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Does intraoperative use of vancomycin powder help reduce prosthetic joint infection?
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May contribute to antibiotic resistance
The administration of vancomycin powder into orthopedic surgical wounds has been well described in the setting of posterior spinal fusion. With the clinical evidence demonstrating that this is a successful prophylactic measure in spine patients, there has been interest in adopting this practice in hip and knee replacement surgery. There is currently a dearth of literature on this practice for total joint replacement. There is evidence that local administration of vancomycin achieves high levels of the antibiotic in the hip and knee joint with likely bactericidal properties, without excessive serum levels of the medication. This may translate to lower PJI rates. However, there are a number of unknowns which preclude recommending the widespread adoption of this practice for total joint replacement.
The most relevant concerns include that its use may contribute to antibiotic resistance and the specter of increasing the rates of atypical infections. In theory, the administration of vancomycin powder would be beneficial, especially when considering the individual patient as opposed to population-based health. At this time, further research is needed prior to encouraging others to adopt the practice of using vancomycin more broadly in joint replacement. Ideally, a multicenter, randomized, controlled trial with a priori power analysis would need to be conducted to answer this question. The results of that investigation would then also have to be analyzed in the context of the historical impact of widespread use of vancomycin powder.
Joseph J. Kavolus II, MD, is an orthopedic resident at Duke University School of Medicine in Durham, North Carolina.
Disclosure: Kavolus reports no relevant financial disclosures.
More evidence needed for vancomycin use
Surgical site infection will forever be an unfortunate and costly complication of surgery. Published guidelines based on systematic, full-text reviews of the literature clearly support prophylactic use of preoperative systemic antibiotics to prevent surgical site infection (SSI). Adjuvant antibiotic-based modalities to further diminish the risk of SSI have also been studied in the past few decades with a renewed interest in local antibiotic delivery. Some of these methods include direct placement of lyophilized antibiotic powder into the wound or adding antibiotics to bone graft, calcium sulfate beads, cement, collagen sponges and a variety of other potential vectors.
A wear simulation study has shown that vancomycin powder is most likely safe in terms of third-body polyethylene wear. A basic science study on rats that have a contaminated intra-articular implant has shown that when combined with systemic antibiotics, vancomycin powder eliminates MRSA bacterial contamination. Another study showed that vancomycin powder produced highly therapeutic wound concentrations even at 24 hours after primary hip and knee replacement.
Several studies, mostly retrospective ones and studies in the spine literature, have suggested that local delivery of vancomycin powder could lower the risk of SSI. Data in the arthroplasty world is truly lacking. Two retrospective studies are just not convincing that adding vancomycin powder in the surgical wound diminishes the risk of SSI. One of the studies comparing two cohorts that involved 1,640 hip and knee arthroplasties showed only the revision procedures were associated with a significant reduction in the rate of early infections. The second study, which was published in an open access journal not found on PubMed, examined 125 patients and found there was a significantly lower infection rate for patients who received topical vancomycin.
Given the lack of current clinical evidence on this topic, I support the 2017 CDC Guideline for the Prevention of Surgical Site Infection that states, “Do not apply antimicrobial agents (ie, ointments, solutions or powders) to the surgical incision for the prevention of SSI.” Stronger studies are needed to answer the question of whether the application of powdered antibiotics in the deep or superficial space around a joint arthroplasty will diminish the risk of SSI.
- References:
- Berríos-Torres SI, et al. JAMA Surg. 2017;doi:10.1001/jamasurg.2017.0904.
- Edelstein AI, et al. J Bone Joint Surg Am. 2017;doi:10.2106/JBJS.16.00127.
- Johnson JD, et al. J Arthroplasty. 2017;doi:10.1016/j.arth.2015.10.015.
- Omrani FA, et al. Biosci Biotechnol Res Asia. 2015;doi:10.13005/bbra/1914.
- Otte JE, et al. Surg Technol Int. 2017;30:284-289.
- Qadir R, et al. J Arthroplasty. 2014;doi:10.1016/j.arth.2014.02.012.
Calin S. Moucha, MD, is chief of adult reconstruction and joint replacement surgery at The Mount Sinai Hospital in New York.
Disclosure: Moucha reports he is on the speakers panel for 3M and Biocomposites.