CORRInsights®: Vancomycin Prophylaxis for Total Joint Arthroplasty: Incorrectly Dosed and Has a Higher Rate of Periprosthetic Infection Than Cefazolin

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In 2010, US patients underwent more than 1 million total joint arthroplasties (TJAs), and the number is projected to reach 4 million by 2030 [4, 10]. With a recent surveillance study reporting a post-TJA infection risk of 2% in the United States [19], it seems likely that there were tens of thousands of post-TJA infections in 2010 alone. If we cannot decrease the infection rate, there will be approximately 80,000 in 2030. These patients generally experience multiple operations, long periods of disability, and extended treatment with antibiotics [7], all of which contribute to a major economic burden [9].
In the past 15 years, we have seen a rise in the prevalence of methicillin-resistant staphylococci [1, 15], leading to an intense debate about switching the routine approach to antimicrobial prophylaxis from a cephalosporin to a glycopeptide. In addition, 10% to 20% of patients undergoing TJA self-report allergy to penicillin [13, 17], and many of them receive vancomycin as prophylaxis under current guidelines [3].
Recent studies [2, 5, 6] comparing beta-lactams to glycopeptides found no differences in effectiveness for preventing surgical site infection. For the glycopeptide cohort, infections caused by methicillin-resistant Staphylococcus aureus (MRSA) were less frequent and were offset by an increase in both methicillin-sensitive S aureus (MSSA) and Gram-negative bacilli (GNB). These findings are not entirely surprising considering that vancomycin has a lower bactericidal activity than beta-lactams against susceptible staphylococci and has no activity against GNB [17]. More worrisome are the results from the current study and another recent study [16], which showed a higher risk of infection using prophylaxis with vancomycin alone.
Prophylaxis with vancomycin alone reduces MRSA infections, but it is associated with a higher risk of MSSA and GNB compared to cephalosporins. Indeed, vancomycin is associated with a lower cure rate than beta-lactams in patients with MSSA bacteremia [11]. A potential explanation, among others, could be insufficient vancomycin dosing [6]. There are no data directly evaluating the best prophylactic dose of vancomycin, but current guidelines [3] recommend the administration of 15 mg/kg (according to actual body weight) in order to obtain a serum concentration ≥ 15 mg/L until the end of surgery. Unfortunately, the standard protocol in many centers is 1 g of vancomycin, without regard for body weight.
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