Vancomycin prophylaxis and periprosthetic shoulder infecions.

Vancomycin is often used as antimicrobial prophylaxis for shoulder arthroplasty when first generation cephalosporins are thought to be contraindicated or colonization with resistant bacteria is anticipated. In general, vancomycin necessitates longer infusion times to mitigate potential side effects; thus logistical problems may complicate the desired completion of the infusion by 30 minutes prior to the procedure.

The authors of Intravenous Vancomycin Prophylaxis is Needed in Shoulder Arthroplasty, Incomplete Administration is Associated with Increased Infectious Complications sought to determine whether the timeliness of the administration of intravenous vancomycin prior to shoulder arthroplasty affected the rate of infectious complications.

They identified 461 primary arthroplasties performed for elective and trauma indications in which IV vancomycin was the primary antibiotic prophylaxis and 2 year followup was available.

The indication for Vancomycin was penicillin/cephalosporin allergy in 95% of the cases.

A total of 298 (64.6%) of patients received IV vancomycin at least 30 minutes before the procedure start (complete administration) and 163 (35.4%) began infusions less than 30 minutes before the procedure start (incomplete administration).

While most of the "on time" infusions took place in the preoperative holding area, all of the "late" infusions took place in the OR.




The incomplete group demonstrated higher rates of any infectious complication (8% vs. 2.3%; periprosthetic joint infectons (PJI) (5.5% vs. 1%; and reoperation inclusive of revision due to infectious complications (4.9% vs. 1%.

Survivorship free of PJI was worse in SA with incomplete compared to those with complete vancomycin administration. Of interest is that the survivorship for the incomplete infusion group continued to drop years after the procedure.

Multivariable analyses confirmed that incomplete vancomycin administration was an independent risk factor for PJI compared with complete administration (hazard ratio [HR], 4.22). Male sex (HR 4.6), MRSA colonization (HR 8.0), and followup time (HR 1.2) were also independent risk factors.


Comment: Even at the major medical center at which this study was performed, 1/3rd of the patients received "incomplete" vancomycin prophylaxis.

This paper did not present data on the causative organisms responsible for the cases of PJI; it is of interest, however, that the difference in the incidence of PJI from Cutibacterium (the most common causative organism for shoulder PJI) between the incomplete and complete vancomycin groups failed to reach statistical significance.

It is recognized that vancomycin demonstrates an inferior ability to prevent PJI when compared to cefazolin (see What antibiotic prophylaxis should be used against shoulder periprosthetic infection?)

The predominant reason for giving Vancomycin was "allergy to penicillin/cephalosporin". It is known that individuals with medical allergies have a higher rate of shoulder arthroplasty complications (see
The risk of total shoulder complications is significantly greater in patients with antibiotic allergies - why?).

Perhaps of even greater importance is that patients reporting penicillin allergy are very often not actually allergic to penicillin (see What if my total shoulder patient says she is allergic to penicillin? and When is it safe to give cephalosporin antibiotic prophylaxis to patients who are "allergic to penicillin"?

Thus while timing of Vancomycin administration may be an important factor in preventing shoulder periprosthetic infections, it may be even more important to evaluate the necessity of using Vancomycin for prophylaxis.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).ore important to ascertain whether or not the patient must actually receive Vancomycin rather than the more effective cephalosporin.