{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,9]],"date-time":"2026-02-09T05:17:06Z","timestamp":1770614226111,"version":"3.49.0"},"reference-count":31,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2025,10,5]],"date-time":"2025-10-05T00:00:00Z","timestamp":1759622400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.mdpi.com"],"crossmark-restriction":true},"short-container-title":["Antibiotics"],"abstract":"<jats:p>Surgical site infections (SSIs) remain a significant complication in spine surgery, especially in instrumented procedures with long operative times. Although guidelines recommend cefazolin as the first-line agent due to its efficacy against Staphylococcus aureus, predictable pharmacokinetics, and safety, its real-world practice is highly variable, with inappropriate and prolonged regimens reported across Europe. Vancomycin is often used as the first choice of therapy empirically and without screening, exposing patients to risks such as delayed infusion, nephrotoxicity, and the emergence of vancomycin-resistant enterococci (VRE).This review assesses the present function of vancomycin in relation to cefazolin for spinal prophylaxis and examines wider trends in the misuse of surgical antibiotic prophylaxis, which were identified through PubMed and Scopus searches. Evidence from randomized and prospective studies consistently supports cefazolin as the preferred prophylactic agent in clean spinal surgery. Observational data suggest that adjunctive or topical vancomycin may reduce infection rates in selected high-risk or revision cases, though the results are inconsistent and frequently limited by retrospective designs and heterogeneous outcome reporting. Importantly, the most rigorous randomized controlled trial found no benefit of intrawound vancomycin over the placebo. A small number of available investigations in vancomycin use with major design limitations have resulted in no significant VRE emergency. Unexpectedly, widespread use of vancomycin was followed by a notable transition toward Gram-negative and opportunistic organisms. In summary, vancomycin may only be considered in patients with documented MRSA colonization, \u03b2-lactam allergy, or selected revision procedures, but its widespread empirical use as a first-choice therapy is not supported.<\/jats:p>","DOI":"10.3390\/antibiotics14100996","type":"journal-article","created":{"date-parts":[[2025,10,6]],"date-time":"2025-10-06T15:05:06Z","timestamp":1759763106000},"page":"996","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Does Vancomycin as the First-Choice Therapy for Antibiotic Prophylaxis Increase the Risk of Surgical Site Infections Following Spine Surgery?"],"prefix":"10.3390","volume":"14","author":[{"given":"Vojislav","family":"Bogosavljevic","sequence":"first","affiliation":[{"name":"Clinic of Neurosurgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dusan","family":"Spasic","sequence":"additional","affiliation":[{"name":"Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-4174-3481","authenticated-orcid":false,"given":"Lidija","family":"Stanic","sequence":"additional","affiliation":[{"name":"Clinic of Neurosurgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marija","family":"Kukuric","sequence":"additional","affiliation":[{"name":"Department of Emergency Radiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4564-5238","authenticated-orcid":false,"given":"Milica","family":"Bajcetic","sequence":"additional","affiliation":[{"name":"Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,10,5]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1199","DOI":"10.1016\/S0140-6736(24)01867-1","article-title":"Global Burden of Bacterial Antimicrobial Resistance 1990\u20132021: A Systematic Analysis with Forecasts to 2050","volume":"404","author":"Naghavi","year":"2024","journal-title":"Lancet"},{"key":"ref_2","unstructured":"Suetens, C., K\u00e4rki, T., and Plachouras, D. (2025, July 29). Point Prevalence Survey of Healthcare-Associated Infections and Antimicrobial Use in European Acute Care Hospitals\u20142022\u20132023; Stockholm. Available online: https:\/\/www.ecdc.europa.eu\/sites\/default\/files\/documents\/healthcare-associated-point-prevalence-survey-acute-care-hospitals-2022-2023.pdf."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1186\/s13756-021-00889-9","article-title":"A Nationwide Assessment of the Burden of Healthcare-Associated Infections and Antimicrobial Use among Surgical Patients: Results from Serbian Point Prevalence Survey, 2017","volume":"10","author":"Dragovac","year":"2021","journal-title":"Antimicrob. Resist. Infect. Control"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1387","DOI":"10.1016\/j.spinee.2013.06.030","article-title":"An Evidence-Based Clinical Guideline for Antibiotic Prophylaxis in Spine Surgery","volume":"13","author":"Shaffer","year":"2013","journal-title":"Spine J."},{"key":"ref_5","first-page":"100278","article-title":"Antibiotic Use in Spine Surgery: A Narrative Review Based in Principles of Antibiotic Stewardship","volume":"16","author":"Anwar","year":"2023","journal-title":"N. Am. Spine Soc. J."},{"key":"ref_6","first-page":"184","article-title":"Principles of Antibiotic Therapy","volume":"9","author":"Varley","year":"2009","journal-title":"Contin. Educ. Anaesth. Crit. Care Pain"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"152","DOI":"10.1016\/j.clineuro.2019.05.017","article-title":"Cefazolin versus Vancomycin for Neurosurgical Operative Prophylaxis\u2014A Single Institution Retrospective Cohort Study","volume":"182","author":"Nguyen","year":"2019","journal-title":"Clin. Neurol. Neurosurg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"E366","DOI":"10.1097\/BRS.0000000000002839","article-title":"The Impact of Vancomycin and Cefazolin as Standard Preoperative Antibiotic Prophylaxis on Surgical Site Infections Following Instrumented Spinal Fusion","volume":"44","author":"Lopez","year":"2019","journal-title":"Spine"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"337","DOI":"10.1016\/j.jhin.2008.04.032","article-title":"Vancomycin versus Cefazolin Prophylaxis for Cerebrospinal Shunt Placement in a Hospital with a High Prevalence of Meticillin-Resistant Staphylococcus Aureus","volume":"69","author":"Tacconelli","year":"2008","journal-title":"J. Hosp. Infect."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1016\/j.jhin.2019.04.017","article-title":"Antibiotic Prophylaxis in Spine Surgery: A Comparison of Single-Dose and 72-Hour Protocols","volume":"103","author":"Maciejczak","year":"2019","journal-title":"J. Hosp. Infect."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1890","DOI":"10.1177\/21925682241270097","article-title":"Comparison of Surgical Site Infection After Instrumented Spine Surgery in Patients with High Risk of Infection According to Different Antibiotic Prophylaxis Protocols: A Cohort Study of 132 Patients With a Minimum Follow-Up of 1 Year","volume":"15","year":"2025","journal-title":"Glob. Spine J."},{"key":"ref_12","unstructured":"Singh, P., and Wattier, R. (2025, July 29). Surgical and Trauma Antimicrobial Prophylaxis Guidelines; Oakland, San Francisco. Available online: https:\/\/idmp.ucsf.edu\/sites\/g\/files\/tkssra4251\/f\/Surgical%20Ppx%20Guidelines%202023_1.pdf."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Zelenitsky, S.A. (2023). Effective Antimicrobial Prophylaxis in Surgery: The Relevance and Role of Pharmacokinetics-Pharmacodynamics. Antibiotics, 12.","DOI":"10.3390\/antibiotics12121738"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"21925682251341833","DOI":"10.1177\/21925682251341833","article-title":"Vancomycin Antibiotic Prophylaxis Compared to Cefazolin Increases Risk of Surgical Site Infection Following Spine Surgery","volume":"7","author":"Herrington","year":"2025","journal-title":"Glob. Spine J."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1186\/s13756-020-00784-9","article-title":"Indirect Comparison of Efficacy between Different Antibiotic Prophylaxis against the Intracranial Infection after Craniotomy","volume":"9","author":"Cao","year":"2020","journal-title":"Antimicrob. Resist. Infect. Control"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"142","DOI":"10.1016\/j.spinee.2008.05.008","article-title":"Antibiotic Prophylaxis in Spine Surgery: An Evidence-Based Clinical Guideline for the Use of Prophylactic Antibiotics in Spine Surgery","volume":"9","author":"Watters","year":"2009","journal-title":"Spine J."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e001305","DOI":"10.1136\/tsaco-2023-001305","article-title":"Surgical and Procedural Antibiotic Prophylaxis in the Surgical ICU: An American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document","volume":"9","author":"Farrell","year":"2024","journal-title":"Trauma Surg. Acute Care Open"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"173","DOI":"10.21037\/jss.2018.05.04","article-title":"The Combined Administration of Vancomycin IV, Standard Prophylactic Antibiotics, and Vancomycin Powder in Spinal Instrumentation Surgery: Does the Routine Use Affect Infection Rates and Bacterial Resistance?","volume":"4","author":"Park","year":"2018","journal-title":"J. Spine Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1002\/phar.1678","article-title":"A Retrospective Study on the Protective Effects of Topical Vancomycin in Patients Undergoing Multilevel Spinal Fusion","volume":"36","author":"Gaviola","year":"2016","journal-title":"Pharmacother. J. Hum. Pharmacol. Drug Ther."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2084","DOI":"10.1097\/BRS.0b013e3181ff2cb1","article-title":"Intrawound Application of Vancomycin for Prophylaxis in Instrumented Thoracolumbar Fusions","volume":"36","author":"Sweet","year":"2011","journal-title":"Spine"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"746","DOI":"10.1093\/neuros\/nyw097","article-title":"Does Intrawound Vancomycin Application During Spine Surgery Create Vancomycin-Resistant Organism?","volume":"80","author":"Chotai","year":"2017","journal-title":"Neurosurgery"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1016\/j.aott.2018.05.004","article-title":"The Effectiveness of Pedicle Screw Immersion in Vancomycin and Ceftriaxone Solution for the Prevention of Postoperative Spinal Infection: A Prospective Comparative Study","volume":"52","author":"Eren","year":"2018","journal-title":"Acta Orthop. Traumatol. Turc."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"196","DOI":"10.4184\/asj.2013.7.3.196","article-title":"Prospective Randomized Study for Antibiotic Prophylaxis in Spine Surgery: Choice of Drug, Dosage, and Timing","volume":"7","author":"Nishant","year":"2013","journal-title":"Asian Spine J."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"366","DOI":"10.3171\/2020.11.SPINE201891","article-title":"Antimicrobial Prophylaxis in Noninstrumented Spine Surgery: A Prospective Study to Determine Efficacy and Drawbacks","volume":"35","author":"Amelot","year":"2021","journal-title":"J. Neurosurg. Spine"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"696","DOI":"10.1016\/j.jspd.2019.01.005","article-title":"Local Application of Vancomycin in Spine Surgery Does Not Result in Increased Vancomycin-Resistant Bacteria\u201410-Year Data","volume":"7","author":"Khanna","year":"2019","journal-title":"Spine Deform."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"136","DOI":"10.1186\/s13756-021-01006-6","article-title":"Effectiveness of Topical Vancomycin in the Prevention of Spinal Surgical Site Infections: A Retrospective Cohort Study","volume":"10","author":"Tafish","year":"2021","journal-title":"Antimicrob. Resist. Infect. Control"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"331","DOI":"10.3171\/2013.6.SPINE121105","article-title":"Comparative Effectiveness and Cost-Benefit Analysis of Local Application of Vancomycin Powder in Posterior Spinal Fusion for Spine Trauma","volume":"19","author":"Godil","year":"2013","journal-title":"J. Neurosurg. Spine"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"2710","DOI":"10.1016\/j.spinee.2014.03.011","article-title":"Cost Savings Analysis of Intrawound Vancomycin Powder in Posterior Spinal Surgery","volume":"14","author":"Emohare","year":"2014","journal-title":"Spine J."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"816","DOI":"10.1016\/j.wneu.2014.12.033","article-title":"The Use of Vancomycin Powder In Modern Spine Surgery: Systematic Review and Meta-Analysis of the Clinical Evidence","volume":"83","author":"Bakhsheshian","year":"2015","journal-title":"World Neurosurg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"473","DOI":"10.3171\/2019.6.SPINE19120","article-title":"Double-Blind Randomized Clinical Trial of Vancomycin in Spinal Arthrodesis: No Effects on Surgical Site Infection","volume":"32","author":"Finger","year":"2020","journal-title":"J. Neurosurg. Spine"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"e42818","DOI":"10.1097\/MD.0000000000042818","article-title":"A Meta-Analysis of the Efficacy of Topical Antibiotics in Spinal Surgery for the Prevention of Surgical Site Infection","volume":"104","author":"Wang","year":"2025","journal-title":"Medicine"}],"container-title":["Antibiotics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2079-6382\/14\/10\/996\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,6]],"date-time":"2025-10-06T15:31:27Z","timestamp":1759764687000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2079-6382\/14\/10\/996"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,10,5]]},"references-count":31,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2025,10]]}},"alternative-id":["antibiotics14100996"],"URL":"https:\/\/doi.org\/10.3390\/antibiotics14100996","relation":{},"ISSN":["2079-6382"],"issn-type":[{"value":"2079-6382","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,10,5]]}}}