Using a systematic review, these authors asked:
(1) Does topical vancomycin (vancomycin powder) reduce the risk of periprosthetic infection (PJI) in hip and knee arthroplasty?
(2) Does topical vancomycin lead to an increased risk of complications after hip and knee arthroplasty?
They found nine eligible studies reviewing 3371 patients who received topical vancomycin (vancomycin powder) during a primary THA or TKA and 2884 patients who did not receive it. Patients 18 years or older with a minimum follow-up of 3 months were included. Studies were excluded if they included patients with a history of septic arthritis, used an antibiotic other than vancomycin or a different route of administration for the intervention, performed additional interventions that differed between groups, or omitted a control group.
One of nine studies found a lower risk of PJI after primary THA or TKA, while eight did not, with odds ratios that broadly bracketed the line of no difference.
In the six studies where overall complications could be compared between topical vancomycin and
control groups in primary THA or TKA, there was no difference in overall complication risks with vancomycin. These studies may have been underpowered to detect differences in the types of uncommon complications associated with vancomycin use (such as allergy, ototoxicity, and nephrotoxicity).
The authors point out that previous studies have sought to investigate the impact of topical vancomycin on PJI after THA and TKA with meta-analyses. In that some of these included studies that were predominantly retrospective, those of poor quality, and some that combined topical vancomycin with Betadine irrigation it has been difficult to draw meaningful conclusions regarding the effectiveness of vancomycin.
The authors of the current study restricted their inclusion criteria to patients without a history of
septic arthritis undergoing primary THA or TKA and limited the interventions to include only topical vancomycin powder administration. They found that the results of their systematic review were not sufficiently convincing on the topic of efficacy to allow them to recommend the routine use of topical vancomycin in THA and TKA.
In a discussion with the journal editor, the author of this paper stated, "While the risk of a patient experiencing a PJI is quite low, it is still a devastating complication to the patient and puts a much larger burden on the medical system. When I treat a patient with PJI, I always ask myself how we can bring the risk to 0%. We’ll never get there, but I believe it is worth exploring potential options that may further decrease the risk of PJI without increasing the risk of other complications, such as the incorporation of topical antibiotic powder. Yes, it would require quite a large sample size to detect a possible difference with the use of vancomycin powder, but our study alone is not enough to conclude whether vancomycin powder is worth using to prevent PJIs. "
Comment: In the shoulder arthroplasty world we have much less data to inform the decision to use or not use topical vancomycin in the prevention of PJI.
What we do know is that the organism most commonly causing shoulder PJI is Cutibacterium; this is in marked contrast to the Staph, Strep and gram negative organisms that cause hip and knee PJI. Cutibacterium is an anaerobic organism that can thrive in the oxygen poor environment of the medullary canal. It is fond of forming biofilms on the titanium alloy used for most humeral components. See Shoulder joint infections and biofilms. We also know that shoulder arthroplasty incisions are routinely inoculated with Cutibacterium when the skin incision transects the dermal pilosebaceous units - especially in male patients that have high levels of Cutibacterium in their sebaceous glands. See 10 points about Cutibacterium, periprosthetic infection, and revision for failed shoulder arthroplasty
There is in vitro evidence of the effectiveness of topical vancomycin in preventing Cutibacterium growth. See, for example, Vancomycin is Effective in Preventing C. acnes Growth in a Shoulder Arthroplasty Mimetic. In this study the authors investigated the effect of vancomycin powder on Cutibacterium growth within the first 48 hrs. after surgery. Cutibacterium were applied to titanium alloy foil and embedded beneath multiple layers of collagen-impregnated cellulose scaffold strips containing human shoulder joint capsular fibroblasts, facilitating the development of an oxygen gradient with an anaerobic environment around the foil and inner layers.
10 mg of vancomycin powder was applied between the Cutibacterium layer and the human cell containing scaffold strips to model direct antibiotic application and intravenous vancomycin prophylaxis was modelled by adding vancomycin in media at 5μg/mL or 20 μg/mL.
After 48 h, the C. acnes inoculum layer was sub-cultured onto agar plates to assess the formation of viable Cutibacterium colonies. Primary human shoulder capsule cells were assessed microscopically to detect any detrimental effects of Vancomycin on cellular integrity.
Agar plates inoculated with extracts from untreated shoulder-joint implant mimetic consistently resulted in the growth of large numbers of Cutibacterium colonies, whereas treatments with vancomycin powder or vancomycin in media at 20μg/dL dilution effectively prevented the recovery of any Cutibacterium colonies.
Vancomycin powder had no discernable short-term impact on shoulder capsule cell morphology and the presence of these cells had no discernable impact on vancomycin degradation over time.
The authors concluded that vancomycin administration effectively prevented Cutibacterium growth in a bioartificial shoulder-joint implant mimetic. These results support the hypothesis that intra incisional vancomycin application may limit Cutibacterium prosthetic joint infections.
Another paper estimated the size of reduction in PJI rate that would be necessary to justify the use of topical vancomycin, The cost effectiveness of vancomycin for preventing infections after shoulder arthroplasty: a break-even analysis These authors concluded that prophylactic administration of local vancomycin powder during shoulder arthroplasty could be highly cost-effective. They estimated that the overall cost to treat an infection is $46,745. Vancomycin costs vary from $2.50 to $44 per gram of vancomycin. At $2.50 per gram, vancomycin only needs to obtain an efficacy of 0.005% in reducing the rate of PJI to be cost-effective, whereas at $44 per gram, the efficacy needs to be 0.09% to be cost- effective.
So, admitting that a large-scale randomized controlled trial would be necessary to determine the efficacy and safety of vancomycin in an attempt to reduce the rate of Cutibacterium PJI, the question is, "what should shoulder surgeons do while waiting for the results of such a study - use or do not use topical vancomycin?"
An example of a Cutibacterium PJI
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Here are some videos that are of shoulder interest
