Efficacy of Vancomycin Powder Prophylaxis in 987 Cranial Surgeries for Nonmalignant Pathology

Neurosurgery 98:1076–1084, 2026

This study evaluates whether prophylactic subgaleal vancomycin powder reduces surgical site infections (SSIs) after 987 craniotomies for nonmalignant pathology. In a retrospective cohort (682 with vancomycin, 305 without), overall SSI incidence was very low and did not differ significantly between groups, with six infections recorded and diverse cultured pathogens.

The authors contrast prior studies biased toward malignant, high-risk populations, discuss potential harms of indiscriminate vancomycin use (resistance, wound complications), and recommend a more selective, evidence-based application while calling for larger multicenter research to define high-risk subgroups and dosing effects.

Objective Assess whether prophylactic subgaleal vancomycin powder reduces surgical site infections (SSI) in nonmalignant cranial surgeries.

Design Retrospective chart review of 987 nonmalignant cranial surgeries (July 2021–June 2024), comparing vancomycin powder (n=682) vs no vancomycin powder (n=305).

Intervention Vancomycin cohort received 1 g powder applied over the bone flap before galeal closure; all patients received standard IV cefazolin, chlorhexidine prep, and postoperative incisional bacitracin.

Primary outcome SSI incidence was not significantly different: 0.3% without vancomycin vs 0.7% with vancomycin (P = .578), with 6 total infections.

SSI distribution Infections occurred mainly with atypical meningiomas (3/6) and schwannomas (2/6), plus 1 amoebic abscess case.

Pathogens 7 pathogens were cultured from 6 SSI cases; Cutibacterium acnes was most common (3/6), and Klebsiella aerogenes occurred in 2 vancomycin cases (vancomycin-resistant).

Interpretation Routine prophylactic vancomycin powder in nonmalignant cranial surgery may be unnecessary given the very low SSI rate and lack of demonstrated benefit.

Caveats Retrospective design with potential selection bias and only 6 SSI events; larger/multicenter studies are needed to identify any high-risk subgroups who might benefit.