Topical Vancomycin for Infection Prophylaxis in TJA
Primary Purpose
Infection of Total Hip Joint Prosthesis, Infection of Total Knee Joint Prosthesis
Status
Not yet recruiting
Phase
Phase 4
Locations
Study Type
Interventional
Intervention
Vancomycin Powder
Sponsored by
About this trial
This is an interventional prevention trial for Infection of Total Hip Joint Prosthesis
Eligibility Criteria
Inclusion Criteria:
- Adult patients aged 18 years or older, who are undergoing elective primary THA or TKA for osteoarthritis
- Patients must be able and willing to complete one year of follow-up postoperatively
Exclusion Criteria:
- Patients undergoing surgery for inflammatory arthritis, post-traumatic arthritis, or avascular necrosis
- History or septic arthritis based on history or synovial aspirate
- Prior major operation on the affected joint including osteotomy, open reduction internal fixation, or major open ligamentous repair, but excluding arthroscopic procedures such as ACL reconstruction or meniscus or labral debridement/repair
- Current immunosuppressive medications
- Vancomycin allergy or history of a vancomycin-related complication such as ototoxicity or nephrotoxicity
Sites / Locations
Arms of the Study
Arm 1
Arm 2
Arm Type
Experimental
No Intervention
Arm Label
Vancomycin Group:
Control Group
Arm Description
patients will have single dose of 1g vancomycin powder placed on their incision during surgery in addition to: pre- and post-operative intravenous antibiotic administration, sterile surgical helmet systems, saline pulse lavage irrigation, and antimicrobial drapes.
pre- and post-operative intravenous antibiotic administration, sterile surgical helmet systems, saline pulse lavage irrigation, and antimicrobial drapes.
Outcomes
Primary Outcome Measures
Rate of Periprosthetic Joint Infection in the same joint
Peri-operative Joint Infection in the operated joint
Rate of Periprosthetic Joint Infection in the same joint
Peri-operative Joint Infection in the operated joint
Rate of Periprosthetic Joint Infection in the same joint
Peri-operative Joint Infection in the operated joint
Secondary Outcome Measures
Rate of reoperation
Reoperation on the same joint
Rate of reoperation
Reoperation on the same joint
Rate of reoperation
Reoperation on the same joint
Rate of superficial and non-infectious wound complications
Superficial signs of infection including erythema and warmth requiring antibiotics in the opinion of the treating physician
Persistent drainage lasting greater than 7 days
Delayed incision healing beyond 14 days
Seroma or hematoma requiring surgical drainage
Rate of superficial and non-infectious wound complications
Superficial signs of infection including erythema and warmth requiring antibiotics in the opinion of the treating physician
Persistent drainage lasting greater than 7 days
Delayed incision healing beyond 14 days
Seroma or hematoma requiring surgical drainage
Rate of superficial and non-infectious wound complications
Superficial signs of infection including erythema and warmth requiring antibiotics in the opinion of the treating physician
Persistent drainage lasting greater than 7 days
Delayed incision healing beyond 14 days
Seroma or hematoma requiring surgical drainage
Rate of all complications
Anaphylactic reaction
Ototoxicity
Development of laboratory confirmed antibiotic resistant organism infection or colonization
Acute kidney injury, defined by a serum creatine increase 1.5 times baseline
Blood transfusion
Periprosthetic fracture
Prosthetic dislocation
Radiographic osteolysis or loosening
Venous thromboembolism
Acute coronary syndrome or arrhythmia
Cerebrovascular accident or transient ischemic attack
Death
Rate of all complications
Anaphylactic reaction
Ototoxicity
Development of laboratory confirmed antibiotic resistant organism infection or colonization
Acute kidney injury, defined by a serum creatine increase 1.5 times baseline
Blood transfusion
Periprosthetic fracture
Prosthetic dislocation
Radiographic osteolysis or loosening
Venous thromboembolism
Acute coronary syndrome or arrhythmia
Cerebrovascular accident or transient ischemic attack
Death
Rate of all complications
Anaphylactic reaction
Ototoxicity
Development of laboratory confirmed antibiotic resistant organism infection or colonization
Acute kidney injury, defined by a serum creatine increase 1.5 times baseline
Blood transfusion
Periprosthetic fracture
Prosthetic dislocation
Radiographic osteolysis or loosening
Venous thromboembolism
Acute coronary syndrome or arrhythmia
Cerebrovascular accident or transient ischemic attack
Death
Full Information
NCT ID
NCT04993027
First Posted
May 13, 2021
Last Updated
May 8, 2023
Sponsor
Alberta Hip and Knee Clinic
Collaborators
University of Calgary
1. Study Identification
Unique Protocol Identification Number
NCT04993027
Brief Title
Topical Vancomycin for Infection Prophylaxis in TJA
Official Title
Topical Vancomycin for Infection Prophylaxis in Total Hip and Knee Arthroplasty
Study Type
Interventional
2. Study Status
Record Verification Date
May 2023
Overall Recruitment Status
Not yet recruiting
Study Start Date
June 30, 2023 (Anticipated)
Primary Completion Date
June 15, 2025 (Anticipated)
Study Completion Date
June 15, 2025 (Anticipated)
3. Sponsor/Collaborators
Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
Alberta Hip and Knee Clinic
Collaborators
University of Calgary
4. Oversight
Studies a U.S. FDA-regulated Drug Product
Yes
Studies a U.S. FDA-regulated Device Product
No
Product Manufactured in and Exported from the U.S.
Yes
Data Monitoring Committee
Yes
5. Study Description
Brief Summary
11% of the general population undergo total hip arthroplasty (THA) in their lifetime and 7% undergo total knee arthroplasty (TKA), with these rates expected to rise up to 50% by 2026. Periprosthetic joint infection (PJI) remains one of the most common complications, accounting for 30% of THA/TKA revision surgeries. Topical delivery of antibiotic powder may reduce the incidence of PJI but its potential drawbacks include wound healing complications, reduced osteoblast activity, third body wear, and antibiotic resistance. In THA and TKA, topical administration of vancomycin powder for the primary prevention of PJI has been studied in observational studies, but conclusions are limited due to the low incidence of PJI and high number of patients required to detect a significant difference. Investigators therefore propose a randomized controlled trial (RCT) investigating the impact of topical vancomycin compared to standard care on PJI rates following THA and TKA.
Aim: To determine whether topical vancomycin is a safe and effective intervention for the primary prevention of PJI after THA and TKA.
Study Design: This is a pilot multi-centre RCT to evaluate the study design and assess feasibility prior to implementation across Canada. Investigators aim to recruit 50 THA and 50 TKA patients.
Inclusion Criteria THA or TKA Patients aged 18 years or older Patients must complete 1 year follow-up Exclusion Criteria Patients undergoing surgery for inflammatory arthritis, post-traumatic arthritis, or avascular necrosis History or septic arthritis based on history or synovial aspirate Prior major operation on the affected joint Current immunosuppressive medications Vancomycin allergy or history of a vancomycin-related complication Recruitment: surgeons introduce study to the patients, research staff will conduct recruitment.
Intervention: Patients will be randomized preoperatively and remain blinded to their treatment arm. Patients allocated to the control group will have all standard care infection prophylaxis interventions. Patients allocated to the vancomycin group will undergo all the standard care measures in addition to 1g of powdered vancomycin applied to the wound.
Follow-up: Patients will complete follow-up at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year visits.
Primary outcome: PJI in the same joint. Secondary outcome: PJI in THA and TKA subgroups:
Reoperation on the same joint Superficial and non-infectious wound complications All complications
Detailed Description
Hip and knee arthroplasty are the third and second most performed inpatient surgeries, respectively. Eleven percent of the general population undergo total hip arthroplasty (THA) in their lifetime and 7% undergo total knee arthroplasty (TKA), with these rates expected to rise up to 50% by 2026. Unfortunately, periprosthetic joint infection (PJI) remains one of the most common and devastating complications of hip and knee arthroplasty, accounting for 30% of revision surgeries.The incidence of PJI ranges from 0.2-1.6% for primary THA and 1-2% for primary TKA. Patients with PJI are subjected to repeated hospitalization and revision surgeries, which leads to increased morbidity and mortality as well as decreased functional outcomes. An estimated $1.6 billion USD is spent on treating hip and knee PJI in the United States yearly.
Topical delivery of antibiotic powder is a simple intervention which may reduce the incidence of PJI. Direct delivery of antibiotics to a target area allows for high local drug concentrations while limiting systemic side effects.Potential drawbacks of topical antibiotics include wound healing complications, reduced osteoblast activity, third body wear, and contribution to antibiotic resistance. Though systemic absorption is reduced, complications such as anaphylaxis, nephrotoxicity, and ototoxicity remain possible. Topical, intrawound administration of vancomycin powder has been well studied in spinal surgery for the prevention of surgical site infections (SSI), with good results. Based on this literature, vancomycin powder has been investigated for the prevention of SSI in multiple orthopaedic domains. In THA and TKA, topical administration of vancomycin powder for the primary prevention of PJI has been studied in a number of recent observational studies, but conclusions are limited due to the low incidence of PJI and high number of patients required to detect a significant difference.
Investigators have completed a systematic review meta-analysis of nine comparative observational studies investigating topical vancomycin for the primary prevention of PJI after hip and knee arthroplasty. Patients treated with topical vancomycin had a lower incidence of PJI compared to the control group (0.6% versus 1.8%, OR 0.40, p = 0.003). Excluding revision cases, patients undergoing primary hip or knee arthroplasty also had a lower incidence of PJI after topical vancomycin (0.6% versus 1.6%, OR 0.46, p = 0.001). After total hip arthroplasty 0.4% of patients developed a PJI in the vancomycin group compared to 1.8% of patients in the control group (OR 0.26, p = 0.003). After unicondylar or total knee arthroplasty, topical vancomycin led to a 0.8% rate of PJI compared to 1.8% in the control group. However, this difference failed to reach statistical significance (OR 0.55, p = 0.07). Topical vancomycin did not increase the rate of wound complications (4.5% versus 5.4%, OR 0.83, p = 0.40). There was no significant difference in overall complication rates between vancomycin and control groups (5.8% versus 7.0%, OR 0.87, p = 0.45).
The conclusions of this meta-analysis are limited by the retrospective nature of the included studies. Most studies use a consecutive series of patients without vancomycin administration followed sequentially by a series implementing topical vancomycin, or a single surgeon using vancomycin compared to a different surgeon as a control.
Additionally, results are limited by the relatively short minimum follow-up period, as many studies reported only three-month results, along with varied definitions of PJI and reporting of complications.
PJI after hip and knee arthroplasty remains a devastating and difficult to treat complication following hip and knee arthroplasty. Low level evidence suggests that topical vancomycin may be effective prophylaxis against PJI. However, given the substantial limitations of prior studies and potential for harm, higher quality studies are required before topical vancomycin can be routinely recommended. Investigators therefore propose a randomized controlled trial investigating the impact of topical vancomycin compared to standard care on PJI rates following THA and TKA.
Research Question: The overarching aim of this study is to determine whether topical vancomycin is a safe and effective intervention for the primary prevention of PJI after THA and TKA. Understanding its impact on PJI and other complication rates with high quality evidence can help make recommendations for or against its routine use and reduce risks to patients.
Study Design: The proposed research project is a pilot study which will precede a multi-centre randomized controlled trial to evaluate complication rates in THA and TKA following vancomycin administration compared to standard care. This pilot study will allow us to evaluate the study design and assess feasibility prior to implementation across Canada. Surgery will take place at one of the four major academic adult orthopedic hospitals: Peter Lougheed Center, Foothills Medical Centre, Rockyview General Hospital, and South Health Campus either Peter Lougheed Centre or Rockyview General Hospital with plans to expand to hospitals across Calgary and Canada in the future study. Investigators aim to recruit 50 patients undergoing THA and 50 patients undergoing TKA and will follow patients for one year postoperatively.
Recruitment: Initial introduction to the study will be done by the surgeons, followed by screening and recruitment, which will be completed by the research coordinator. Patients will have an opportunity to read the consent form and ask questions prior to signing the consent form. Baseline demographics including age, sex, gender, BMI, ethnicity, comorbidities, and smoking status will be recorded.
Intervention: Once enrolled, patients will be randomized preoperatively on the day of surgery Randomization will be done using R software (version 4.0.2), randomize R package. Block Randomization with randomly mixed block sizes to assign equal sample numbers to control and treatment groups (the allocator will hide the block size from the executer). This will be done via 'blockrand' Function in R. with an online randomizer (e.g. studyrandomizer.com). Patients will be blinded to their treatment arm.
Patients allocated to the control group will have all standard care infection prophylaxis interventions such as pre- and post-operative intravenous antibiotic administration, sterile surgical helmet systems, saline pulse lavage irrigation, and antimicrobial drapes. No povidone-iodine lavage will be used. Antibiotic impregnated cement may be used according to the individual surgeons' routine practices but will not differ for an individual surgeon between treatment arms.
Patients allocated to the vancomycin group will undergo all the standard care measures in addition to 1g of powdered vancomycin applied to the wound, in the intra-articular space and along wound edges after irrigation and prior to fascial closure.
Follow-up: Patients will complete follow-up at their regularly scheduled clinical follow-ups. At two weeks, six weeks, three months, six months, and one year visits patients will be assessed for the outcomes noted below.
6. Conditions and Keywords
Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Infection of Total Hip Joint Prosthesis, Infection of Total Knee Joint Prosthesis
7. Study Design
Primary Purpose
Prevention
Study Phase
Phase 4
Interventional Study Model
Parallel Assignment
Masking
Outcomes Assessor
Allocation
Randomized
Enrollment
100 (Anticipated)
8. Arms, Groups, and Interventions
Arm Title
Vancomycin Group:
Arm Type
Experimental
Arm Description
patients will have single dose of 1g vancomycin powder placed on their incision during surgery in addition to: pre- and post-operative intravenous antibiotic administration, sterile surgical helmet systems, saline pulse lavage irrigation, and antimicrobial drapes.
Arm Title
Control Group
Arm Type
No Intervention
Arm Description
pre- and post-operative intravenous antibiotic administration, sterile surgical helmet systems, saline pulse lavage irrigation, and antimicrobial drapes.
Intervention Type
Drug
Intervention Name(s)
Vancomycin Powder
Other Intervention Name(s)
Vancomycin Hydrochloride
Intervention Description
Vancomycin is a bactericidal aminoglycoside antibiotic which inhibits cell wall synthesis. It is effective against gram positive bacteria. Though most commonly administered intravenously, it can be delivered orally or directly into surgical incisions and wounds in certain indications.
Primary Outcome Measure Information:
Title
Rate of Periprosthetic Joint Infection in the same joint
Description
Peri-operative Joint Infection in the operated joint
Time Frame
at six weeks post-operative.
Title
Rate of Periprosthetic Joint Infection in the same joint
Description
Peri-operative Joint Infection in the operated joint
Time Frame
at three months post-operative.
Title
Rate of Periprosthetic Joint Infection in the same joint
Description
Peri-operative Joint Infection in the operated joint
Time Frame
at one year post-operative.
Secondary Outcome Measure Information:
Title
Rate of reoperation
Description
Reoperation on the same joint
Time Frame
at six weeks post-operative.
Title
Rate of reoperation
Description
Reoperation on the same joint
Time Frame
at three months post-operative.
Title
Rate of reoperation
Description
Reoperation on the same joint
Time Frame
at one year post-operative.
Title
Rate of superficial and non-infectious wound complications
Description
Superficial signs of infection including erythema and warmth requiring antibiotics in the opinion of the treating physician
Persistent drainage lasting greater than 7 days
Delayed incision healing beyond 14 days
Seroma or hematoma requiring surgical drainage
Time Frame
at six weeks post-operative.
Title
Rate of superficial and non-infectious wound complications
Description
Superficial signs of infection including erythema and warmth requiring antibiotics in the opinion of the treating physician
Persistent drainage lasting greater than 7 days
Delayed incision healing beyond 14 days
Seroma or hematoma requiring surgical drainage
Time Frame
at three months post-operative.
Title
Rate of superficial and non-infectious wound complications
Description
Superficial signs of infection including erythema and warmth requiring antibiotics in the opinion of the treating physician
Persistent drainage lasting greater than 7 days
Delayed incision healing beyond 14 days
Seroma or hematoma requiring surgical drainage
Time Frame
at one year post-operative.
Title
Rate of all complications
Description
Anaphylactic reaction
Ototoxicity
Development of laboratory confirmed antibiotic resistant organism infection or colonization
Acute kidney injury, defined by a serum creatine increase 1.5 times baseline
Blood transfusion
Periprosthetic fracture
Prosthetic dislocation
Radiographic osteolysis or loosening
Venous thromboembolism
Acute coronary syndrome or arrhythmia
Cerebrovascular accident or transient ischemic attack
Death
Time Frame
at six weeks post-operative.
Title
Rate of all complications
Description
Anaphylactic reaction
Ototoxicity
Development of laboratory confirmed antibiotic resistant organism infection or colonization
Acute kidney injury, defined by a serum creatine increase 1.5 times baseline
Blood transfusion
Periprosthetic fracture
Prosthetic dislocation
Radiographic osteolysis or loosening
Venous thromboembolism
Acute coronary syndrome or arrhythmia
Cerebrovascular accident or transient ischemic attack
Death
Time Frame
at three months post-operative.
Title
Rate of all complications
Description
Anaphylactic reaction
Ototoxicity
Development of laboratory confirmed antibiotic resistant organism infection or colonization
Acute kidney injury, defined by a serum creatine increase 1.5 times baseline
Blood transfusion
Periprosthetic fracture
Prosthetic dislocation
Radiographic osteolysis or loosening
Venous thromboembolism
Acute coronary syndrome or arrhythmia
Cerebrovascular accident or transient ischemic attack
Death
Time Frame
at one year post-operative.
10. Eligibility
Sex
All
Minimum Age & Unit of Time
18 Years
Maximum Age & Unit of Time
90 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria:
Adult patients aged 18 years or older, who are undergoing elective primary THA or TKA for osteoarthritis
Patients must be able and willing to complete one year of follow-up postoperatively
Exclusion Criteria:
Patients undergoing surgery for inflammatory arthritis, post-traumatic arthritis, or avascular necrosis
History or septic arthritis based on history or synovial aspirate
Prior major operation on the affected joint including osteotomy, open reduction internal fixation, or major open ligamentous repair, but excluding arthroscopic procedures such as ACL reconstruction or meniscus or labral debridement/repair
Current immunosuppressive medications
Vancomycin allergy or history of a vancomycin-related complication such as ototoxicity or nephrotoxicity
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Nicholas Desy, MD
Phone
4034047212
Email
nicholas.desy@albertahealthservicecs.ca
First Name & Middle Initial & Last Name or Official Title & Degree
Teresa HL Nguyen, BSc
Phone
4035873725
Email
thlnguye@ucalgary.ca
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Nicholas Desy, MD
Organizational Affiliation
University of Calgary
Official's Role
Principal Investigator
12. IPD Sharing Statement
Plan to Share IPD
No
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Topical Vancomycin for Infection Prophylaxis in TJA
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