Topical antibiotic powder reduces fracture-related infections in pelvic and lower limb fractures: a systematic review and meta-analysis.

Abstract

Fracture-related infection (FRI) remains a significant public health issue. Intrawound vancomycin and tobramycin powder achieve high local antibiotic concentrations, yet their efficacy and safety remain uncertain. We aimed to evaluate the effect of prophylactic topical antibiotic powder in patients undergoing operative treatment for pelvic and lower-limb fractures. PubMed, Embase, and the Cochrane Library were systematically searched for randomized controlled trials (RCTs) and observational studies comparing intrawound antibiotic powder (vancomycin and/or tobramycin) with standard systemic prophylaxis in operatively treated pelvic and lower limb fractures. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled using random-effects models, and the certainty of evidence was assessed with the GRADE approach. Fourteen studies (three RCTs and 11 observational studies) comprising 4906 patients were included, of whom 1779 received topical antibiotic powder. Topical antibiotic powder reduced the odds of FRI (OR 0.63; 95% CI 0.45 to 0.87), with the greatest effect in high-risk and open fractures (OR 0.54 and 0.49, respectively). No significant effect was observed on superficial surgical site infection (OR 0.79; 95% CI 0.51 to 1.21) or nonunion (OR 1.03; 95% CI 0.64 to 1.66). Gram-negative organisms were more frequent in the intervention group (OR 2.52; 95% CI 1.24 to 5.14), whereas the trend for Gram-positive organisms favored the intervention (OR 0.42; 95% CI 0.16 to 1.08). No significant difference was found for acute kidney injury (AKI) (OR 0.94; 95% CI 0.44 to 2.02) or length of hospital stay (MD - 1.72 days; 95% CI - 4.05 to 0.61). Moderate-certainty evidence, derived predominantly from observational studies, indicates that intrawound antibiotic powder is associated with a 37% reduction in FRI without an increase in nonunion or AKI. However, the safety outcomes were informed by a few studies with low to very low certainty and should be interpreted with caution; the observed shift toward Gram-negative infections warrants further investigation.