Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
Washington University School of Medicine, St Louis, MO, USA.
J Shoulder Elbow Surg. 2023 Apr;32(4):803-812. doi: 10.1016/j.jse.2022.10.012. Epub 2022 Nov 12.
Vancomycin is often used as antimicrobial prophylaxis for shoulder arthroplasty (SA) either when first generation cephalosporins are contraindicated or colonization with resistant bacteria is anticipated. In general, vancomycin necessitates longer infusion times to mitigate potential side effects. When infusion is started too close to the time of the incision, administration may not be complete during surgery. This study evaluated whether incomplete administration of intravenous vancomycin prior to SA affects the rate of infectious complications.
Between 2000 and 2019, all primary SA types (hemiarthroplasty, anatomic total SA, reverse SA) performed at a single institution for elective and trauma indications using intravenous vancomycin as the primary antibiotic prophylaxis and a minimum follow-up of 2 yr were identified. The time between the initiation of vancomycin and skin incision was calculated. Complete administration was defined as at least 30 min of infusion prior to incision. Demographic characteristics and infectious complications including survival free of prosthetic joint infection (PJI) were generated. Multivariable analyses were conducted to evaluate the association between vancomycin timing and the development of PJI.
A total of 461 primary SAs were included. Infusion was incomplete (< 30 minutes preoperatively) for 163 [35.4%] SA and complete (> 30 minutes preoperatively) for 298 [64.6%] SAs. The incomplete group demonstrated higher rates of any infectious complication (8% vs. 2.3%; P = .005), PJI (5.5% vs. 1%; P = .004), and reoperation inclusive of revision due to infectious complications (4.9% vs. 1%; P = .009). Survivorship free of PJI was worse in SA with incomplete compared to those with complete vancomycin administration. Survival rates for incomplete and complete administration were 97.6% and 99.3% at 1 mo, 95.7% and 99.0% at 2 yr, 95.1% and 99.0% at 5 yr, and 93.9% and 99.0% at 20 yr, respectively (P = .006). Multivariable analyses confirmed that incomplete vancomycin administration was an independent risk factor for PJI compared with complete administration (hazard ratio, 4.22 [95% confidence interval, 1.12-15.90]; P = .033), even when other independent predictors of PJI (age, male sex, prior surgery, methicillin-resistant Staphylococcus aureus colonization, and follow-up) were considered.
When vancomycin is the primary prophylactic agent used at the time of primary SA, incomplete administration (infusion to incision time under 30 min) seems to adversely increase the rates of infectious complications and PJI. Prophylaxis protocols should ensure that complete vancomycin administration is achieved to minimize infection after SA.
万古霉素常用于预防肩关节炎（SA），尤其是在第一代头孢菌素禁忌或预期存在耐药菌定植时。一般来说，万古霉素需要更长的输注时间来减轻潜在的副作用。如果在手术切口附近开始输注，可能无法在手术期间完成给药。本研究评估了在进行 SA 之前，静脉万古霉素给药不完全是否会影响感染性并发症的发生率。
在 2000 年至 2019 年期间，对在单家机构进行的所有择期和创伤性原发性 SA 类型（半关节成形术、解剖全关节成形术、反式 SA）进行了评估，这些手术均使用静脉万古霉素作为主要抗生素预防药物，且最低随访时间为 2 年。计算了从万古霉素开始到皮肤切口的时间。将至少 30 分钟的输注时间定义为完全给药。生成了人口统计学特征和感染性并发症，包括无假体关节感染（PJI）的生存情况。进行了多变量分析，以评估万古霉素时间与 PJI 发展之间的关联。
共纳入 461 例原发性 SA。163 例（35.4%）SA 输注不完全（<30 分钟术前），298 例（64.6%）SA 输注完全（>30 分钟术前）。不完全组的任何感染性并发症发生率（8% vs. 2.3%；P=0.005）、PJI（5.5% vs. 1%；P=0.004）和因感染性并发症（4.9% vs. 1%；P=0.009）而进行的翻修手术率均较高。与完全万古霉素给药相比，不完全万古霉素给药的 SA 无 PJI 生存情况较差。不完全和完全给药的 1 个月时无 PJI 生存率分别为 97.6%和 99.3%，2 年时分别为 95.7%和 99.0%，5 年时分别为 95.1%和 99.0%，20 年时分别为 93.9%和 99.0%（P=0.006）。多变量分析证实，与完全给药相比，不完全万古霉素给药是 PJI 的独立危险因素（风险比，4.22[95%置信区间，1.12-15.90]；P=0.033），即使考虑了其他 PJI 的独立预测因素（年龄、男性、既往手术、耐甲氧西林金黄色葡萄球菌定植和随访）。
当万古霉素是原发性 SA 时的主要预防药物时，不完全给药（输注至切口时间<30 分钟）似乎会增加感染性并发症和 PJI 的发生率。预防方案应确保完全给予万古霉素，以最大程度地减少 SA 后的感染。
