Answer to “The Vancomycin Question” in THA/TKA — What Now?

In the CORRelations post, “Answer to ‘The Vancomycin Question’ in THA/TKA," a robust RCT in NEJM found that routine prophylactic use of vancomycin (in addition to cefazolin) in patients undergoing THA or TKA is unwarranted. In fact, male patients who received vancomycin had a higher risk of surgical site infections than their cefazolin-only counterparts. The post recommends only using prophylactic vancomycin in patients who screen positive as MRSA carriers.

I recently saw an excellent presentation on PJI by arthroplasty subspecialist and past-president of the AAOS Dan Berry MD. He described PJI as the last frontier in total joint research, and in particular, he expressed that advancement in prevention and treatment of PJI is lagging.

There also has been a tendency in trauma surgery to alter prophylaxis in open fractures away from cefazolin and toward vancomycin. While many of us have abandoned the prophylactic use of gentamycin for safer third-generation cephalosporins (like ceftriaxone), I believe that vancomycin for surgical antibiotic prophylaxis should seldom be used. In my practice, we limit its use to patients with type III open fractures who have a history of MRSA infection.

As prescribers and stewards of our antibiotic resources, we must all protect the few remaining effective antibiotics that are available. Indiscriminate use of vancomycin may certainly lead to increased resistance, and in this NEJM study, its use seemed to increase the risk of infection in some patients (males).

Instead of making visceral assumptions about best practices, let’s use the evidence available to make wise decisions based on science. And in case you missed it, here’s a related post in CORRelations on the use of intrawound antibiotics, showing them not to be as effective as any of us would’ve hoped.