Why use topical Vancomycin powder as infection prophylaxis in shoulder arthroplasty?

Periprosthetic infection is a serious complication of shoulder arthroplasty. The most common causative organism is Cutibacterium residing in the pilosebaceous units of the dermis overlying the shoulder. As pointed out in a recent post (see this link), these commensal organisms cannot be eradicated by skin preparation prior to making the incision for shoulder arthroplasty. The result is unavoidable contamination of the wound (see Propionibacterium can be isolated from deep cultures obtained at primary arthroplasty despite intravenous antimicrobial prophylaxis). 

Whether or not this contamination results in a periprosthetic infection depends on (1) the interaction between the host and bacterium and (2) the details of the surgical procedure: the intravenous prophylactic antibiotics used, open wound time, and the composition of the implants. Other measures may help manage the contamination before it establishes a biofilm on the implants: copious irrigation, povidone-iodine lavage and topical in-wound vancomycin. The effectiveness of these measures is difficult investigate rigorously because of the relative infrequency of Cutibacterium infections, the stealthy way in which they typically present, and - in most cases - the need to obtain deep tissue or explant specimens for cultures to determine if an infection is present.

Admitting the need for more robust evidence, let us review some of the information supportive of the use of topical vancomycin in reducing the risk of Cutibacterium periprosthetic infection. 

(1) The cost is low: if 1 to 2 grams are used, the total cost per surgery would range from $10 to $40.

(2) The risk is low:  The risks of vancomycin intravenous infusion reaction are minimized with topical use. The risks of allergy, nephrotoxity and ototoxicity are low with topical administration due to the limited systemic levels.

(3) In vitro data supportive of its effectiveness

    a) 2013 Antimicrobial Susceptibility of Propionibacterium acnes Isolates from Shoulder Surgery: Cutibacterium isolates from shoulder surgery were susceptible to vancomycin.

    b) 2017 In vitro susceptibility of Propionibacterium acnes to simulated intrawound vancomycin concentrations: When administered in a fashion meant to simulate time-dependent in vivo intrawound concentrations, vancomycin exhibited bactericidal activity against P. acnes [Cutibacterium].

     c) 2022 Vancomycin is effective in preventing Cutibacterium acnes growth in a mimetic shoulder arthroplasty: Vancomycin administration effectively prevented C acnes growth in a bioartificial shoulder joint mimetic implant.

(4) Clinical data

    a) 2011 Intrawound application of vancomycin for prophylaxis in instrumented thoracolumbar fusions.   Adjunctive local application of vancomycin powder decreased the postsurgical wound infection rate with statistical significance in posterior instrumented thoracolumbar spine fusions.

    b) 2017 The cost effectiveness of vancomycin for preventing infections after shoulder arthroplasty: a break-even analysis: the prophylactic administration of local vancomycin powder during shoulder arthroplasty is a highly cost-effective practice.

    c) 2017 Intrawound Vancomycin Powder Reduces Early Prosthetic Joint Infections in Revision Hip and Knee Arthroplasty: The use of intrawound vancomycin powder was associated with a significant reduction in the overall incidence of early PJIs following joint arthroplasty, however, only the revision procedures demonstrated a significant reduction in the rate of early PJIs.

    d) 2023 Vancomycin powder embedded in collagen sponge decreases the rate of prosthetic shoulder infection: Intrawound vancomycin powder significantly reduced the rate of periprosthetic shoulder infections without any increase in local and systemic aseptic complications at a minimum follow-up of 12 months. 

    e) 2024 Prophylactic use of vancomycin powder on postoperative infection after total joint arthroplasty: This systematic review of retrospective studies found that local prophylactic use of vancomycin powder in TJA can significantly reduce the incidence of postoperative infection.

Comment: Periprosthetic infection are devastating for the patient. Many variables influence a patient's risk, including sex, age, immune defenses, medications, comborbidities, prior surgery, prior injections, skin microbiome, bacterial virulence, surgical procedure, surgical time, as well as preoperative, intraoperative and postoperative prophylactic measures. Controlling for these variables to single out the clinical effectiveness of topical vancomycin in reducing infection rate would be a statistical nightmare. Laboratory data are encouraging and have the advantage of tightly controlling the variables, but they cannot duplicate the clinical situation.

Let's keep our eyes out for more light to shine on this topic.

Comments welcome at shoulderarthritis@uw.edu

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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).