Regional antibiotic delivery for sternal wound infection prophylaxis a systematic review and meta-analysis of randomized controlled trials
Authors: Kowalewski Mariusz , Kołodziejczak Michalina M. , Urbanowicz Tomasz , De Piero Maria Elena , Mariani Silvia , Pasierski Michał , Makhoul Maged , Comanici Maria , Dąbrowski Emil Julian , Matteucci Matteo , Massimi Giulio , Litwinowicz Radosław , Kowalówka Adam , Wańha Wojciech , Jiritano Federica , Martucci Gennaro , Raffa Giuseppe Maria , Malvindi Pietro Giorgio , Kuźma Łukasz , Suwalski Piotr , Lorusso Roberto , Meani Paolo , Lazar Harold ,   Thoracic Research Centre, Brączkowski Jakub , Fina Dario , Gozdek Mirosław , Chiarini Giovanni , Jiritano Federica , Kołodziejczak Michalina M. , Kowalówka Adam , Kowalewski Mariusz , Kuźma Łukasz , Lorusso Roberto , Litwinowicz Radosław , Li Tong , Marchese Giuseppe , Martucci Gennaro , Massimi Giulio , Matteucci Matteo , Makhoul Maged , Malvindi Pietro Giorgio , Mariani Silvia , Meani Paolo , Olasińska Anna , Pasierski Michał , Pannone Luigi , De Piero Maria Elena , Raffa Giuseppe Maria , Stec Sebastian , Staromłyński Jakub , Todaro Serena , Urbanowicz Tomasz , Wańha Wojciech 
Published: April 2024

Despite evidence suggesting the benefit of prophylactic regional antibiotic delivery (RAD) to sternal edges during cardiac surgery, it is seldom performed in clinical practice. The value of topical vancomycin and gentamicin for sternal wound infections (SWI) prophylaxis was further questioned by recent studies including randomized controlled trials (RCTs). The aim of this systematic review and meta-analysis was to comprehensively assess the safety and effectiveness of RAD to reduce the risk of SWI.We screened multiple databases for RCTs assessing the effectiveness of RAD (vancomycin, gentamicin) in SWI prophylaxis. Random effects meta-analysis was performed. The primary endpoint was any SWI; other wound complications were also analysed. Odds Ratios served as the primary statistical analyses. Trial sequential analysis (TSA) was performed.Thirteen RCTs (N = 7,719 patients) were included. The odds of any SWI were significantly reduced by over 50% with any RAD: OR (95%CIs): 0.49 (0.35–0.68);p < 0.001 and consistently reduced in vancomycin (0.34 [0.18–0.64];p < 0.001) and gentamicin (0.58 [0.39–0.86];p = 0.007) groups (psubgroup = 0.15). Similarly, RAD reduced the odds of SWI in diabetic and non-diabetic patients (0.46 [0.32–0.65];p < 0.001 and 0.60 [0.44–0.83];p = 0.002 respectively). Cumulative Z-curve passed the TSA-adjusted boundary for SWIs suggesting adequate power has been met and no further trials are needed. RAD significantly reduced deep (0.60 [0.43–0.83];p = 0.003) and superficial SWIs (0.54 [0.32–0.91];p = 0.02). No differences were seen in mediastinitis and mortality, however, limited number of studies assessed these endpoints. There was no evidence of systemic toxicity, sternal dehiscence and resistant strains emergence. Both vancomycin and gentamicin reduced the odds of cultures outside their respective serum concentrations’ activity: vancomycin against gram-negative strains: 0.20 (0.01–4.18) and gentamicin against gram-positive strains: 0.42 (0.28–0.62);P < 0.001. Regional antibiotic delivery is safe and effectively reduces the risk of SWI in cardiac surgery patients.