Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial.

Importance: Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist. Objective: To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections. Design, Setting, and Participants: This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers. Interventions: A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder. Main Outcomes and Measures: The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence. Results: The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections. Conclusions and Relevance: Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin. Trial Registration: ClinicalTrials.gov Identifier: NCT02227446.

Seasonal drivers of chemical and hydrological patterns in roadside infiltration-based green infrastructure.

Infiltration-based green infrastructure has become a popular means of reducing stormwater hazards in urban areas. However, the long-term effects of green infrastructure on the geochemistry of roadside environments are poorly defined, particularly given the considerable roadside legacy metal contamination from historic industrial activity and vehicle emissions (e.g., Pb). Most current research on green infrastructure geochemistry is restricted to time periods of less than a year or limited sets of chemical species. This further limits our understanding of systems that evolve over time and are subject to seasonal variability. Between 2016 and 2018, two infiltration trenches in Pittsburgh, PA, were monitored to determine infiltration rates and dissolved nutrient and metal content. The trench water was analyzed to characterize seasonal patterns in both trench function and chemistry. Shifting patterns in infiltration rate and geochemical activity show trends corresponding with seasonal changes. Trench function is dependent on the local water table, with the highest infiltration rates occurring when evapotranspiration is active and groundwater elevation is low. Two seasonal chemical patterns were identified. The first is driven by road salt application in the winter and interaction of the salt pulse increase Pb and Cu concentrations. The second is driven by the formation of summer reducing environments that increase dissolved Fe and Mn. These findings suggest that chemical and hydrological activity in infiltration-based green infrastructure varies seasonally and may remobilize legacy contamination.