Prophylactic peri-operative local antibiotic irrigation

Abstract

An extensive review of the spinal and arthroplasty literature was undertaken to evaluate the effectiveness of local antibiotic irrigation during surgery. The efficacy of antibiotic irrigation for the prevention of acute post-operative infection after total joint arthroplasty was evaluated retrospectively in 2293 arthroplasties (1990 patients) between January 2004 and December 2013. The mean follow-up was 73 months (20 to 139). One surgeon performed all the procedures with minimal post-operative infection. The intra-operative protocol included an irrigation solution of normal saline with vancomycin 1000 mg/l and polymyxin 250,000 units/l at the rate of 2 l per hour. No patient required re-admission for primary infection or further antibiotic treatment. Two morbidly obese patients (two total hip arthroplasties) developed subcutaneous fat necrosis requiring debridement and one was revised because the deep capsular sutures were contaminated by the draining subcutaneous haematoma. One patient who had undergone total knee arthroplasty had unrecognised damage to the lateral superior geniculate artery and developed a haematoma that became infected secondarily four months after the surgery and underwent revision. The use of antibiotic irrigation during arthroplasty surgery has been highly effective for the prevention of infection in the author's practice. However, it should be understood that any routine prophylactic use of antibiotics may result in resistant organisms, and the wise stewardship of the use of antibiotics is an important part of surgical practice.

Local Vancomycin Concentrations after Intra-articular Injection into the Knee Joint: An Experimental Porcine Study

“…If implants are inserted, intra-articular vancomycin injection may be even more valuable to meet the more aggressive targets needed to prevent bacterial implant colonization. 3,24 Given that intravenous vancomycin administration might not provide adequate target-site concentrations, [5][6][7] intra-articular vancomycin injection can be an important supplement to systemic administration in the prevention of PJI. Interestingly, the vancomycin concentrations found in the synovial fluid of the pig knee joints demonstrated a rather large variation.…”

“…28 Finally, development of antimicrobial resistance is widely discussed and concerns still remain. 3,28 Further in vivo investigations of these matters are warranted.…”

“…[5][6][7] Various perioperative local vancomycin applications have been employed, given its potential to reach high target-site concentrations and at the same time lowering the systemic toxic side effects due to lower systemic concentrations. 3,8,9 Especially when implants are involved, local vancomycin application may be promising, given the increasing bacterial virulence. 3,10 Intra-articular injection of vancomycin is an example of local vancomycin delivery, which is both practical and safe to handle.…”

“…3,8,9 Especially when implants are involved, local vancomycin application may be promising, given the increasing bacterial virulence. 3,10 Intra-articular injection of vancomycin is an example of local vancomycin delivery, which is both practical and safe to handle. 11,12 Traditionally, vancomycin bone and synovial fluid concentrations have been assessed using bone tissue samples and drain fluid.…”

Intra-Operative Surgical Irrigation of the Surgical Incision: What Does the Future Hold—Saline, Antibiotic Agents, or Antiseptic Agents?

“…Several studies have explored the addition of antibiotic agents to lavage fluid to reduce the risk of SSI. In a single physician practice [27], the efficacy of antibiotic irrigation for the prevention of early SSI after total joint surgical procedures was evaluated retrospectively in 2293 arthroplasties (1990 patients) between January 2004 and December 2013. The mean follow-up time was 73 months (20-139).…”