Is Topical Vancomycin an Option? A Randomized Controlled Trial to Determine the Safety of the Topical Use of Vancomycin Powder in Preventing Postoperative Infections in Total Knee Arthroplasty, as Compared With Standard Postoperative Antibiotics

Effectiveness of intra-articular vancomycin in preventing prosthetic joint infections in hip and knee arthroplasty: A systematic review and meta-analysis of RCT's

Introduction

This study aimed to evaluate the effectiveness and safety of intra-articular vancomycin powder in reducing prosthetic joint infections (PJIs) in primary hip and knee arthroplasty through a meta-analysis of randomized controlled trials (RCTs).

Methods

A research in Pubmed, Embase and Cochrane databases was performed to identify randomized clinical trials comparing intra-articular vancomycin use to conventional antibiotic prophylaxis in total hip or knee arthroplasty patients, assessing postoperative infection rates, adverse drug reactions, and venous thrombotic events. Statistical analysis was performed using R (RStudio 2024.04.2), and heterogeneity was assessed with the I2 test.

Results

A total of 1485 patients from five randomized clinical trials were included, with 737 receiving intra-articular vancomycin. The infection rate was 0.54 % in the intervention group and 1.73 % in the control group (RR 0.37; 95 % CI 0.02-8.95; p = 0.369; I2 = 49 %), showing no statistically significant difference between the groups. Adverse reactions to the glycopeptide were reported in six cases (0.8 %) in the intervention group compared to four cases (0.5 %) in the control group (RR 1.50; 95 % CI 1.50-150; p = 0.001; I2 = 0 %). Regarding thrombotic events, there was one case in 647 patients in the intervention group and three cases in 660 patients in the control group (RR 0.45; 95 % CI 0.03-7.02; p = 0.169; I2 = 0 %).

Conclusion

Although no significant difference was found, the intervention group showed a trend toward lower infection rates. Additional RCTs with larger sample sizes are required to confirm these findings.

Trial registration

The prospective registration of the meta-analysis was conducted on PROSPERO in July 2024 with the protocol number 565988.

Intraoperative Irrigation and Topical Antibiotic Use Fail to Reduce Early Periprosthetic Joint Infection Rates: A Michigan Arthroplasty Registry Collaborative Quality Initiative Study

BACKGROUND

Periprosthetic joint infections remain a major complication in total joint arthroplasty. Tremendous efforts made intraoperatively to prevent periprosthetic joint infection during primary procedures include antiseptics or antibiotics in irrigation solutions. This study analyzed the incidence of postoperative infection in relation to use of irrigation solutions and antibiotic powder.

METHODS

We reviewed primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) cases from the Michigan Arthroplasty Registry Collaborative Quality Initiative between January 2019 and December 2022. Data on irrigation solutions were categorized by those containing antibiotics, chlorhexidine-gluconate, povidone-iodine, or other substances, compared to normal saline. Logistic regression analyses were conducted, adjusting for various factors such as age, body mass index, sex, American Society of Anesthesiologists score, smoking, and more. There were 67,871 THA and 105,963 TKA cases analyzed, with an overall infection rate of 0.6% (confidence interval: 0.6 to 0.7, n = 420) for THA and 0.4% (0.36 to 0.43, n = 419) for TKA within 90 days postsurgery.

RESULTS

There were statistical differences between the use of normal saline alone versus other irrigation solutions in THA, including povidone and others. For TKA, there was a statistically significant difference with lower infection rates using normal saline alone than multiple types, chlorhexidine-gluconate, and povidone. Notably, the use of nonsaline irrigation increased over the study period.

CONCLUSIONS

There was no reduction in 90-day infection rates for primary THA or TKA with irrigation additives. Higher infection rates were noted with povidone than saline for THA and TKA, potentially due to selection bias or local adverse tissue effects. Topical powders did not improve infection control. While irrigation is strongly recommended in all patients having TKA or THA, multiple irrigation solutions were not correlated with lower infection rates, suggesting importance of patient selection and optimization over irrigation type.

Effectiveness of Local Antibiotics for Infection Prevention in Primary Joint Arthroplasty: A Systematic Review and Meta-Analysis

Background/Objectives: To evaluate the effectiveness of local antibiotic prophylaxis (e.g., powder, bone cement, intraosseous injection) in reducing periprosthetic joint infections (PJI) and deep wound infections in adults undergoing primary joint replacement surgery. Methods: A comprehensive search of PubMed, EMBASE, and the Cochrane Library was conducted from inception to 7 September 2024, including randomized controlled trials (RCTs) and cohort studies without language restrictions. Quality assessment was performed using the Cochrane Risk of Bias (RoB) 2.0 for RCTs and the Newcastle-Ottawa Scale (NOS) for cohort studies. Infection rates were extracted and analyzed using risk ratios (RR) or odds ratios (OR) in a random-effects model with Review Manager (RevMan) 5.4. Sensitivity analysis and meta-regression were also performed to validate the study results and possible risk factors. Results: Twelve RCTs and 21 cohort studies were included in the review. Vancomycin powder in the cohort studies demonstrated statistical significance (OR = 0.47, 95% confidence interval (CI): 0.36-0.61, I2 = 0%), in contrast to the results in the RCTs (RR = 0.37, 95% CI: 0.06-2.47, I2 = 49%). Sensitivity analyses confirmed the robustness and statistical significance of these findings. Both the control and treatment groups primarily cultured Gram-positive pathogens, including in the overall data and specifically for vancomycin powder. The evidence for the use of intraosseous injection (RR of RCTs not estimable, I2 not applicable; OR of cohorts = 0.12, 95% CI: 0.02-0.63, I2 = 0%) and bone cement (RR of RCTs = 0.40, 95% CI: 0.14-1.17, I2 = 56%; OR of cohorts = 1.88, 95% CI: 1.25-2.82, I2 not applicable) was inconclusive. Smoking was identified as an important risk factor for post-operative infection. Further research, including more robust trials and cohort studies, is needed to confirm these findings. Conclusions: Local administration of vancomycin powder appears effective in preventing deep wound infection after arthroplasty.

Does the use of topical vancomycin during primary hip or knee arthroplasty protect from infections?

BACKGROUND

Infection is one of the main complications of hip and knee arthroplasties. Topical application vancomycin to prevent postoperative infections is efficient in spine surgery, and is spreading in prosthetic surgery. However, its clinical relevance and safety are still under debate. Thus, we conducted the present study to (1) assess whether topical vancomycin reduces peri-prosthetic infection rate, and (2) investigate its influence on surgical wound complications.

HYPOTHESIS

Our hypothesis was that topical administration of diluted vancomycin during arthroplasty would reduce infection rate within the first postoperative year.

MATERIAL AND METHODS

In total, 1900 hip and knee arthroplasties were performed between 2014 and 2021 in a single hospital. From July 2018 and December 2021, 910 prostheses were implanted with intra-articular instillation of vancomycin and tranexamic acid. From November 2014 to June 2018, 990 prostheses were set up without vancomycin. During a follow-up of minimum 12 months, we reported periprosthetic infections occurring during the first postoperative year, as well as vancomycin-induced general or cutaneous complications.

RESULTS

We observed periprosthetic infections in 9/990 cases (0.91%) of the control group and 10/910 cases (1.1%) of the vancomycin group (p = 0.82). In parallel, we observed wound complications (erythema, seroma, hematoma, dehiscence and delay in wound healing) in 19/990 (1.9%) and 10/910 cases (1.1%) of the control and vancomycin group, respectively (p = 0.19). There were no general complications resulting from the application of vancomycin.

DISCUSSION

Topical diluted vancomycin does not reduce periprosthetic infection risk, and has no effect on the occurrence of surgery wound complications. Considering the present findings, the use of vancomycin cannot be recommended in current practice to prevent infections following hip and knee arthroplasties. Finally, its use does not induce any specific complications, whether local (cicatrisation) or general (related to ototoxicity or nephrotoxicity).

LEVEL OF EVIDENCE

III; case control study.

Preoperative, intraoperative, and postoperative concepts to prevent infection for unicompartmental knee arthroplasty

Periprosthetic joint infection (PJI) is a complication that occurs in less than 1% of patients after unicompartmental knee arthroplasty (UKA). Though infrequent, it may potentially lead to revision while placing a significant financial burden on the healthcare system. Preoperative, intra-operative, and postoperative strategies should be implemented to minimize the risk of PJI. Patient optimization prior to surgery can help to identify patients at risk for PJI and also maximize the health of the patient prior to surgery. Intraoperative and postoperative strategies can also mitigate the risk of postoperative infection. This article will summarize the evidence for preoperative, intra-operative, and postoperative strategies to prevent PJI in UKA. This will include topics on malnutrition and obesity, Staphylococcus aureus, smoking, human immunodeficiency virus, rheumatoid arthritis, as well as skin preparation, laminar air flow, preoperative antibiotic administration antimicrobial incision drapes, pulsatile lavage, vancomycin powder, wound closure method, thromboprophylactic agents, and closed incisional negative pressure wound therapy dressings.

Effect of topical vancomycin powder on surgical site infection prevention in major orthopaedic surgery: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis

BACKGROUND

Evidence has been mixed regarding the effect of topical vancomycin (VCM) powder in reducing surgical site infection (SSI).

AIM

To clarify the effect of topical VCM powder for the prevention of SSI in major orthopaedic surgeries.

METHODS

The MEDLINE, Embase, CENTRAL, ICTRP, and ClinicalTrials.gov databases were searched from their inception to September 25th, 2023. Randomized controlled trials comparing topical VCM powder and controls for the prevention of SSI in major orthopaedic surgeries were included. Two reviewers independently screened the title and abstract and extracted relevant data, followed by the assessment of the risk of bias and the certainty of the evidence. Main outcome measures were overall SSI, reoperation, and adverse events. Summary results were obtained using random-effects meta-analysis. Trial sequential analysis (TSA) was performed.

FINDINGS

Eight randomized controlled trials yielded data on 4307 participants. VCM powder showed no difference in reducing overall SSI. The cumulative number of patients did not exceed the required information size of 19,233 in our TSA, and the Z-curves did not cross the trial sequential monitoring or futility boundary, suggesting an inconclusive result of the meta-analysis. No difference was found for reoperation. Among SSIs, VCM powder showed a statistically significant difference in reducing Gram-positive cocci SSI. However, the certainty of this evidence was very low.

CONCLUSION

This systematic review and meta-analysis suggests inconclusive results regarding the effect of VCM powder in reducing SSI in major orthopaedic surgeries. Further trials using rigorous methodologies are required to elucidate the effect of this intervention.

Comparison of the effect of combined usage of povidone-iodine irrigation and topical vancomycin powder to the use of povidone-iodine irrigation alone on the periprosthetic joint infection incidence rate in patients undergoing primary total hip and knee arthroplasty: a protocol for multicenter prospective randomized clinical trial

BACKGROUND

With the increasing number of joint replacement surgeries, periprosthetic joint infection (PJI) has become a significant concern in orthopedic practice, making research on PJI prevention paramount. Therefore, the study will aim to compare the effect of combined usage of povidone-iodine and topical vancomycin powder to the use of povidone-iodine alone on the PJI incidence rate in patients undergoing primary total hip (THA) and total knee arthroplasty (TKA).

METHODS

The prospective randomized clinical trial will be conducted in two independent voivodeship hospitals with extensive experience in lower limb arthroplasties. The studied material will comprise 840 patients referred to hospitals for primary THA or TKA. The patients will be randomly allocated to two equal groups, receiving two different interventions during joint replacement. In group I, povidone-iodine irrigation and consecutively topical vancomycin powder will be used before wound closure. In group II, only povidone-iodine lavage irrigation will be used before wound closure. The primary outcome will be the incidence rate of PJI based on the number of patients with PJI occurrence within 90 days after arthroplasty. The occurrence will be determined using a combined approach, including reviewing hospital records for readmissions and follow-up phone interviews with patients. The infection will be diagnosed based on Musculoskeletal Infection Society criteria. The chi-square test will be used to compare the infection rates between the two studied groups. Risk and odds ratios for the between-groups comparison purposes will also be estimated. Medical cost analysis will also be performed.

DISCUSSION

A randomized clinical trial comparing the effect of combined usage of povidone-iodine irrigation and vancomycin powder to the use of povidone-iodine irrigation alone in preventing PJIs after primary arthroplasty is crucial to advancing knowledge in orthopedic surgery, improving patient outcomes, and guiding evidence-based clinical practices.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05972603 . Registered on 2 August 2023.

The effect of different preventive strategies during total joint arthroplasty on periprosthetic joint infection: a network meta-analysis

BACKGROUND

Periprosthetic joint infection after total joint arthroplasty has a large incidence, and it may often require two or more stages of revision, placing an additional burden on clinicians and patients. The purpose of this network meta-analysis is to evaluate the effect of four different preventive strategies during total joint arthroplasty on the prevention of periprosthetic joint infection.

METHODS

The study protocol was registered at PROSPERO (CRD: 42,023,448,868), and the literature search databases included Web of Science, PubMed, OVID Cochrane Central Register of Controlled Trials, OVID EMBASE, and OVID MEDLINE (R) ALL that met the requirements. The network meta-analysis included randomized controlled trials, retrospective cohort studies and prospective cohort studies with the outcome of periprosthetic joint infection. The gemtc R package was applied to perform the network meta-analysis to evaluate the relative results of different preventive strategies.

RESULTS

This network meta-analysis study included a total of 38 articles with 4 preventive strategies and negative controls. No improvement was observed in antibiotic-loaded bone cement compared with negative controls. Chlorhexidine showed the highest probability of delivering the best preventive effect, and povidone iodine had the second highest probability. Although vancomycin ranked after chlorhexidine and povidone iodine, it still showed a significant difference compared with negative controls. In addition, the incidence after applying chlorhexidine was significantly lower than that after applying negative controls and vancomycin. In the heterogeneity test between direct and indirect evidence, there was no apparent heterogeneity between them.

CONCLUSION

The study indicated that chlorhexidine, povidone iodine and vancomycin showed significant efficacy in preventing periprosthetic joint infection after total joint arthroplasty, while antibiotic-loaded bone cement did not. Therefore, more high-quality randomized controlled trials are needed to verify the results above.

Efficacy of Intrawound Vancomycin in Prevention of Periprosthetic Joint Infection After Primary Total Knee Arthroplasty: A Prospective Double-Blinded Randomized Control Trial

BACKGROUND

Periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is a devastating complication. Intrawound vancomycin powder has been shown to reduce infection rates in spine surgery, but its role in arthroplasty remains controversial. This prospective randomized control trial aimed to evaluate the efficacy of intrawound vancomycin in preventing PJI after primary TKA.

METHODS

A total of 1,022 patients were randomized to the study group (n = 507, who received 2 grams intrawound vancomycin powder before arthrotomy closure) or to the control group (n = 515, no local vancomycin) with a minimum follow-up of 12-months. The primary outcome was the incidence of PJI or surgical site infection (SSI). Secondary outcomes included associated minor complications such as stitch abscess, persistent wound drainage, and delayed stitch removal. Other parameters evaluated include reoperation rates and incidences of nephrotoxicity.

RESULTS

The overall infection rate in 1,022 patients was 0.66%. There was no significant difference in PJI rate in the study group (N = 1; 0.2%) versus the control group (N = 3; 0.58%), P = .264. Reoperation rates in the study group (N = 4; 0.78%) and control (N = 5; 0.97%), and SSI rates in the study (N = 1; 0.2%) and control groups (N = 2; 0.38%) were comparable. The Vancomycin cohort, however, demonstrated a significantly higher number of minor wound complications (n = 67; 13.2%) compared to the control group (n = 39; 7.56%, P < .05). Subgroup analysis showed diabetics in the study group to also have a higher incidence of minor wound complications (24 [14.1%] versus 10 [6.2%]; P < 05]. Multivariate analyses found that vancomycin use (odds ratio = 1.64) and smoking (odds ratio = 1.85) were associated with an increased risk of developing minor wound complications. No cases of nephrotoxicity were reported.

CONCLUSIONS

Intrawound vancomycin powder does not appear to reduce PJI/SSI rate in primary total knee arthroplasties, including high-risk groups. Although safe from a renal perspective, intrawound vancomycin was associated with an increase in postoperative aseptic wound complications. Intrawound vancomycin may not be effective in reducing the rate of PJI in primary TKA.

Prophylactic use of vancomycin powder on postoperative infection after total joint arthroplasty

OBJECTIVE

By reviewing the literature analyzing vancomycin powder for preventive surgery, the effect of this method on reducing the infection rate after TJA was systematically evaluated to provide a basis for future clinical work.

METHODS

Using PubMed, Medline, Elsevier, and CNKI, with the following mesh words: "vancomycin", "local / intraoperative / topical / intrawound", "TJA", "TKA", "THA", "total joint arthroplasty", "total knee arthroplasty", "total hip arthroplasty", "infection", and "SSI", to search for case-control research papers on the impact of prophylactic application of vancomycin powder on the incidence of postoperative infection, we compared the overall infection rate in the literature by using RevMan 5.3 meta-analysis software and analyzed the impact of vancomycin on the infection rate of different parts and types of TJA according to different subgroups.

RESULTS

A total of 22 qualified studies were selected; twenty-five studies compared the effect of prophylactic use of vancomycin powder on infection rates after TJA. There were 23,363 cases in total, including 9545 cases in the vancomycin group and 13,818 cases in the control group. The results of the meta-analysis showed that the possibility of postoperative infection after prophylactic use of vancomycin powder was significantly lower than that without vancomycin risk ratio: 0.38 [0.23,0.59], P < 0.01). However, a meta-analysis of randomized controlled trials (RCTs) showed no significant effect of vancomycin on postoperative infection (P = 0.52).

CONCLUSION

Based on the retrospective studies, local prophylactic use of vancomycin powder in TJA can significantly reduce the incidence of postoperative infection. High-quality RCTs should be carried out to further evaluate these results.