Does Combining Vancomycin Powder with Dilute Povidone-Iodine Lavage Affect PJI Rates, Organism Profiles?
A recently published study from a single institution evaluates whether this increasingly popular infection prevention strategy reduces periprosthetic joint infections in primary total joint arthroplasty patients without worsening the infectious organism profile.
Daniel B. Buchalter, MD; Ran Schwarzkopf, MD, MSc; Vinay K. Aggarwal, MD; and William J. Long, MD, FRCSC
Buchalter DB, Teo GM, Kirby DJ, et al. Does the organism profile of periprosthetic joint infections change with a topical vancomycin powder and dilute povidone-iodine lavage protocol? J Arthroplasty 2020 Dec 26;S0883-5403(20)31296-1. doi: 10.1016/j.arth.2020.12.036.
The use of vancomycin powder and dilute povidone-iodine lavage, individually or together, is becoming a popular infection prevention strategy in total joint arthroplasty (TJA). Although both have been independently associated with decreased perioperative infections in orthopaedic surgery, [1-13] no study has evaluated whether vancomycin powder and dilute povidone-iodine used together (VIP) reduces periprosthetic joint infections (PJIs) or whether that reduction negatively affects the infectious organism profile.
In a single-center, retrospective cohort study, Buchalter et al reviewed 18,299 primary TJAs performed before and after the introduction of VIP to prevent PJI (January 2012 through December 2013 and January 2016 through December 2019, respectively). Using Musculoskeletal Infection Society criteria,  the researchers identified 103 PJIs (32/3982 pre-VIP; 71/14,317 with VIP) that occurred within 90 days of the index arthroplasty.
The primary endpoint of the study was determination of whether the organism profile of primary TJA PJIs changed following the introduction of VIP. Infecting organisms were grouped as follows:
- Methicillin-sensitive Staphylococcus aureus (MSSA)
- Methicillin-resistant Staphylococcus aureus (MRSA)
- Coagulase-negative staphylococcal species
- Streptococcal species
- Gram-negative species
- Obligate anaerobes
- Polymicrobial species
- Culture-negative infections
Overall organism incidences (n/TJAs) and relative organism incidences (n/PJIs) were compared, using the total number of TJAs or PJIs that occurred during each respective VIP cohort as the denominator.
In addition, the study sought to determine whether VIP affected the incidence of primary TJA PJIs. Sub-analyses were performed on PJIs in total knee arthroplasty (TKA) patients and PJIs in total hip arthroplasty (THA) patients, with comparisons of demographics (age, gender, BMI, presence of diabetes, presence of rheumatoid arthritis, and ASA class) in the pre-VIP and VIP cohorts for TJAs, TKAs, and THAs.
There were no significant demographic differences among the groups before or after the introduction of VIP. The PJI rate decreased significantly following introduction of VIP for the TJA group overall (0.80% [32/3982] to 0.50% [71/14317], P=0.030) and for the TKA sub-group (1.01% [22/2182] to 0.44% [31/7045], P=0.005). No significant difference was seen in the PJI rate in the THA sub-group (0.56% [10/1800] to 0.55% [40/7272], P>0.999).
The use of VIP was associated with a significantly lower overall and relative incidence of coagulase-negative staphylococcal PJIs (overall: 0.20% to 0.04%, P<0.004; relative: 25.00% to 8.45%, P=0.031) and a significantly higher relative incidence of MSSA PJIs (18.75% to 40.85%, P=0.042) in the TJA group as a whole.
In the TKA sub-group analysis, VIP was associated with a significantly lower overall incidence of coagulase-negative staphylococcal PJIs (0.27% to 0.06%, P=0.015) and of MRSA PJIs (0.18% to 0.03%, P=0.031), as well as a non-significant decrease in the overall incidence of gram-negative PJIs (0.18% to 0.04%, P=0.59).
No significant organism profile changes were noted for PJIs in the THA sub-group following the introduction of VIP.
In addition, no vancomycin-intermediate or vancomycin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus, acid-fast bacteria, or fungal infections were identified among the reported PJIs.
This study is the first to show that VIP reduces the incidence of PJIs in primary TJA patients overall, as well as in primary TKA patients, regardless of preoperative risk. In addition, this reduction does not come at the cost of more-difficult-to-treat PJI organism profiles. In fact, it appears that VIP decreases the incidence of coagulase-negative staphylococcal PJIs in TJA patients overall and of MRSA PJIs in TKA patients. It may also reduce the incidence of gram-negative PJIs in TKA patients.
These findings are highly clinically relevant: The literature suggests that MRSA and gram-negative PJIs are more difficult to treat and lead to poorer outcomes. [15,16]
In addition, this paper is unique in that its grouping and analysis of organism profiles provides a template for future authors. Modeled after a study published by Aggarwal et al,  the organism groupings defined within this study are clinically relevant, thorough yet concise, easy to replicate, and easy to evolve if future authors see a need to restructure, add, or subtract groupings based on relevance to their particular study.
The findings suggest that VIP is a great tool for reducing infection rates and reducing negatively prognostic PJI organism profiles, therefore both improving outcomes and containing costs. However, there are notable limitations that the authors discuss, the most important being the retrospective design: The use of the historical cohorts could lead to confounding that cannot be addressed without a prospective trial. Other potential confounders are institutional changes to prophylaxis for deep vein thrombosis and perioperative patient optimization, the hiring of new surgeons and surgical staff, implant changes, and evolving perioperative wound management practices.
With funding from the American Association of Hip and Knee Surgeons, the Hip Society, and the Knee Society, the authors are using the data from this retrospective study to support a prospective, multicenter, randomized controlled trial evaluating the ability of VIP to decrease PJIs without worsening organism profiles in high-risk TJA patients. The ongoing study will be crucial in confirming the findings reported by Buchalter et al.
Daniel B. Buchalter, MD, is a third-year orthopaedic resident in the Department of Orthopedic Surgery at NYU Langone Health, New York, New York.
Ran Scwharzkopf, MD, MSc, is a Professor Department of Orthopedic Surgery at in the Department of Orthopaedic Surgery at NYU Langone Health and Associate Director of the NYU Langone Orthopedic Residency Program, New York, New York.
Vinay K. Aggarwal, MD, is an Assistant Professor in the Department of Orthopaedic Surgery at NYU Langone Health and Chief of the Adult Reconstructive Surgery Service at Bellevue Hospital, New York, New York.
William J. Long, MD, FRCSC, is a Clinical Associate Professor in the Department of Orthopedic Surgery at NYU Langone Health. He is also a Director and the Chief of Research for the Insall Scott Kelly Institute for Orthopaedics & Sports Medicine, New York, New York.
Disclosures: The authors have no disclosures relevant to this article.
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