Efficacy of Vancomycin Powder Prophylaxis in 987 Cranial Surgeries for Nonmalignant Pathology

BACKGROUND AND OBJECTIVES: The use of prophylactic subgaleal vancomycin powder for preventing surgical site infections (SSI) has gained traction among cranial surgeons. However, its broad application remains controversial as the studies supporting its use are skewed toward high infection risk pathologies and have significant limitations. This study aimed to evaluate the efficacy of vancomycin powder in reducing SSIs in a cohort of patients with nonmalignant cranial pathologies. METHODS: A retrospective chart review was conducted for 987 patients who underwent cranial surgeries for nonmalignant pathologies between July 2021 and June 2024 at a major academic center. Patients were divided into 2 groups: those who received prophylactic vancomycin powder (682 patients) and those who did not (305 patients). Data on demographics, comorbidities, procedure types, and SSI occurrences were collected. RESULTS: Established infection risk characteristics were nonsignificantly different between groups. There was no significant SSI difference when comparing patients not receiving vancomycin vs those who received the antibiotic (0.3% vs 0.7%, P = .578). There were 6 infections in total, 3/6 (50%) occurred with atypical meningiomas, 2/6 (33%) occurred with schwannomas, and 1/6 (17%) occurred with an amoebic abscess. Supratentorial craniotomies (odds ratio 0.95, P = .810) and posterior fossa craniotomies (odds ratio 1.18, 0.545) were the most common procedures and were nonsignificantly different between the cohorts. Meningiomas represented the largest portion of pathologies and were equally represented in both groups. CONCLUSION: This study suggests that the routine use of prophylactic vancomycin powder in nonmalignant cranial surgeries may be unnecessary, given an overall low incidence and lack of significant difference in SSIs between groups. These findings advocate for a more tailored approach to antibiotic prophylaxis, weighing the potential benefits against the known risks.