Thursday, December 26, 2013

Vancomycin, is there a better way to give it for infection prophylaxis?

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

Because of our concern about Proprionibacterium and Coagulase negative Staph in shoulder arthroplasty, we now use IV perioperative  Ceftriaxone and Vancomycin X 24 hours as our preferred antibiotic prophylaxis.

However, as these authors point out, routine use of IV Vancomycin carries with it the risk of eventual antibiotic resistance and systemic toxicity (red man syndrome, renal toxicity, otic toxicity, for example). They have explored the use of intraosseous regional administration (IORA) in arthroplasty infection prophylaxis.

They randomized 30 patients undergoing primary knee arthroplasty 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. 

They found that 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.

While these authors used preoperative infusion via a cannula inserted into the tibia before surgery, it is possible that shoulder surgeons could administer Vancomycin during impaction autografting of the medullary canal and achieve a similar effect. Topical administration may have the advantages of increased local levels of antibiotic and diminished systemic effects as well as diminished chance of inducing resistance.


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