Complications - Infection
Dual-Agent Antibiotic Prophylaxis Using a Single Preoperative Vancomycin Dose Effectively Reduces Prosthetic Joint Infection Rates With Minimal Renal Toxicity Risk

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Abstract

Background

We performed this study to compare prosthetic joint infection (PJI) and renal toxicity rates following hip and knee total joint arthroplasty (TJA) when a first-generation cephalosporin was administered either alone or in combination with a single preoperative vancomycin dose, whether vancomycin administration timing potentially influenced dual-antibiotic PJI prophylaxis approach effectiveness, and whether single-dose vancomycin use increased risk of renal impairment.

Methods

This was a retrospective study of 1997 consecutive primary TJAs (1871 patients) treated with cefazolin alone (1044 TJAs) or cefazolin with single-dose vancomycin (953 TJAs). The vancomycin group included 476 TJAs (450 patients) with infusion started at least 45 minutes before the skin incision and 477 TJAs (464 patients) with infusion started less than 45 minutes before the skin incision.

Results

The addition of a single dose of vancomycin did not significantly reduce PJI rates when compared with cefazolin alone (1.6% vs 2.1%, P = .32). However, the PJI rate was significantly lower following primary TJA when vancomycin administration was initiated at least 45 minutes before incision (0.2%) when compared with other TJA procedures performed using cefazolin and vancomycin (2.9%, P < .01) or cefazolin alone (2.1%, P < .01). We observed no difference in renal toxicity between treatment groups.

Conclusion

In our institution, the addition of vancomycin to cefazolin at least 45 minutes before incision reduced PJI infection rates in primary hip and knee TJA with a low risk of renal impairment.

Section snippets

Methods

After obtaining institutional review board approval, we retrospectively identified a consecutive series of 2712 primary THA or TKA procedures performed at a tertiary care institution between January 1, 2012, and April 30, 2016. After excluding 346 patients who had received clindamycin as their primary antibiotic prophylaxis, 22 patients who had received vancomycin alone, and 472 patients who had received dual-antibiotic prophylaxis with a first-generation cephalosporin and gentamicin, we

Differences Between Prophylaxis Groups

The demographic features for patients treated with each antibiotic approach were documented for all arthroplasty patients, for patients undergoing THA, and for patients undergoing TKA (Table 1). Patients receiving the CV prophylaxis were slightly younger (mean age, 59.1 vs 60.3 years, P = .02), had a higher mean body mass index [BMI] (35.6 vs 34.0 kg/m2, P < .001), and a slightly greater medical complexity (mean ASA, 2.52 vs 2.40, P < .001) than patients receiving the C approach.

There were 26

Discussion

PJI is a devastating complication of primary or revision TJA. Minimizing infection risks is an important goal as long as these efforts do not introduce unacceptably high systemic complication risks. In our institution, concerns over the importance of covering against gram-negative organisms and low-virulence organism resulted in individual surgeons engaging dual-agent antibiotic prophylaxis regimens with a single perioperative dose of either gentamicin or vancomycin. Findings from this study

Conclusion

Reducing rates of PJI are important to reduce social, emotional, physical, and economic costs. While first-generation cephalosporins lower PJI infection rates, infections with low virulence and high resistance organisms may still occur. In our institution, the timely administration of a single preoperative vancomycin dose in a dual-agent prophylaxis approach resulted in a reduced rate of PJI following primary THA and TKA when incorporated as a component of a multimodal approach. The addition of

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    One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2018.03.009.

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