Intrawound Vancomycin Powder in Surgical Site Infection Prophylaxis: A Comprehensive Review of Mechanisms, Efficacy, Safety, and Clinical Controversies.

Surgical site infections (SSIs) remain a critical postoperative complication that causes significant morbidity, mortality, and healthcare costs. To mitigate these risks, intrawound vancomycin powder has been increasingly adopted as a prophylactic option, particularly for high-risk procedures such as spine, orthopedic trauma, and cardiothoracic surgeries. However, the decision ultimately remains at the surgeon's discretion. This comprehensive review evaluates the mechanisms, clinical efficacy, and controversies surrounding the application of topical vancomycin. The current literature shows that intrawound vancomycin powder effectively reduces Gram-positive SSIs, overcomes ischemic barriers to early biofilm formation, and maintains a safe systemic profile while remaining highly cost-effective. However, serious clinical concerns remain about its widespread use, including higher rates of sterile wound dehiscence, possible localized cellular toxicity that may impair bone fusion, changes in pathogen profiles, and the growing threat of antimicrobial resistance. The absence of a US Food and Drug Administration (FDA) approval, lack of standardized dosing regimens, and warnings from major health organizations complicate its true clinical utility. Ultimately, the available literature suggests a shift away from universal application and toward tightly controlled, targeted interventions guided by strict antimicrobial stewardship. However, it remains for surgeons to evaluate risks versus benefits when administering vancomycin powder into incisions. Ongoing large-scale randomized controlled trials and emerging translational approaches, such as extended-release carrier systems and personalized bacteriological profiling, are essential for establishing definitive, evidence-based clinical guidelines.