Vancomycin Powder Falls Short for Infection Prevention in Hip and Knee Arthroplasty

Heidi Splete

August 11, 2021

Topical vancomycin powder failed to reduce periprosthetic joint infection after hip and knee arthroplasty, based on data from approximately 5000 patients.

Periprosthetic joint infection (PJI) remains a common complication of hip and knee arthroplasty, but studies of topical vancomycin powder as a strategy to manage these infections have yielded conflicting results, wrote Murray T. Wong, MD, from the University of Calgary, Canada, and colleagues. In a study published in Clinical Orthopaedics and Related Research, the investigators conducted a systematic review of nine studies, including 3371 hip or knee arthroplasty patients who received topical vancomycin and 2884 who did not. The primary outcome was the overall PJI rate in knee and hip arthroplasty patients.

Only one of the nine studies showed a decreased risk for PJI with vancomycin, and eight did not. Odds ratios ranged from 0.09 to 1.97; eight of these had a P value greater than .05 and one had a P value of .04.

In a subgroup analysis of total hip arthroplasty (THA) patients alone, one of five studies showed a lower risk for PJI, and none of seven studies of total knee arthroplasty (TKA) patients alone showed an effect from vancomycin use on PJI risk.

Overall complication data including wound and nonwound complications were available for six studies and showed no difference in complication risk between the vancomycin and control patients, with odds ratios ranging from 0.48 to 0.94 (P > .05 for all).

"Importantly, no study was sufficiently powered to detect differences in uncommon complications associated with vancomycin including allergy, ototoxicity, and nephrotoxicity, nor was there sufficient follow-up to detect medium- and long-term complications," the researchers wrote.

The study findings were limited mainly by the low level of evidence of the included studies, which were small and mainly retrospective, the researchers noted. The short follow-up period of the studies also limited the ability to assess the impact of vancomycin on delayed PJI, they said.

Ideally, the use of vancomycin powder would help reduce infection and avoid drug-related complications, the researchers said. "Unfortunately, the available studies have low levels of evidence and methodologic flaws, and in aggregate, they were not sufficiently convincing on the topic of efficacy to allow us to recommend the routine use of topical vancomycin in THA and TKA," and large studies of both safety and efficacy are needed, they concluded.

Beware Weak Evidence for Sensible-Seeming Interventions

"Performing this review was eye-opening," said senior author Nicholas Desy, MD, from the University of Calgary, Canada, in an interview with Seth S. Leopold, MD, editor-in-chief of Clinical Orthopaedics and Related Research. The interview was published in the journal accompanying the study. Desy said that since the review he has stopped using vancomycin powder. "The evidence was not nearly as robust as it seemed before we began, and more of my choice than I realized was based on anecdotes and papers that were not of good quality," he said.

The fact that the researchers found no benefit to vancomycin in preventing PJI does not exclude the possibility of some benefit, but it seems unlikely based on the studies included in this review, Desy noted. He extrapolated the take-home message to clinicians in fields outside of primary joint arthroplasty as "continue to ask questions and look for better evidence, and not jump straightaway to a large practice change, such as the one I made prior to this review, when I incorporated vancomycin powder into my practice for primary total hip and knee arthroplasty based on paper with lower levels of evidence and anecdotes."

PJI remains a severe potential complication in arthroplasty, Desy said. Despite the lack of benefit in this review, he suggested that a large, randomized trial with multicenter collaboration would provide additional information.

"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," he said. He added that "a good use of resources would be to fund projects that look at preventing PJI in conjunction with studies that look to improve its treatment."

Findings Promote Caution

"This study is extremely important because the practice of using intrawound vancomycin during elective total hip and total knee arthroplasty is being done with increased frequency despite a lack of high-quality evidence," said Nathanael Heckmann, MD, from the Keck School of Medicine of the University of Southern California in Los Angeles, in an interview with Medscape Medical News. "This study underscores the lack of conclusive data presently available in the arthroplasty literature," he said.

Heckmann said that the findings were not surprising, "given the rare nature of periprosthetic joint infection." He added, "In a non-pooled analysis of studies of this size, no statistical significance would be expected even if a real effect was present."

The overall conclusion of the study is a recommendation against the use of topical vancomycin in the hip and knee arthroplasty patient population, Heckmann said.

The take-home message for clinicians is "to proceed with caution as there are no conclusive high-quality data to support the practice of topical intrawound vancomycin in total joint arthroplasty; currently, the efficacy and safety of this practice is unknown," he emphasized.

"A prospective randomized multicenter trial is needed to conclusively answer the question regarding the safety and efficacy of topical intrawound vancomycin when used during total hip and total knee arthroplasty," Heckmann said. "However, given the low rate of PJI following primary total joint arthroplasty, more than 9,000 patients would be required to demonstrate a 50% effect size for an outcome that only occurs in approximately 1% of patients," he noted. "While this may seem like a Herculean task, several studies of this scope have been performed assessing the safety and efficacy of various [deep vein thrombosis] prophylaxis medications," he said.

The researchers and Heckmann have disclosed no relevant financial relationships.

Clin Orthop Relat Res. 2021. 479:1655-1664. doi: 10.1097/CORR.0000000000001777.

Clin Orthop Relat Res. 2021. 79:1651-1654. doi: 10.1097/CORR.0000000000001883

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