Saturday, October 22, 2016

Systemic reaction after a Vancomycin spacer and systemic Vancomycin for treating a periprosthetic infection

Drug eruption secondary to vancomycin-laden spacer in the shoulder: a case report

These authors point out that periprosthetic joint infections (PJIs) after shoulder arthroplasty are often treated with two-stage revisions, involving prosthesis explantation, thorough débridement, and implantation of an antibioticimpregnated cement spacer with a course of IV antibiotics followed by a revision arthroplasty. Antibiotic-impregnated cement spacers containing aminoglycosides or vancomycin are commonly used. Whereas the use of antibiotic spacers is generally considered safe, there have been previous reports of a diffuse desquamating rash from vancomycin-laden cement and cases of hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms after concurrent use of systemic vancomycin and vancomycin laden bone cement in the hip and knee. They report a case of a drug eruption caused by parenteral vancomycin in combination with a vancomycin-impregnated spacer inserted for a shoulder PJI.

The details of the case are interesting.  The patient was a 69-year-old with the diagnosis of rotator cuff arthropathy. He underwent a right reverse total shoulder arthroplasty in December 2012. In November 2014, the patient underwent a revision surgery to manage loose hardware and a broken baseplate screw. No culture specimens were taken at the time of the revision surgery.

The patient continued to have significant pain and was subsequently found to have a Propionibacterium infection diagnosed by aspiration. He then underwent an initial irrigation and débridement with retention of implants and was prescribed a 60-day course of doxycycline.

Six weeks later, the patient was noted to have significant wound site drainage.

He was given a peripherally inserted central catheter line, through which he received multiple infusions of vancomycin 1000 mg during the course of 2 weeks without any adverse reactions. When that failed to eradicate the PJI, he underwent removal of the prosthesis with placement of a vancomycin-impregnated bone cement spacer; he also received vancomycin 1250 mg every 12 hours starting on postoperative day 1.

On postoperative day 4, he noticed swelling of his right arm, forearm, and hand. During the next 48 hours, he developed an erythematous, pruritic, maculopapular rash that spread to his entire torso and extremities.

These symptoms resolved after removal of the vancomycin spacer and a course of systemic steroids. 

Comment: Pharmacokinetic studies of vancomycin-loaded bone cement show that blood vancomycin levels reach peak blood concentration between 6 and 24 hours and fall to undetectable levels by the tenth day (see this link).

The point is that drug eruption reactions can occur after both systemic and local diffusion from antibiotic-laden cement spacers.