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Background <p>Surgical site infections (SSIs) following cranial neurosurgical procedures contribute to significant morbidity, prolonged hospitalisation and healthcare expenditure. Intrawound vancomycin powder (IVP), extensively investigated in spinal surgery, has been increasingly applied as a prophylactic adjunct in cranial neurosurgery. However, the supporting evidence is methodologically limited and inconsistent, comprising predominantly retrospective single-centre studies with conflicting findings across procedure types, the retraction of two influential meta-analyses in April 2025 and the recent publication of the first large randomised controlled trial (RCT)—all of which mandate a critical re-appraisal of current practice.</p> Objective <p>This narrative review synthesises the current evidence regarding the efficacy, safety and clinical application of IVP for SSI prevention following cranial neurosurgery, with attention to procedure-specific outcomes, dosing considerations, controversies and knowledge gaps.</p> Methods <p>A comprehensive narrative literature search was performed in PubMed/MEDLINE, Scopus and Web of Science for English-language studies published between January 2000 and March 2026 evaluating IVP use in cranial neurosurgery. Randomised trials, cohort studies, systematic reviews and meta-analyses were included and synthesised by procedure type.</p> Results <p>Observational evidence has been associated with reduced SSI rates following craniotomy with IVP; however, the first adequately powered RCT, by Kannan and colleagues (<i>n</i> = 1,103), demonstrated no significant difference between treatment and control groups (3.94% versus 4.10%; <i>p</i> = 0.90), and the suggestion of greater benefit in higher-risk subgroups is not consistently supported. Findings in cranioplasty remain markedly conflicting, with some studies reporting near-elimination of SSI and others showing no benefit. Data on deep brain stimulation (DBS) and ventriculoperitoneal (VP) shunt surgery are sparse and inconclusive. Reported doses range from 500&#xa0;mg to 2&#xa0;g, with minimal systemic absorption and a favourable safety profile. A large retrospective study of 987 nonmalignant cranial procedures further questioned routine IVP prophylaxis in low-risk populations.</p> Conclusion <p>IVP is a pharmacologically rational, low-cost and generally well-tolerated adjunct that may have a role in SSI prevention in selected cranial procedures. However, the heterogeneity of evidence, the negative first RCT and the absence of adequately powered confirmatory trials preclude universal adoption. A risk-stratified, procedure-specific approach is prudent until more robust evidence emerges.</p>

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Intrawound vancomycin powder for the prevention of surgical site infection in cranial neurosurgery: a narrative review

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2026年7月8日

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  • Mustafa Tufan Pehlivan,
  • Serhat Hızal,
  • Kenan Şimşek

摘要

Background

Surgical site infections (SSIs) following cranial neurosurgical procedures contribute to significant morbidity, prolonged hospitalisation and healthcare expenditure. Intrawound vancomycin powder (IVP), extensively investigated in spinal surgery, has been increasingly applied as a prophylactic adjunct in cranial neurosurgery. However, the supporting evidence is methodologically limited and inconsistent, comprising predominantly retrospective single-centre studies with conflicting findings across procedure types, the retraction of two influential meta-analyses in April 2025 and the recent publication of the first large randomised controlled trial (RCT)—all of which mandate a critical re-appraisal of current practice.

Objective

This narrative review synthesises the current evidence regarding the efficacy, safety and clinical application of IVP for SSI prevention following cranial neurosurgery, with attention to procedure-specific outcomes, dosing considerations, controversies and knowledge gaps.

Methods

A comprehensive narrative literature search was performed in PubMed/MEDLINE, Scopus and Web of Science for English-language studies published between January 2000 and March 2026 evaluating IVP use in cranial neurosurgery. Randomised trials, cohort studies, systematic reviews and meta-analyses were included and synthesised by procedure type.

Results

Observational evidence has been associated with reduced SSI rates following craniotomy with IVP; however, the first adequately powered RCT, by Kannan and colleagues (n = 1,103), demonstrated no significant difference between treatment and control groups (3.94% versus 4.10%; p = 0.90), and the suggestion of greater benefit in higher-risk subgroups is not consistently supported. Findings in cranioplasty remain markedly conflicting, with some studies reporting near-elimination of SSI and others showing no benefit. Data on deep brain stimulation (DBS) and ventriculoperitoneal (VP) shunt surgery are sparse and inconclusive. Reported doses range from 500 mg to 2 g, with minimal systemic absorption and a favourable safety profile. A large retrospective study of 987 nonmalignant cranial procedures further questioned routine IVP prophylaxis in low-risk populations.

Conclusion

IVP is a pharmacologically rational, low-cost and generally well-tolerated adjunct that may have a role in SSI prevention in selected cranial procedures. However, the heterogeneity of evidence, the negative first RCT and the absence of adequately powered confirmatory trials preclude universal adoption. A risk-stratified, procedure-specific approach is prudent until more robust evidence emerges.