Antibiotics, Kidney Injury and Joint Infection: New Mayo Study

When surgeons have to contend with a periprosthetic joint infection (PJI) after total knee arthroplasty (TKA), says a group of researchers from Mayo Clinic, most reach for the following solution, a 2-stage exchange arthroplasty with a high-dose antibiotic-loaded bone cement spacer and organism-specific intravenous (IV) or oral antibiotics. However, there is concern that a high dose of local antibiotics can spread systemically and harm the kidneys.

A new study addressing this issue, “Acute Kidney Injury When Treating Periprosthetic Joint Infections After Total Knee Arthroplasties with Antibiotic-Loaded Spacers,” was published in the May 5, 2021 edition of The Journal of Bone and Joint Surgery.

To the best of their knowledge, say the authors, this is the first study to examine the long-term outcomes of renal injury in this setting.

Working with the Mayo total joint registry, the researchers identified all 2-stage exchange arthroplasties treated with an antibiotic-loaded bone cement spacer following resection arthroplasty for a chronic periprosthetic joint infection after TKA from 2000 to 2017. The final group included 455 knees (424 patients) who were treated with antibiotic-loaded bone cement spacers and systemic antibiotics for a chronic periprosthetic joint infection after TKA.

The 2-stage exchange arthroplasties were performed by high-volume Mayo surgeons. Following resection of the periprosthetic joint infection after TKA, the surgeons completed a thorough irrigation and debridement.

“Each high-dose ALBC [antibiotic-loaded bone cement] spacer contained hand-mixed Simplex bone cement (Stryker) with a mean of 3 batches (120 g of cement; range, 1 to 10 batches) of cement and contained a combination of vancomycin and gentamicin (325 spacers; 71%), a combination of vancomycin and tobramycin (126 spacers; 28%), or a combination of vancomycin and daptomycin (4 spacers; 1%).”

“In addition, 86 spacers (19%) contained amphotericin B (mean, 412 mg). A mean of 3.1 g of vancomycin and 3.4 g of gentamicin (or 3 g of tobramycin or 3 g of daptomycin) was mixed with or without 140 mg of amphotericin B with methylene blue in each batch of cement. Given that there was a mean of 3 batches of cement per ALBC spacer construct, the mean amount of antibiotics per ALBC spacer construct per patient was 17 g (range, 5 to 46 g), excluding the spacers that also contained amphotericin B.”

Matthew Abdel, M.D., the Andrew A. and Mary S. Sugg Professor of Orthopedic Surgery and Chair of the Division of Orthopedic Surgery Research at the Mayo Clinic College of Medicine in Minnesota, outlined the results for OTW: “We found that risk was 14% in those without a history of chronic kidney disease, but 45% in those with a history of chronic kidney disease (odds ratio of 5). In the largest series to date, we found that 2% of patients will go onto chronic kidney disease. This knowledge is essential for clinicians who manage these patients in the perioperative setting.”

Note:  Dr. Abdel receives royalties from Stryker.