Answer to “The Vancomycin Question” in THA/TKA

An "as good as you're going to get" RCT says skip the vanco in patients undergoing THA or TKA who don't have MRSA colonization before surgery

Smart Practice: Adding vancomycin to cefazolin for preoperative prophylaxis did not reduce the 90-day risk of PJI after TKA or THA — so, skip the vanco

What’s the Claim?

Surgeons worry that even patients who screen negative for methicillin-resistant Staphylococcus aureus (MRSA) colonization before arthroplasty may develop prosthetic joint infections (PJIs) with it afterward, since first-generation cephalosporins obviously don’t cover MRSA. Many, if not most, Staphylococcus epidermidis infections are resistant to cefazolin (Ancef), and S. epi has become the dominant PJI pathogen in many areas. For those reasons, many wonder whether making vancomycin a part of routine preoperative antibiotic prophylaxis is sensible in patients undergoing THA or TKA.

This question was addressed in an enormous multicenter randomized trial of patients without MRSA colonization who underwent hip or knee arthroplasty. In it, trialists found that adding 1.5 g of vancomycin to cefazolin prophylaxis (2 g) conferred no reduction in the risk of surgical-site infection relative to cefazolin alone. Hypersensitivity reactions were more common in the vancomycin group.

How’s It Stack Up?