Is Vancomycin-only Prophylaxis for Patients With Penicillin Allergy Associated With Increased Risk of Infection After Arthroplasty?

Abstract

Background Preoperative antibiotic prophylaxis remains one of the most important strategies for prevention of postoperative infection. In patients with penicillin allergy, alternative medications such as vancomycin are often used despite reduced antimicrobial coverage and recent literature questioning the efficacy of vancomycin monotherapy. Questions/purposes (1) Are patients who receive vancomycin alone for penicillin allergy at greater odds of developing surgical site infection (SSI) as compared with patients who receive cefazolin for prophylaxis before total joint arthroplasty (TJA) without a patient-reported allergy? (2) What organism profile is associated with vancomycin monotherapy?Methods We performed a retrospective study of 10,391 primary TJAs performed between 2005 and 2014 at two institutions with a minimum of 1-year followup. Patients reporting penicillin or cephalosporin allergy were electronically queried from the anesthesia note. The odds of deep SSI and causative organisms were compared using multivariate analysis between b-lactam-allergic patients receiving vancomycin and nonallergic patients receiving cefazolin. Results After controlling for potential confounders, including comorbidities, we found that vancomycin alone did not affect the odds of deep SSI development (adjusted odds ratio [OR], 0.98; 95% confidence interval [CI], 0.67-1.43; p = 0.907). Although the overall odds of deep SSI were not different for patients receiving vancomycin versus cefazolin, we found that vancomycin was associated with a reduced risk of infection with Gram-positive organisms (adjusted OR, 0.25 [CI,; p = 0.003) and antibiotic-resistant organisms (adjusted OR, 0.10 [CI,

Vancomycin Prophylaxis for Total Joint Arthroplasty: Incorrectly Dosed and Has a Higher Rate of Periprosthetic Infection Than Cefazolin

“…In a study of 18,830 primary TJAs utilizing the Veterans Affairs database, Ponce et al [21] found that the SSI rate was higher in patients who received vancomycin as the sole prophylactic agent compared with cefazolin (2.6% versus 1.3%). The main reason for this observation is that unlike cephalosporins, which have some Gram-negative coverage, vancomycin has no coverage against Gram-negative organisms [12,30]. One study by Tan et al [30] demonstrated that administration of vancomycin as a sole agent for patients undergoing TJA resulted in a higher rate of Gram-negative deep SSI (odds ratio, 2.42), perhaps highlighting the issue regarding lack of coverage against some pathogens.…”

“…The main reason for this observation is that unlike cephalosporins, which have some Gram-negative coverage, vancomycin has no coverage against Gram-negative organisms [12,30]. One study by Tan et al [30] demonstrated that administration of vancomycin as a sole agent for patients undergoing TJA resulted in a higher rate of Gram-negative deep SSI (odds ratio, 2.42), perhaps highlighting the issue regarding lack of coverage against some pathogens. Another study by Tyllianakis et al [31] demonstrated no difference in the SSI rate between patients receiving cefuroxime (six of 188) and those receiving vancomycin (six of 129) in a prospective randomized study.…”

“…This study was set up to determine the incidence of PJI in patients undergoing TJA who received cefazolin only versus those who received vancomycin only as the perioperative prophylaxis. Although it is known that vancomycin does not have coverage against Gram-negative organisms [12,30] and has been shown to have a higher risk of surgical site infections [21,30], it is unknown whether patients who receive vancomycin as their sole prophylactic agent have a higher rate of PJI compared with those receiving cefazolin.…”

Adverse reactions of vancomycin in humans

“…[ 2 , 3 ] It is commonly used for methicillin-resistant Staphylococcus aureus (MRSA), ampicillin-resistant enterococci and Gram-positive organisms in patients allergic to penicillin. [ 4 – 6 ] Vancomycin is usually given by intravenous drip. In the treatment of Clostridium difficile-associated disease, vancomycin is taken orally.…”

Editor's Spotlight/Take 5: Vancomycin Prophylaxis for Total Joint Arthroplasty: Incorrectly Dosed and Has a Higher Rate of Periprosthetic Infection Than Cefazolin

“…Dr. Kheir: Patient-reported penicillin allergy has important consequences for antibiotic selection, as cephalosporin agents normally used for perioperative prophylaxis are avoided due to the potential for cross-reactivity, even though the associated risks are unclear [3,8,15]. Of consequence, administering suboptimal antibiotics can increase the risk of infection in these patients [5,13,18,22]. The current guidelines established by the International Consensus Meeting on PJI recommends that vancomycin substitution only be in cases of severe anaphylactic penicillin allergy [6,20].…”