The role of vancomycin in surgical antimicrobial prophylaxis and high-risk patients who are most likely to benefit remains unclear.
We determined the impact of targeted use of vancomycin on (1) the incidence of periprosthetic joint infection (PJI); and (2) the incidence of PJI from methicillin-resistant organisms in patients undergoing revision total knee arthroplasty (TKA) at our institution.
In an effort to reduce PJI rates, we added vancomycin to cefazolin as surgical antimicrobial prophylaxis for patients undergoing revision TKA in October 2010. Internal data indicated a high rate of PJI in revision TKA and in particular PJI resulting from methicillin-resistant organisms, including methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant Staphylococcus epidermidis (MRSE). We retrospectively reviewed infection control surveillance data on 414 revision TKAs performed between July 2008 and June 2012 (fiscal years 2009–2012).
The overall rate of PJI in fiscal years 2009–2010 among 190 patients undergoing revision TKA was 7.89%. After the change in surgical antimicrobial prophylaxis, there was a significant reduction in PJI among patients undergoing revision TKA in fiscal years 2011–2012 to 3.13% (p = 0.046). In particular, we observed a reduction in PJI resulting from methicillin-resistant organisms over this same time period, from 4.21% to 0.89% (p = 0.049).
Targeted use of vancomycin in patients undergoing revision TKA was effective in reducing the rate of PJI and PJI resulting from methicillin-resistant organisms in an institution with a high baseline rate of PJI due to MRSA and MRSE. Identification of high-risk subgroups of patients within a surgical population can help target infection prevention strategies to those who are most likely to benefit and thus minimize potential risks (eg, selection of resistant organisms, adverse drug events) associated with broader application of such an intervention.
Level of Evidence
Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
American Academy of Orthopaedic Surgeons (AAOS). Recommendations for the use of intravenous antibiotic prophylaxis in primary total joint arthroplasty. Available at: http://www.aaos.org/about/papers/advistmt/1027.asp. Accessed December 10, 2012.
Anderson DJ, Kaye KS, Classen D, Arias KM, Podgorny K, Burstin H, Calfee DP, Coffin SE, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Klompas M, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(Suppl 1): S51–61.
Bolon MK, Morlote M, Weber SG, Koplan B, Carmeli Y, Wright SB. Glycopeptides are no more effective than beta-lactam agents for prevention of surgical site infection after cardiac surgery: a meta-analysis. Clin Infect Dis. 2004;38:1357–1363.
Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004;38:1706–1715.
Centers for Disease Control and Prevention (CDC). Surgical site infection (SSI) event 2011. Available at: http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf. Accessed December 10, 2011.
Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty. 2008;23:984–991.
Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty. 2012;27:61–65.e61.
Mortazavi SM, Schwartzenberger J, Austin MS, Purtill JJ, Parvizi J. Revision total knee arthroplasty infection: incidence and predictors. Clin Orthop Relat Res. 2010;468:2052–2059.
Poss R, Thornhill TS, Ewald FC, Thomas WH, Batte NJ, Sledge CB. Factors influencing the incidence and outcome of infection following total joint arthroplasty. Clin Orthop Relat Res. 1984;182:117–126.
Ritter MA, Barzilauskas CD, Faris PM, Keating EM. Vancomycin prophylaxis and elective total joint arthroplasty. Orthopedics. 1989;12:1333–1336.
Savarese A, Nanni ML, Pasquali C, Egidio AC. Vancomycin prophylaxis in joint arthroplasty. Chir Organi Mov. 1999;84:247–251.
Sculco TP. The economic impact of infected joint arthroplasty. Orthopedics. 1995;18:871–873.
Sewick A, Makani A, Wu C, O’Donnell J, Baldwin KD, Lee GC. Does dual antibiotic prophylaxis better prevent surgical site infections in total joint arthroplasty? Clin Orthop Relat Res. 2012;470:2702–2707.
Sierra RJ, Cooney WP, Pagnano MW, Trousdale RT, Rand JA. Reoperations after 3200 revision TKAs: rates, etiology, and lessons learned. Clin Orthop Relat Res. 2004;425:200–206.
Smith EB, Wynne R, Joshi A, Liu H, Good RP. Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total joint arthroplasty patients? J Arthroplasty. 2012;27:55–60.
Song KH, Kang YM, Sin HY, Yoon SW, Seo HK, Kwon S, Shin MJ, Chang CB, Kim TK, Kim HB. Outcome of cefazolin prophylaxis for total knee arthroplasty at an institution with high prevalence of methicillin-resistant Staphylococcus aureus infection. Int J Infect Dis. 2011;15:e867–870.
Wymenga AB, van Horn JR, Theeuwes A, Muytjens HL, Slooff TJ. Perioperative factors associated with septic arthritis after arthroplasty. Prospective multicenter study of 362 knee and 2,651 hip operations. Acta Orthop Scand. 1992;63:665–671.
We thank Laurel Gibbs MT, CIC, for her assistance with data collection and validation, Steven Takemoto PhD, for providing assistance with data analysis, and Vanessa Chan MPH, for her help in preparing the manuscript.
Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.
About this article
Cite this article
Liu, C., Kakis, A., Nichols, A. et al. Targeted Use of Vancomycin as Perioperative Prophylaxis Reduces Periprosthetic Joint Infection in Revision TKA. Clin Orthop Relat Res 472, 227–231 (2014). https://doi.org/10.1007/s11999-013-3029-0
- Total Knee Arthroplasty
- Periprosthetic Joint Infection
- Primary Total Knee Arthroplasty