Incomplete Administration of Intravenous Vancomycin Prophylaxis is Common and Associated With Increased Infectious Complications After Primary Total Hip and Knee Arthroplasty

Feder, Oren I.; Yeroushalmi, David; Lin, Charles C.; Galetta, Matthew S.; Meftah, M.; Lajam, Claudette M.; Slover, James; Schwarzkopf, Ran; Bosco, Joseph; Macaulay, William

doi:10.1016/j.arth.2021.03.035

Cited by 12 publications

(10 citation statements)

References 29 publications

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“…Furthermore, vancomycin monotherapy used for prophylaxis had a 1.587 odds ratio of suffering a PJI compared to cefazolin monotherapy. 12 Feder et al 24 similarly found that late (within 30 minutes of incision), incomplete administration of intravenous vancomycin prophylaxis had a greater than five-fold increased risk of PJI (OR 5.22; p = 0.112). Notably, our institution used a weight-based dosing regimen for vancomycin started 120 minutes before skin incision, which mitigates confounding from potentially incomplete or inappropriately dosed vancomycin.…”

Section: Discussionmentioning

confidence: 97%

Cefazolin remains the linchpin for preventing acute periprosthetic joint infection following primary total knee arthroplasty

et al. 2022

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Aims Despite recent literature questioning their use, vancomycin and clindamycin often substitute cefazolin as the preoperative antibiotic prophylaxis in primary total knee arthroplasty (TKA), especially in the setting of documented allergy to penicillin. Topical povidone-iodine lavage and vancomycin powder (VIP) are adjuncts that may further broaden antimicrobial coverage, and have shown some promise in recent investigations. The purpose of this study, therefore, is to compare the risk of acute periprosthetic joint infection (PJI) in primary TKA patients who received cefazolin and VIP to those who received a non-cephalosporin alternative and VIP. Methods This was a retrospective cohort study of 11,550 primary TKAs performed at an orthopaedic hospital between 2013 and 2019. The primary outcome was PJI occurring within 90 days of surgery. Patients were stratified into two groups (cefazolin vs non-cephalosporin) based on their preoperative antibiotic. All patients also received the VIP protocol at wound closure. Bivariate and multiple logistic regression analyses were performed to control for potential confounders and identify the odds ratio of PJI. Results In all, 10,484 knees (90.8%) received cefazolin, while 1,066 knees (9.2%) received a non-cephalosporin agent (either vancomycin or clindamycin) as preoperative prophylaxis. The rate of PJI in the cefazolin group (0.5%; 48/10,484) was significantly lower than the rate of PJI in the non-cephalosporin group (1.0%; 11/1,066) (p = 0.012). After controlling for confounding variables, the odds ratio (OR) of developing a PJI was increased in the non-cephalosporin cohort compared to the cefazolin cohort (OR 2.389; 1.2 to 4.6); p = 0.01). Conclusion Despite the use of topical irrigant solutions and addition of local antimicrobial agents, the use of a non-cephalosporin perioperative antibiotic continues to be associated with a greater risk of TKA PJI compared to cefazolin. Strategies that increase the proportion of patients receiving cefazolin rather than non-cephalosporin alternatives must be emphasized. Cite this article: Bone Jt Open 2022;3(1):35–41.

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Section: Discussionmentioning

confidence: 97%

Cefazolin remains the linchpin for preventing acute periprosthetic joint infection following primary total knee arthroplasty

et al. 2022

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“…Correct dosing of vancomycin to achieve the required minimum inhibitory concentration is challenging, which may limit its effectiveness [ 28 ]. Incomplete administration [ 29 ] of vancomycin or vancomycin as monotherapy used in prophylaxis [ 28 ] is reported to have a greater risk for PJI. The use of vancomycin could therefore significantly contribute to the higher incidence of PJI in the non-cephalosporin cohorts of the aforementioned studies.…”

Section: Discussionmentioning

confidence: 99%

The Impact of Patient-Reported Penicillin or Cephalosporin Allergy on the Occurrence of the Periprosthetic Joint Infection in Primary Knee and Hip Arthroplasty

et al. 2022

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Reducing the risk of periprosthetic joint infections (PJI) requires a multi-pronged strategy including usage of a prophylactic antibiotic. A history of penicillin or cephalosporin allergy often leads to a change in prophylactic antibiotic regimen to avoid serious side effects. The purpose of the present retrospective study was to determine incidence of PJI based on perioperative antibiotic regimen in total hip arthroplasty (THA), total knee arthroplasty (TKA) or unicompartmental knee arthroplasty (UKA). A review of all primary THAs, primary TKAs and primary UKAs, undertaken between 2011 and 2020 in a tertiary referral hospital, was performed. The standard perioperative antibiotic for joint arthroplasty (JA) in the analyzed tertiary hospital is cefuroxime. There were no differences in prophylactic antibiotic regimen over time. In 7.9% (211 of 2666) of knee arthroplasties and in 6.0% (206 of 3419) of total hip arthroplasties, a second-line prophylactic antibiotic was used. There was no statistically significant higher occurrence of PJI between the first-line and second-line prophylactic antibiotic in knee arthroplasties (p = 0.403) as well as in total hip arthroplasties (p = 0.309). No relevant differences in age, American Society of Anesthesiologists (ASA) score and body mass index (BMI) between the groups were observed.

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“…Incomplete infusion before incision or infusion postincision places the patient at risk for surgical site infection or prosthetic joint infection [22]. In addition, specific to vancomycin, given the long infusion time required for vancomycin, several studies have shown an increased risk of PJI associated with incomplete infusion before incision [5,23].…”

Section: When Should Antibiotics Be Administered and For How Long?mentioning

confidence: 99%

Preoperative Prophylactic Antibiotics in Total Hip and Knee Arthroplasty: What, When, and How

Spangehl

2022

The Journal of Arthroplasty

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Incomplete Administration of Intravenous Vancomycin Prophylaxis is Common and Associated With Increased Infectious Complications After Primary Total Hip and Knee Arthroplasty

Cited by 12 publications

References 29 publications

Cefazolin remains the linchpin for preventing acute periprosthetic joint infection following primary total knee arthroplasty

Cefazolin remains the linchpin for preventing acute periprosthetic joint infection following primary total knee arthroplasty

The Impact of Patient-Reported Penicillin or Cephalosporin Allergy on the Occurrence of the Periprosthetic Joint Infection in Primary Knee and Hip Arthroplasty

Preoperative Prophylactic Antibiotics in Total Hip and Knee Arthroplasty: What, When, and How

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