High-risk ≠ mandatory prophylaxis: a real-world study of 274 PVP patients who omitted antimicrobial prophylaxis

Abstract Background Surgical site infections (SSIs) following percutaneous vertebroplasty (PVP) are infrequent but can have serious consequences. Current guidelines suggest that antimicrobial prophylaxis “may be considered” for high-risk patients undergoing PVP due to the implantation of bone cement. However, in practice, this conditional recommendation is often misinterpreted as a requirement, resulting in unnecessary antibiotic use. This study aimed to assess the safety of omitting antimicrobial prophylaxis in high-risk PVP patients. Methods We conducted a retrospective analysis of data from patients who underwent PVP at a tertiary hospital between January 2024 and January 2026. These patients did not receive preoperative antimicrobial prophylaxis and had at least 90 days of follow-up. The decision to omit prophylaxis was made by a clinical pharmacist during a preoperative multidisciplinary team (MDT) evaluation. This decision was based on the absence of active infection, indicated by no fever, no identifiable infectious focus, and normal procalcitonin levels when measured. The primary outcome was a 90-day SSI, defined by US CDC criteria, which includes a 90-day surveillance window for procedures involving implant placement. Postoperative follow-up was conducted via telephone, and patients were instructed to return immediately if they experienced wound redness, purulent discharge, fever, or any other signs of infection. Results The percentage of PVP procedures performed without antimicrobial prophylaxis rose from 52.2% (117/224) in 2024 to 66.3% (136/205) in 2025, and further increased to 87.5% (21/24) by January 2026. Throughout the study period (January 2024–January 2026), 274 PVP patients did not receive preoperative antimicrobial prophylaxis. Of these patients, 103 (37.6%) were aged 75 or older, 35 (12.8%) had diabetes mellitus, 21 (7.7%) had malignancy, 79 (28.8%) had chronic pulmonary disease, and 2 (0.7%) had hypoalbuminaemia. Three patients had both diabetes and malignancy. All 274 patients completed a 90-day follow-up, and none developed a surgical site infection. The 90-day SSI rate was 0% (95% CI 0–1.35%). Conclusions Once active infection is definitively ruled out, antimicrobial prophylaxis can be safely omitted, even for patients with conventional risk factors like advanced age, diabetes, and malignancy. A multidisciplinary team (MDT) approach, led by pharmacists and centered on confirming the absence of active infection, offers a safe and practical strategy for managing perioperative antimicrobial use.