CORRInsights®: Vancomycin Prophylaxis for Total Joint Arthroplasty: Incorrectly Dosed and Has a Higher Rate of Periprosthetic Infection Than Cefazolin
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 .
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 . More worrisome are the results from the current study and another recent study , 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 . A potential explanation, among others, could be insufficient vancomycin dosing . There are no data directly evaluating the best prophylactic dose of vancomycin, but current guidelines  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.