Does Vancomycin as the First-Choice Therapy for Antibiotic Prophylaxis Increase the Risk of Surgical Site Infections Following Spine Surgery?

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, β-lactam allergy, or selected revision procedures, but its widespread empirical use as a first-choice therapy is not supported.