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Clinical Orthopaedics and Related Research®

, Volume 472, Issue 1, pp 57–65 | Cite as

The Mark Coventry Award: Higher Tissue Concentrations of Vancomycin With Low-dose Intraosseous Regional Versus Systemic Prophylaxis in TKA

A Randomized Trial
  • Simon W. YoungEmail author
  • Mei Zhang
  • Joshua T. Freeman
  • John Mutu-Grigg
  • Paul Pavlou
  • Grant A. Moore
Symposium: 2013 Knee Society Proceedings

Abstract

Background

In response to increasing antibiotic resistance, vancomycin has been proposed as an alternative prophylactic agent in TKA. However, vancomycin requires a prolonged administration time, risks promoting further antibiotic resistance, and can cause systemic toxicity. Intraosseous regional administration (IORA) is known to achieve markedly higher antibiotic concentrations than systemic administration and may allow the use of a lower vancomycin dose.

Questions/purposes

We assessed whether low-dose IORA vancomycin can achieve tissue concentrations equal or superior to those of systemic administration in TKA and compared complications between patients treated with IORA and intravenous vancomycin.

Methods

We randomized 30 patients undergoing primary TKA to receive 250 or 500 mg vancomycin via IORA or 1 g via systemic administration. IORA was performed as a bolus injection into a tibial intraosseous cannula below an inflated thigh tourniquet immediately before skin incision. Subcutaneous fat and bone samples were taken during the procedure and antibiotic concentrations measured.

Results

The overall mean tissue concentration of vancomycin in subcutaneous fat was 14 μg/g in the 250-mg IORA group, 44 μg/g in the 500-mg IORA group, and 3.2 μg/g in the systemic group. Mean concentrations in bone were 16 μg/g in the 250-mg IORA group, 38 μg/g in the 500-mg IORA group, and 4.0 μg/g in the systemic group. One patient in the systemic group developed red man syndrome during infusion.

Conclusions

Low-dose IORA vancomycin results in tissue concentrations equal or superior to those of systemic administration. IORA optimizes timing of vancomycin administration, and the lower dose may reduce the risk of systemic side effects while providing equal or enhanced prophylaxis in TKA.

Level of Evidence

Level I, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Keywords

Vancomycin Teicoplanin Femoral Nerve Block Vancomycin Concentration High Tissue Concentration 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgments

We thank Irene Zeng MSc (Hons) for her assistance with statistical analysis and the Awhina Trust for their funding support, and we thank Dr Kelly Vince for his advice and guidance on the project. We also thank Vidacare Corp for supplying the intraosseous needles without charge.

Supplementary material

Supplementary material 1 (MPG 14956 kb)

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Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Simon W. Young
    • 1
    Email author
  • Mei Zhang
    • 2
    • 3
  • Joshua T. Freeman
    • 4
  • John Mutu-Grigg
    • 1
  • Paul Pavlou
    • 1
  • Grant A. Moore
    • 3
  1. 1.Department of OrthopaedicsNorth Shore HospitalAucklandNew Zealand
  2. 2.Clinical Pharmacology, Department of MedicineUniversity of OtagoChristchurchNew Zealand
  3. 3.ToxicologyCanterbury Health LaboratoriesChristchurchNew Zealand
  4. 4.Clinical MicrobiologyAuckland City HospitalAucklandNew Zealand

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