Perioperative Vancomycin Inferior to Standard Postoperative Antibiotics in TKR

Periprosthetic joint infection following total knee replacement was more likely among patients who received perioperative vancomycin vs standard postoperative antibiotics.

Topical vancomycin powder is inferior to standard intravenous (IV) antibiotic therapy for decreasing the risk for periprosthetic joint infection (PJI) following total knee replacement (TKR), according to study findings published in The Journal of Arthoplasty.

Researchers conducted a double-blinded, non-inferiority, randomized controlled trial to determine whether perioperative vancomycin powder (treatment) is as effective as standard postoperative IV antibiotic therapy (control) for reducing PJI risk among patients undergoing TKR. Patients were randomly assigned in a 1:1 fashion into the treatment (n=80) and control (n=85) groups and matched by baseline characteristics. The primary outcome was the incidence of acute surgical site infection within 42 days of TKR.

A total of 165 adult patients (mean age, 65 years) participated in the study. Of the total cohort, 102 (62%) patients had an American Society of Anesthesiologist III classification, with even distribution between the treatment and control groups.

All patients received a preoperative dose (2-3 g) of IV cefazolin (or, in the case of cefazolin allergy, vancomycin) within an hour of skin incision. Patients in the treatment group received a perioperative dose (1 g) of topical vancomycin powder, with 500 mg applied to the prosthesis and 500 mg applied above the closed joint capsule.

We therefore recommend against the use of intraoperative topical vancomycin without posterative antibiotics in TKA.

The study was halted at month 12 when it was determined that a statistically significantly greater percentage of patients in the treatment vs control groups were diagnosed with PJI (3.75% vs 0%; P =.03). It was noted, however, that more patients in the control group experienced postoperative complications compared with those in the treatment group (9% vs 4%, respectively).

The researchers noted that a 1-mg dose of vancomycin powder may not have been sufficient to maintain the minimum inhibitory concentration within the joint capsule over an extended time period.

The results of this study may not be generalizable to other populations as enrolled patients were at relatively increased risk for PJI.

Based on these findings, “We therefore recommend against the use of intraoperative topical vancomycin without posterative antibiotics in TKA [total knee arthroplasty],” the researchers concluded.


Abuzaiter W, Bolton C, Drakos A, et al. Is topical vancomycin an option? a randomized controlled trial to determine the safety of the topical use of vancomycin powder in preventing postoperative infections in total knee arthroplasty, as compared with standard postoperative antibiotics. J Arthroplasty. Published online January 31, 2023. doi: 10.1016/j.arth.2023.01.040.