New Infection Prevention Strategies Similar to Saline in High-Risk Hip Arthroplasty

SAN DIEGO — Vancomycin powder, dilute povidone-iodine lavage, and a combination of both treatments were not superior to standard saline for the prevention of periprosthetic joint infection (PJI) in patients undergoing high-risk total hip arthroplasty, a randomized trial showed.

Among 821 patients assigned to the four groups, no statistically significant differences were noted in rates of persistent wound drainage or dehiscence, cellulitis or abscess, 3-month infection rates, type of septic revisions performed, aseptic revision rates, emergency department visits, or readmissions, reported Ran Schwarzkopf, MD, MSc, of NYU Langone Health in New York City, at the American Academy of Orthopaedic Surgeons annual meeting.

The incidence rate of wound complications was 3.2% (drainage, dehiscence, cellulitis), and eight total THA revisions occurred (four aseptic, four septic).

The researchers ended the study early because they realized the differences between the groups were so tiny that they’d need to enroll 80,000 patients instead of the planned 15,000 to reach statistically and clinically useful findings, Schwarzkopf told MedPage Today.

“All of these options are reasonable and acceptable,” he said. “We didn’t find any negative effects from using these options, which are not expensive.”

As Schwarzkopf explained, infections are rare in joint replacement surgeries, at about 0.5% to 1%, but they’re a “devastating complication” when they occur. “They can lead to multiple surgeries,” he noted. “We do everything we can to try to avoid them.”

To reduce the risk of infections, surgeons encourage patients to lose weight (especially if they have obesity), control their diabetes, and stop smoking at least 6 weeks before surgery, he added. In addition to prescribing prophylactic antibiotic therapy, surgeons also turn to vancomycin powder, dilute povidone-iodine lavage, and saline irrigation during procedures.

The study findings regarding the combined use of vancomycin powder and povidone-iodine were surprising, since other studies have shown a benefit, Schwarzkopf said. It’s possible that the infection-fighting properties of the agents “may not come into play as much as our surgical time goes down, and we use other prophylactic measures.”

Schwarzkopf noted that his institution continues to use all three strategies.

Fabio Mancino, MD, of Fremantle Hospital and Fiona Stanley Hospital in Perth, Australia, told MedPage Today that the findings don’t provide a “definitive answer” about the comparative value of the prophylaxis strategies due to the low rate of PJIs.

Other research has been conflicting, he said, but overall it doesn’t seem to recommend either vancomycin powder or povidone-iodine. “Vancomycin powder has shown sometimes an increased rate of wound complications, especially in total knee arthroplasty, though this may be related to the technique used and the joint involved.”

As for povidone-iodine, Mancino noted that his experience suggests that “lavage is useful, especially in revision settings.”

In regard to infection prevention in general, he highlighted the importance of antibiotic cement, preoperative screening, intraoperative sterility, and optimization of the patients, “not only from a medical point of view but also from a nutritional point; for example, identifying frail patients and hypoproteinemia and hypoalbuminemia.”

“When combining everything, we try to reduce the risk of PJI as much as possible,” he said. “But we have yet to find the single strategy that causes the PJI rate to drop significantly.”

For this open-label, 17-center study, the researchers focused on high-risk patients — those with a body mass index (BMI) over 40 (patients with BMI over 50 are estimated to face an 18-fold higher risk of PJI), age over 75, active smoking, American Society of Anesthesiologists (ASA) physical status score ≥3, immunosuppression (such as diabetes, rheumatoid arthritis, hepatitis C, HIV), Staphylococcus aureus colonization, and any aseptic revision THA.

They assigned 199 patients to vancomycin powder, 215 to povidone-iodine, 220 to both therapies, and 187 to saline.

Among the four groups, mean age was 63 to 67, 54% to 58% were women, 67% to 74% were white, and 14% to 24% were Black.

As for comorbidities, 20% to 30% had diabetes, 14% to 19% were current smokers, 32% to 40% were former smokers, and 52% to 54% had an ASA score of 3.

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