Addition of Vancomycin to Cefazolin Prophylaxis Is Associated With Acute Kidney Injury After Primary Joint Arthroplasty

Abstract

Background With increasing prevalence of methicillinresistant Staphylococcus aureus (MRSA) in patients undergoing hip and knee arthroplasty, some have advocated a dual-antibiotic regimen including vancomycin as prophylaxis against surgical site infections. However, routine administration of vancomycin may result in impaired renal functions in susceptible patients. Questions/purposes The purpose of this study was to determine whether patients receiving antibiotic prophylaxis with cefazolin and vancomycin have a higher risk of postoperative acute kidney injury (AKI) compared with patients receiving cefazolin alone before elective primary hip and knee arthroplasty. We also aimed to compare severity and recovery of AKI in these two cohorts and to determine independent risk factors for AKI. Methods We retrospectively evaluated a series of 1828 patients undergoing primary hip and knee arthroplasty over a 2-year period who received either cefazolin (n = 500) or cefazolin and vancomycin (n = 1328) as perioperative antibiotic prophylaxis. During the study period, a perceived high prevalence of MRSA infections at our institution led some surgeons to add vancomycin to the prophylactic antibiotic regimen. The patient characteristics, case mix, and preoperative renal function and baseline creatinine clearance were similar between the two groups. We defined AKI according to the published Acute Kidney Injury Network (AKIN) criteria, and the risk of AKI in both groups was compared. We also compared the proportions of patients by AKIN severity stage and assessed recovery as defined by creatinine levels showing kidney function reaching 50% baseline. The American Society of Anesthesiologists (ASA) classification, preoperative chronic kidney disease, intraoperative fluid requirements, and estimated blood loss were recorded. We analyzed the data using a multivariate logistic regression model to identify potential independent risk factors, including dual antibiotic therapy. Results Patients receiving dual antibiotics were more likely to develop AKI compared with those receiving cefazolin alone (13% versus 8%, p = 0.002). Dual-antibiotic prophylaxis also was associated with greater severity; patients in the dual antibiotic group had higher rates of Grade II and III acute kidney injury (3% versus 0%, p = 0.003). There was no difference in the rate of return to baseline renal function (2 ± 1.4 days versus 3 ± 3.4 days; mean difference, 0.5 days; 95% confidence interval [CI], À0.2 to 1.2 days; p = 0.155). Controlling for confounding variables, dual antibiotic prophylaxis (adjusted odds ratio [OR], 1.82; 95% CI, 1.25-2.64; p = 0.002), ASA class

Antibiotic resistance in early periprosthetic joint infection

“…In a study of 1828 hip and knee arthroplasty patients, Courtney et al . reported a higher rate of acute kidney injury in patients receiving dual prophylaxis than those given cefazolin alone (13% versus 8%, P = 0.002) . Additionally, in the same cohort of patients, Sewick et al .…”

Preoperative antibiotics and cardiovascular implantable electronic device infection: A cohort study in veterans

“…Courtney et al. also showed that patients who received combined vancomycin and cefazolin as prophylaxis for primary joint arthroplasty had a significantly higher risk of acute kidney injury as compared to patients who received cefazolin alone …”

“…The efficacy of vancomycin versus cefazolin or other antistaphylococcal antibiotics as surgical site prophylaxis has not been studied in prospective clinical trials in patients who undergo CIED placement or revision. Ascompared to cefazolin, vancomycin is less effective in vitro and in vivo against methicillin‐susceptible Staphylococcus aureus (MSSA), has no Gram‐negative coverage, and has nephrotoxicity risk (which can occur even with one dose) . Therefore, vancomycin is not used as routine surgical site prophylaxis.…”

Editorial Comment: Symposium: 2014 Musculoskeletal Infection Society

“…However, it is important to assess the efficacy, safety, and cost of these interventions in order to implement prevention protocols that will reduce infection rates in a safe and cost-effective way. More is not necessarily better, as was shown with the addition of vancomycin to cephazolin prophylaxis in primary joint arthroplasty [1]. We should also be aware that a patient with a history of a PJI has increased risk of subsequent PJI at a different site.…”