Editor’s Spotlight/Take 5: Vancomycin Prophylaxis for Total Joint Arthroplasty: Incorrectly Dosed and Has a Higher Rate of Periprosthetic Infection Than Cefazolin

Clinical Orthopaedics and Related Research®, May 2017

M. Daniel Wongworawat MD

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Editor’s Spotlight/Take 5: Vancomycin Prophylaxis for Total Joint Arthroplasty: Incorrectly Dosed and Has a Higher Rate of Periprosthetic Infection Than Cefazolin

Editor's Spotlight/Take 5 M. Daniel Wongworawat - eight-based dosing of medications is not a foreign concept to most of us. We learned it in medical school, especially while rotating on the pediatrics service. We did it while in residency, ordering weight-based gentamicin for certain open fractures [10]. And when we order antibiotics for A note from the Editor-In-Chief: In ‘‘Editor’s Spotlight,’’ one of our editors provides brief commentary on a paper we believe is especially important and worthy of general interest. Following the explanation of our choice, we present ‘‘Take Five,’’ in which the editor goes behind the discovery with a one-on-one interview with an author of the article featured in ‘‘Editor’s Spotlight.’’ The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research1 editors and board members are on file with the publication and can be viewed on request. treatment, we sometimes adjust the dose to ensure therapeutic dosing. But for prophylactic antibiotics before surgery, somehow the fixed 1-g dose has become common practice. Most patients receive a 1-g dose of cefazolin, and for those patients with a beta-lactam allergy, 1-g dose of vancomycin is sometimes substituted. But patients come in different sizes. There is good evidence suggesting that failing to recognize this may increase the risk of prosthetic joint infection (PJI). A recent study [21] looking at trabecular bone harvested from patients who underwent TKA demonstrated that vancomycin levels in bone varied with BMI, where higher concentrations were seen in patients with lower BMI. Additionally, the study points to the pharmacokinetic properties of vancomycin, where it has greater deposition in soft tissues when compared to cefazolin; therefore, a smaller proportion of vancomycin is available in trabecular bone. Surgeons may use vancomycin for prophylaxis in patients colonized with methicillinresistant Staphylococcus aureus (MRSA), and this practice may become more widespread as the prevalence of MRSA infection is increasing [9, 19]. However, we sometimes use vancomycin for patients with a history of penicillin allergy, a practice that perhaps should be abandoned. There is, in fact, little risk that a patient with a reported allergy to penicillin will experience anaphylaxis when given cefazolin [3, 14]. The question we are most concerned about, though, is whether patients are adequately dosed with whatever antibiotic they do receive, and whether those who are underdosed are more likely to develop PJI, which is a dreaded complication. In this context, the work of Dr. Kheir and his team from Thomas Jefferson University in Philadelphia, PA, USA should matter to all orthopaedic surgeons. They found that among primary TJAs, patients receiving vancomycin had a higher rate of PJI compared with patients receiving cefazolin prophylaxis, and that the majority of patients given vancomycin prophylaxis were underdosed based on the weight-based dosage recommendations. In a glimmer of bright news, MRSA did not occur in patients who were adequately dosed with vancomycin. In addition to adequate dosing, this paper gives us an important reminder that surgeons should use vancomycin judiciously and rarely as a sole agent. Please join me for the Take-5 interview with Dr. Michael M. Kheir, as we dig deeper into this critically important clinical problem. Take-5 Interview with Michael M. Kheir MD, primary author of ‘‘Vancomycin Prophylaxis for Total Joint Arthroplasty: Incorrectly Dosed and Has a Higher Rate of Periprosthetic Infection Than Cefazolin’’ M. Daniel Wongworawat MD: What prompted your interest in looking at compliance with vancomycin dosing recommendations? Why did you think there might be low acceptance/implementation of the weight-based dosing guidelines for vancomycin administration? Michael M. Kheir MD: As a large institution, we have surgeons with diverse practices—some who administer vancomycin prophylaxis routinely, and others only in light of patientspecific factors such as being MRSApositive or having a history of anaphylaxis to penicillin. We were interested in studying this because recent guidelines have demonstrated that vancomycin should be weight-based [2, 7], yet many surgeons at our practice and around the country are accustomed to a fixed 1-g dose of vancomycin. The low acceptance of weightbased dosing guidelines may simply be due to unawareness. The guidelines were introduced in the last few years [2, 7], and although they are well-known among infectious disease specialists, orthopaedic surgeons and anesthesiologists may be less familiar since they are not traditionally trained to give weightbased doses (...truncated)


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M. Daniel Wongworawat MD. Editor’s Spotlight/Take 5: Vancomycin Prophylaxis for Total Joint Arthroplasty: Incorrectly Dosed and Has a Higher Rate of Periprosthetic Infection Than Cefazolin, Clinical Orthopaedics and Related Research®, 2017, pp. 1762-1766, Volume 475, Issue 7, DOI: 10.1007/s11999-017-5354-1