Vancomycin Properties in Cement

- Discussion: (see vancomycin and addition of antibiotics to cement,  vanc in ca sulfate and local delivery of antibiotics to infected joints): 
       - dosing:
             - as much as 4 gm of vancomycin (as well as 4.6 gm of tobramycin) can be used per batch of cement; 
             - note that the cost for a 1 gm vial is about 40 US dollars; 
             - in the study by Masri, et al, authors conclude that at least 3.6 g of tobra and 1 g of vanc per package of bone-cement is recommended when
                   antibiotic-loaded cement spacers are used in 2-stage exchange arthroplasty for infected total hip and knee arthroplasties; 
                    - there was a significant increase in elution of vancomycin when dose of tobra was increased from at most 2.4 g to at least 3.6 g; 
                    - Long-term elution of antibiotics from bone-cement: an in vivo study using the prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) system.
       - local pharmokinetics vs systemic:
              - has much slower and more consitent elution characteristics than tobramycin and gent; 
              - vancomycin shows very poor tissue penetration, which is a disadvantage of IV infusion;
              - in contrast, w/ local application there will also be reduced penetration from the implanted site into the vascular system, which
                          keeps local tissue levels high and systemic levels low;
              - references:     
                     - Release of gentamicin and vancomycin from temporary human hip spacers in two-stage revision of infected arthroplasty.
                     - Elution of gentamicin and vancomycin from polymethylmethacrylate beads and hip spacers in vivo
                     - High concentration and bioactivity of vancomycin and aztreonam eluted from Simplex cement spacers in two-stage revision of infected hip implants: a study of 46 patients at an average follow-up of 107 days.
                     - vivo and in vitro studies of antibiotic release from and bacterial growth inhibition by antibiotic-impregnated polymethylmethacrylate hip spacers.
       - safety:
              - vancomycin shows the least cytotoxic effect of all commonly used antibiotics and is not likely to cause systemic side effects after local application;
              - in the report by Springer, et al total antiobiotic load of 10.5 g of vanc and 12.5 g of gent was clinically safe, w/ no evidence of acute
                       renal insufficiency or other systemic side effects; 
              - in the study by Evans, et al, the authors used 4 g of vanc and 4.6 g of tobra per 40 gm batch of cement in 54 periprosthetic joint infections; 
                     - at 2-year follow up there were no no renal, vestibular, or hearing changes; 
                     - Systemic safety of high-dose antibiotic-loaded cement spacers after resection of an infected total knee arthroplasty.
                     - Successful treatment of total hip and knee infection with articulating antibiotic components: a modified treatment method.
      - biofilm: bactericidal activity:
              - vancomycin is one of the antibiotics with intracellular bactericidal activity and therefore should cover small colony variants of staphylococci and MRSA;
              - penetrates glycocalices very rapidly;
              - once incorporated in biofilm Vancomycin shows a strain dependent bactericidal biofilm activity between 8 times and 128 times the MIC of planktonic bacteria;
              - shows superior bactericidal activity against biofilm embedded staphylococci and MRSA compared with most other antibiotics;
              - references:
                    - Impact of biofilm on the in vitro activity of vancomycin alone and in combination with tigecycline and rifampicin against Staphylococcus aureus.
                    - Comparison of biofilm-associated cell survival following in vitro exposure of meticillin-resistant Staphylococcus aureus biofilms to the antibiotics clindamycin, daptomycin, linezolid, tigecycline and vancomycin.

- references: 
      - Use of vancomycin and tobramycin polymethylmethacrylate impregnated beads in the management of chronic osteomyelitis
      - Elution characteristics of vancomycin and tobramycin combined in acrylic bone-cement. 
      - Antibiotic impregnated bone cement in total hip arthroplasty. An in vivo comparison of the elution properties of tobramycin and vancomycin
      - Impregnation of vancomycin, gentamicin, and cefotaxime in a cement spacer for two-stage cementless reconstruction in infected total hip arthroplasty. 
      - Elution of vancomycin, daptomycin, and amikacin from acrylic bone cement. 
      - A sixty-five-year-old man with rash, fever, and generalized weakness
      - Acute renal failure associated with vancomycin- and tobramycin-laden cement in total hip arthroplasty
      - In vitro inhibition of coagulase-negative staphylococci by vancomycin/aminoglycoside-loaded cement spacers.
      - In vitro activities of daptomycin-, vancomycin-, and teicoplanin-loaded polymethylmethacrylate against methicillin-susceptible, methicillin-resistant, and vancomycin-intermediate strains of Staphylococcus aureus.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, April 24, 2015 1:03 pm