Vascular Surgical Antibiotic Prophylactic Study (VSAPS)

Vascular Surgical Antibiotic Prophylactic Study (VSAPS)
BACKGROUND: MRSA is becoming increasingly prevelant in postoperative wound infections, especially vascular surgery. A major concern is the routine use of cefazolin as antimicrobial prophylaxis in open peripheral vascular procedures. This regimine may not provide adequate coverage of resistant organisms, such as MRSA. Therefore, this study is designed to evaluate the efficacy of MRSA specific coverage versus traditional routine surgical prophylaxis.
OBJECTIVE: This prospective, randomized study was performed at a single institution. Its main goal is to deliniate if MRSA specific prophylaxis in elective vascular surgery is efficacious.
METHODS: Upon approval by the IRB, low-risk patients undergoing elective vascular proceedures were enrolled from August 2007 to June 2009. Participants were randomized into three separate arms. They received either cefazolin (dose), cefazolin(dose) + vancomycin(dose), or cefazolin(dose) + daptomycin(dose) as antimicrobial prophylaxis prior to surgery. Patients were blinded to their randomized group.
RESULTS: 203 patients were enrolled over 22 months. After excluding 10 ineligible patients, 193 were randomized to one of three groups. Seventy-five (75) in the cefazolin group, 69 in the cefazolin + vancomycin group and 59 in the cefazolin + daptomycin group. Mean age was 66 (range, 26-89), and the patients' comorbidities were similar across all groups. Presence of postop infection was categorized by a Szlagi I, II, or III designation. Infection was seen in 8 patients (11%) in the cefazolin group, 8 (12.5%) in the cefazolin + vancomycin group, and 2 (3.6%) in the cefazolin + daptomycin group. Pathogens isolated from wound cultures included Proteus mirabilis, Methicilin Sensitive Staph Aureus, Klebsiella pneumonia, Enterobacter cloacae, Pseudomonas, Non-MRSA staph species, Fermenter and non-fermenter species. MRSA infections were found in 1 patient (1.4%) in the cefazolin group, 4 (6.3%) in the cefazolin + vancomycin group, and no patients (0%) in the cefazolin + daptomycin group.
CONCLUSIONS: In this study population of low-risk patients undergoing elective vascular proceedures, there was a trend toward fewer infectious complications in the cefazolin + daptomycin group although it did not reach statistical significance. Further investigation is necessary to deliniate the efficacy of MRSA prophylaxis in other groups, including high-risk individuals.