SLR - February 2024 - Fairman
Title: Is Topical Vancomycin an Option? A Randomized Controlled Trial to Determine the Safety of the Topical Use of Vancomycin Powder in Preventing Postoperative Infections in Total Knee Arthroplasty, as Compared With Standard Postoperative AntibioticsReference: Abuzaiter, Wesam, et al. "Is Topical Vancomycin an Option? A Randomized Controlled Trial to Determine the Safety of the Topical Use of Vancomycin Powder in Preventing Postoperative Infections in Total Knee Arthroplasty, as Compared With Standard Postoperative Antibiotics." The Journal of Arthroplasty (2023).
Level of Evidence: 1
Reviewed by: Brooke Fairman, DPM, PGY-2
Residency Program: Creighton University School of Medicine – Phoenix; Phoenix, Arizona
Podiatric Relevance: This article could help in the post-operative management of total ankle replacements and decrease the rate of post-operative infections. The purpose of this study was to evaluate if topical vancomycin lead to a reduction in periprosthetic joint infections compared to postoperative IV antibiotics.
Methods: Between August 2016 and September 2017, 165 participants were broken into two groups: group 1 received topical vancomycin powder after total knee arthroplasty and group 2 received 24 hours of IV antibiotics post-operatively. The participants were randomly assigned to their respective groups. Patients in group 1 received one gram of topical vancomycin powder directly around the prosthesis (500mg) and external to capsular closure (500mg). Group 2 received 24 hours of post-operative antibiotics, usually cephalosporins were used unless contraindicated. Patients were assessed by a physician assistant at 2-week and 6-week follow-up. Patients were evaluated for incidence of deep skin/soft tissue infection. Prosthetic joint infection was defined as sinus tract communicating with the prosthesis or a pathogen was isolated by culture from at least 2 separate tissue or fluid samples obtained from the affected prosthetic joint. If patients did not have such clear indications, they were required to meet 4 of the 6 following criteria: elevated ESR and CRP, elevated synovial leukocyte count, elevated synovial polymorphonuclear neutrophil percentage, purulent drainage, and more than 5 neutrophils in high power resolution field on histological evaluation at 400 x magnification. Secondary outcomes including length of stay and post-operative complications were also evaluated.
Results: Topical vancomycin powder was inferior to post-operative IV antibiotics in those undergoing total knee arthroplasty. The incidence of post-operative infections in group 1 was 3.75% compared to 0%. The study was stopped prematurely due to a statistically significant difference between the two groups in infection rates
Conclusions: The use of topical vancomycin powder is a controversial topic in orthopedic literature. Recent studies evaluating topical vancomycin use in spinal fusion have shown decreased incidence of post-operative infections. However, this study recommended against the use of topical vancomycin powder. Based on these results of recent spinal literature, however, I believe as a podiatric surgeon this could be used as an adjunctive therapy for total ankle arthroplasty. If patients are not being admitted post-operatively, it may also be beneficial.