given intra-articularly in
4
and revisional surgeries. The remarkable success in limiting combat; it is usually applied IV, IO, or IM. If prophylactic van-
post-amputation infection and post-revisional amputation in- comycin powder is demonstrated to be efficacious in its SOF
fection led the surgeon to apply vancomycin powder during application, this could later be applied across the spectrum of
all surgeries. This retrospective study exemplifies a surgical the DoD, to be used by combat medics and corpsmen.
administration of vancomycin powder that most closely rep-
resents the battlefield application.
Limitations
A concern that was not discussed in these studies was the Though efficacy has been shown in various arenas, what this
higher rates of gram-negative infections. While indeed, overall research does not expound upon is the gram-negative bacte-
infection rates were reduced, the Gande, et al. meta- analysis rial infection concern. S. aureus is one of the causative agents
showed that using vancomycin led to a higher incidence of of combat trauma infection and later osteomyelitis, but so is
20
polymicrobial and gram-negative infections. This finding the gram-negative E. coli, among others. With 57% of ini-
should not be surprising as vancomycin solely targets aerobic tial infections classified as gram-negative, what is unknown
and anaerobic gram-positive bacteria. With this selectivity for is the effect intrawound vancomycin powder will have on in-
gram-positive bacteria, it is to be expected that gram-negative creasing gram-negative infections. The only insight offered
8
infections would increase. An increase in gram-negative E. coli into this knowledge gap was the Gande et al. study, which
infections could be expected, with this being another common researched the selection pressures for gram-negative bacte-
20
cause of osteomyelitis. Increased gram-negative infections can ria. Gram-negative infections were increased in the vanco-
be prevented with the current TCCC antibiotic algorithm. mycin powder treatment group. However, the rate of infection
Moxifloxacin targets gram-negative organisms and is effec- in the control group remained higher (3.8%) than that of the
23
tive against E. coli. This is why the current TCCC guidelines treatment group (2.3%). This finding appears to demonstrate
must not be changed and vancomycin powder should be an that while gram-negative infection incidence increases when
adjunct. treated with prophylactic vancomycin powder, the overall in-
fection rate is still reduced.
Battlefield Application
Taking vancomycin powder from the operating room to the With a minimal amount of research on the battlefield appli-
battlefield is a great leap. Recently published research by Bur- cation, there is a great deal of work that still must be done to
bank et al. and ongoing clinical trials demonstrate that van- deem this application of vancomycin efficacious. There is a
comycin powder’s transition from the operating room to the vast amount of systematic reviews about its peri-operative use,
emergency room has already begun. 12, 25 While a multitude of but the transition to other niches is just beginning. A challenge
research exists for the treatment’s efficacy in surgical scenar- in this research is the breadth of organisms that are cultured in
ios, a wide variety of new variables are introduced in war. The battlefield wounds. The heterogeneity of microorganisms may
purpose of the current TCCC antibiotic guidelines is to pro- be a representation of the various mechanisms of injury, or the
vide the most broad-spectrum antibiotics to assist the innate lack of adherence to antibiotic CPGs, among other factors.
29
immune response in responding to the overwhelming insult. S. aureus is the most likely causative organism of recurrent
As soon as the patient can reach higher levels of care, the phy- osteomyelitis, but there remains significant biodiversity in the
sicians are then able to make an assessment and adjust anti- cultured pathogenic microorganisms. 22
biotic treatment as necessary. While this method is both easy
to train and employ, a shortfall still exists. This prophylaxis Of great concern in the prophylactic utilization of vancomycin
is limited in the diffuse penetration to the area of vascular in- powder is antibiotic stewardship. In an age of rapidly devel-
sult. It penetrates only as far as the intact vasculature can oping resistance, using one of the best weapons against MRSA
5
transport it. This research suggests that a change in the cur- and other multidrug–resistant organisms in a prophylactic
rent antibiotic protocol is not needed, but using vancomycin fashion could be dangerous. This additional selection pressure
as an adjunct therapy may potentiate effects on the inoculated could favor the formation of further resistant microorganisms.
pathogens. With this in mind, the Gande, et al. study demonstrates that in
nearly 20,000 surgeries with vancomycin powder applied, S.
The most effective field that this prophylaxis can be researched aureus never developed resistance. 20
is in the Special Operations Forces (SOF) community. The clin-
ical and surgical expertise at the tactical level of these Service-
members is exceptional and their training is unmatched. There Conclusion
are many different types of operations across the globe, which Near-peer wars will lack the expeditious evacuation times cur-
could expose this treatment to a variety of environments. These rently in place in Afghanistan and Iraq, which have reduced
highly specialized and trained units are deployed in numerous casualty fatality rates. This reality is indeed an area that the
29
countries, hundreds of miles from higher levels of care. In the DoD must have effort and synergistic research to prepare for
event a Servicemember or local national is wounded in the the future. Vancomycin powder certainly is not the antibiotic
conduct of operations, this antibiotic prophylaxis may pro- to stop all post-wound infections. However, vancomycin can
vide an additional tool to prevent morbidity in the extremity be a tremendous adjunctive and cost-effective asset in the fight
by applying it to the wound within 6 hours. Another benefit to save limbs and prevent recurrent osteomyelitis. With the
of using this antibiotic powder is there have been no adverse potential for decreasing cases of infection following combat
effects noted with its topical use. 26,27 Additionally topical van- trauma and the low cost of application of vancomycin powder,
comycin was safe and effective when used with intra-articu- there are few reasons not to explore this approach when the
lar tranexamic acid (TXA) in total joint replacements and the risk of infection is tremendous.

Efficacy of Vancomycin Powder on the Battlefield | 79