Intrawound vancomycin powder associated with increased PJI, reoperation rates after THA
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Key takeaways:
- Use of intrawound vancomycin powder was associated with increased periprosthetic joint infection and reoperation rates.
- Results were compared with patients who did not receive intrawound vancomycin powder.
Results from this prospective quality control study showed patients who received intrawound vancomycin powder had higher rates of periprosthetic joint infection and reoperations vs. patients who did not receive intrawound vancomycin powder.
From October 2021 to September 2022, researchers analyzed 523 patients who underwent primary THA with intrawound vancomycin powder (IVP) and 670 patients with similar age, BMI and sex who did not receive IVP during surgery. Outcome measures were assessed at 90-day follow-up and included culture-positive infection, gram-positive culture, reoperations, readmissions and wound complications.
Overall, patients who received IVP had a higher rate of culture-positive PJIs vs. patients who did not receive IVP (1.7% vs. 0.3%). Researchers noted all PJIs between both groups had gram-positive bacteria.
Researchers found patients who received IVP had an overall reoperation rate of 6.1% vs. 2.4% in patients who did not receive IVP, while rates of reoperation for wound complications were 2.7% and 0.7%, respectively.
Patients who received IVP had increased overall readmission rates (6.1% vs. 2.8%) and increased readmissions for suspected infection (2.1% vs. 0.6%) compared with patients who did not receive IVP.
“These findings suggest that the role of IVP in THA may not provide protective effects against PJI and may even be associated with deleterious effects,” the researchers wrote in the study. “Due to the significant association with surgical site morbidity, we currently recommend against the use of IVP in primary THA,” they concluded.
Perspective
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Stephen A. Doxey, DO, and colleagues tackled a controversial topic in their retrospective review of a prospective, quality control project evaluating the use of IVP in primary THA and its effect on infection prevention. The impetus for such a study is derived mainly from the spine literature, which has demonstrated success with IVP, and the hope is that we can reduce the infection burden in our subspecialty domain as primary joint replacements continue to be performed at an exponential rate.
The authors found that patients who received IVP had a higher rate of infection. The results should be understood in light of the limitations of the study: short follow-up period (90 days), small sample size with significant fragility index (if two additional patients had an infection in the non-IVP group, then statistical significance would be lost), nonstandardized protocol and nonrandomized design. Despite the flaws, I also currently recommend against the routine use of topical vancomycin powder until we have robust randomized controlled trials demonstrating its safety and efficacy. The existing body of evidence does not currently support its use. And if you consider the recent study by Doxey and colleagues, it may even be deleterious to patients.
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