Sternal Application of Vancomycin Greatly Reduces the Incidence of Sternal Wound Complications in Patients undergoing Cardiosurgical Procedures

Objectives: Sternal dehiscence and deep sternal infections are serious and debilitating complications of median sternotomy for cardiosurgical procedures. The efficacy of vancomycin, used either systemically, locally or in combination has been examined by various groups with differing results. We therefore decided to compare patients in whom vancomycin paste was applied to the sternum to a control group that did not receive vancomycin.

Methods: For this prospective, all-comer crossover study we divided our surgical team into a verum and control group. During the first phase, surgeons in the verum group applied a paste consisting of 4.5 g vancomycin powder and 3–5 ml saline to the spongiosa of the divided sternum before closure. In the control group, no vancomycin was used. After 6 months, all surgeons were transferred to the verum group.

Results: During the first phase, performed between July 1st, 2015 and December 1st, 2015, cardiac surgery using sternotomy was performed in 184 patients in the verum and 105 patients in the control cohort. The overall incidence of sternal wound complications was 4.1% (n = 12). In the control group, the complication rate was quite high at 10.5% (n = 11), compared with 0.5% in the verum group (n = 1). Crossover of all surgeons from the control to the verum group took place on January 1st, 2016. Following crossover, the incidence of sternal wound complication for all patients (n = 1273) dropped to 1.2% (n = 16) during a continuing observation period of more than 18 months (p < 0.0001). Side effects were not observed. The cost of treatment in Germany amounts to about six Euros/patient. The number needed to treat is 34.5, which corresponds to a cost/prevented case of only 207 Euros. The average length of stay for patients with sternal wound complications was 42 days, compared with 10 days for patients without sternal complications. At a daily treatment cost of ~150 Euros, ~105,000 Euros in wound treatment costs have been saved through the use of vancomycin at a total cost of ~7,750 Euros. The resultant savings since 2016 is ~97,250 Euros.

Conclusion: Locally applied vancomycin appears to be a safe and highly effective in reducing the incidence of sternal wound complications following cardiac surgery. Given the encouraging results of this preliminary study, a large-scale randomized follow-up trial should be performed to confirm our findings.

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