Modified Protocol Decreases Surgical Site Infections after Total Knee Arthroplasty

Lamplot, Joseph D.; Luther, Gaurav; Mawdsley, Emily Landon; Luu, Hue H.; Manning, David W.

doi:10.1055/s-0035-1544974

Cited by 16 publications

(11 citation statements)

References 34 publications

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“…In the studies that demonstrated a positive effect, however, the infection rate was between 1.6 and 5.5%, and was thus higher than the incidence of less than 1% described for many centers with optimized perioperative prophylaxis [17][18][19][20][21] . It is unclear whether locally applied vancomycin can also lower the risk of infection in an optimized setting with an already low infection rate.…”

mentioning

confidence: 69%

Intraarticular vancomycin powder is effective in preventing infections following total hip and knee arthroplasty

Matziolis

Brodt

Böhle

et al. 2020

Sci Rep

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Locally applied vancomycin is increasingly being used in primary hip and knee arthroplasty to reduce the risk of infection. Despite encouraging initial results, considerable debate remains on the basis of the data currently available. In particular, it has been unclear up to now whether local vancomycin is suitable to further reduce the risk of infection even if the rate of infection is already low (< 1%). In this monocentric retrospective cohort study, all primary total hip and knee arthroplasties performed between 2013 and 2018 were included. After a change in procedure at the hospital, 1 g vancomycin powder was applied intraarticularly before wound closure. The remaining perioperative procedure was constant over the investigation period. The follow-up was one year. The presence of an infection according to the currently valid MSIS criteria was defined as the endpoint. In patients with TKA two infections (0.3%) were observed under vancomycin prophylaxis in contrast to 44 infections (1.3%) in the control group (p = 0.033). In patients with THA two infections (0.5%) were observed under vancomycin prophylaxis and 48 infections (1.1%) in the control group without local vancomycin but this difference was statistically not significant. No wound complications requiring revision were observed as a result of the vancomycin. On the basis of the results of this study, intraarticular application of vancomycin powder in total hip and knee arthroplasty may be considered. Prospective randomized studies have to confirm this promising results prior a common recommendation. Level of Evidence III Retrospective cohort study. Infections after endoprosthetic hip or knee replacement, in spite of all perioperative improvements, are observed with an incidence of 1-2% 1-4. Despite the apparently low risk, efforts to further reduce the risk are sensible in light of the consequences for the patients concerned, with the potential for several follow-up operations and the often limited functional outcome. In spinal surgery, the reduction in the rate of infection through locally applied vancomycin was established more than 10 years ago and has been well documented by meta-analyses and animal experiments 5-8. The positive effect is set against minor complications caused in 0.3% of cases, mostly culture-negative seroma formation 9, so that it is even used successfully in children 10. Otte et al. were able to show that intrawound vancomycin powder lowers the infection rate after knee and hip arthroplasty from 1.6 to 0.5%, compared with a control group 11. In a subgroup analysis, the effect in revision operations was even greater, with a reduction of the infection rate from 3.9 to 0%. Patel et al. showed a reduction in the infection rate through vancomycin of 2.7-0.3% and determined a number needed to treat (NNT) of 47.5 12. Systemic side effects were not observed. The local application of vancomycin was assessed to be safe and cost-effective. Dial et al. observed a similar effect in primary hip arthroplasty, with a lowering of the infection rate...

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mentioning

confidence: 69%

Intraarticular vancomycin powder is effective in preventing infections following total hip and knee arthroplasty

Matziolis

Brodt

Böhle

et al. 2020

Sci Rep

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“…The secret to success probably consists of a well-balanced combination of preventative interventions that will result in a reduction in the number of PJIs in the population and the probability of PJI in a patient [212]. Whether finding it will require trial and error or be facilitated by more modern tools remains to be seen.…”

Section: Who Is the Best Provider?mentioning

confidence: 99%

Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining

Gallo

Nieslanikova

2020

JCM

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A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting.

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“…4 This concept led to the use of weight-based drug dosing, instead of conventional fixed drug doses for both, cefazolin and vancomycin. 26,27 The recommended doses for weight-based dosing of cefazolin is 2-g intravenous for patients weighing less than 120 kg and 3-g intravenous for those patients weighing more than 120 kg. 27 Traditionally, a fixed dose (1 g) of vancomycin has been used for antibiotic prophylaxis.…”

Section: Dual Prophylactic Antibiotics: Dosage and Timing Of Administmentioning

confidence: 99%

“…26,27 The recommended doses for weight-based dosing of cefazolin is 2-g intravenous for patients weighing less than 120 kg and 3-g intravenous for those patients weighing more than 120 kg. 27 Traditionally, a fixed dose (1 g) of vancomycin has been used for antibiotic prophylaxis. However, recent evidence has shown that vancomycin levels drops below 15 mg/L in 60% of the patients who were given a 1-g dose, in contrast to, only 12% of the patients who were treated with a weight-based approach.…”

Section: Dual Prophylactic Antibiotics: Dosage and Timing Of Administmentioning

confidence: 99%

Dual Antibiotic Prophylaxis in Total Knee Arthroplasty: Where Do We Stand?

et al. 2019

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The risk of surgical site infection in primary total knee arthroplasty (TKA) has been reduced with the use of prophylactic antibiotics. First or second generation cephalosporins are still recommended as the primary prophylactic choice, but with the rise in the incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections, evidence has emerged in favor of using dual antibiotics including vancomycin. However, it is unclear whether these combinations of antibiotic regimens further reduce postoperative infection rates. As a result, the objective of this review is to summarize the current literature concerning the use of dual prophylactic antibiotics in TKA. The most common dual prophylactic antibiotic combination is cefazolin (C) and vancomycin (V). In general, when comparing the effectiveness of single versus dual antibiotics, conflicting results have been reported. Three studies demonstrated no substantial decrease in overall postoperative infection rates with the use of dual antibiotics when compared with cefazolin alone. One found a significant decrease only in MRSA infection rates when using cefazolin and vancomycin (CV) (0.8% C alone vs. 0.08% CV, p < 0.05). Another investigation evaluated revision TKA patients who had combined cefazolin and vancomycin prophylaxis and showed a significant decline in both overall infection (7.89% [C] vs. 3.13% [CV]) and MRSA infection rates (4.21% [C] vs. 0.89% [CV]; p < 0.05). Concerning the safety profile of dual antibiotics, particular precautions must be adopted with the use of vancomycin because of the risk of acute kidney injury. Instead of vancomycin, an alternate less nephrotoxic antibiotic option might be teicoplanin. Unfortunately, this latter agent is only available outside of the United States. In conclusion, the value of dual antibiotic prophylaxis for the prevention of periprosthetic knee infections remains unclear primarily because all comparative studies performed between dual and single antibiotics have been of low evidence with retrospective designs. Larger multicenter randomized controlled trials are warranted.

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Modified Protocol Decreases Surgical Site Infections after Total Knee Arthroplasty

Cited by 16 publications

References 34 publications

Intraarticular vancomycin powder is effective in preventing infections following total hip and knee arthroplasty

Intraarticular vancomycin powder is effective in preventing infections following total hip and knee arthroplasty

Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining

Dual Antibiotic Prophylaxis in Total Knee Arthroplasty: Where Do We Stand?

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