局部应用万古霉素预防脊柱后路开放手术部位感染有效性及安全性的Meta分析

A meta-analysis of the efficiency and safety of the topical application of vancomycin to reduce SSI in posterior spinal surgery

目的系统性评价术中局部应用万古霉素(vancomycin)对降低后路脊柱开放手术部位感染(surgical site infections,SSI)的有效性及安全性。方法应用计算机系统使用特定关键词检索CNKI、PubMed、Cochrane library、Embase、Web of science,SinoMed、Springer、Google scholar等中英文数据库,搜集2012年3月1日至2022年3月1日发表的关于局部应用万古霉素降低脊柱后路开放手术SSI的中英文文献,由2位研究人员按照文献纳入及排除标准独立进行文献筛选,汇总纳入文献后进行数据提取及质量评定,选取高质量的研究数据,使用RevMan 5.4软件进行统计分析,评估局部应用万古霉素对降低脊柱开放手术SSI的疗效。结果本研究纳入13篇文献,共8696例患者。所有研究均通过异质性检验,均采用固定效应模型进行数据合并,结果提示局部应用万古霉素未见明确不良反应及并发症,能有效降低脊柱后路开放手术SSI(OR=0.56,95%CI 0.44~0.72,P<0.00001)。对文献中明确提及应用内固定的数据进行二次提取分析,结果示局部应用万古霉素能有效降低后路脊柱内固定手术SSI(OR=0.59,95%CI 0.45~0.77,P<0.0001)。为减少研究间异质性,根据提取信息进行了2项亚组分析,根据万古霉素使用剂量共分为1 g、2 g、混杂剂量亚组,结果不呈剂量相关效应,在局部应用万古霉素1 g(OR=0.59,95%CI 0.41~0.84,P=0.003)及混杂剂量(OR=0.49,95%CI 0.34~0.71,P=0.0001)时能有效降低脊柱后路开放手术术后SSI,2 g剂量时因纳入研究及样本量较少,组间差异无统计学意义(95%CI 0.44~3.15,P=0.74);根据感染类型进行亚组分析提示局部应用万古霉素能有效降低脊柱开放手术术后表浅部位(OR=0.51,95%CI 0.27~0.95,P=0.03)及深部(OR=0.69,95%CI 0.48~0.99,P=0.04)SSI。结论局部应用万古霉素能安全有效降低脊柱后路开放手术及内固定手术的SSI;亚组分析提示其同时能降低脊柱后路开放手术深部及表浅部位SSI;同时亚组分析未见其局部应用呈明显剂量相关效应。

Objective To systematically evaluate the efficiency and safety of topical application of vancomycin in reducing surgical site infections(SSI)in open posterior spinal surgery.Methods A comprehensive search of Chinese and English databases such as CNKI,PubMed,Cochrane library,Embase,Web of science,SinoMed,Springer,Google scholar,etc.was conducted.Using specific keywords to collect literature published from 2012.03.01 to 2022.03.01 on local application of vancomycin for the prevention of open posterior spinal surgery.Two researchers independently screened the literature according to the inclusion and exclusion criteria.Data were extracted and the quality of the included literature was assessed.High-quality studies were identified for metaanalysis.Data were statistically analyzed by using RevMan 5.4 software to assess the efficacy of topical vancomycin in preventing SSI in open posterior spinal surgery.Results A total of 13 publications and 8696 surgical patients were finally identified for meta-analysis.There was no heterogeneity among all studies,and all data were combined using a fixed-effects model.Results suggested that local vancomycin application was safe and effective in reducing SSI in posterior open spine surgery(OR=0.56,95%CI 0.44-0.72,P<0.00001).The application of topical vancomycin was effective in reducing SSI in posterior spinal internal fixation surgery,(OR=0.59,95%CI 0.45-0.77,P<0.0001).Two subgroup analyses were conducted according to the extracted information.According to the dose of vancomycin,all were divided into 1 g,2 g,and mix-dose subgroups,and the results did not show a dose-related effect in the topical application of vancomycin.1g subgroup(OR=0.59,95%CI 0.41-0.84,P=0.003)and mix-dose subgroup(OR=0.49,95%CI 0.34-0.71,P=0.0001)were effective in reducing postoperative SSI after open posterior spinal surgery.For 2 g subgroup,no statistical difference was observed among groups due to the lack of included literatures and small sample size(95%CI 0.44-3.15,P=0.74).Topical vancomycin application was effective in reducing SSI after open posterior spinal surgery at superficial sites(OR=0.51,95%CI 0.27-0.95,P=0.03)and deep sites(OR=0.69,95%CI 0.48-0.99,P=0.04).Conclusions The topical application of vancomycin is effective and safe in reducing SSI in open posterior spinal surgery and internal fixation.Subgroup analysis suggests that deep and superficial SSI in open posterior spinal surgery could be reduced.Meanwhile,no significant dose-related effect is observed.