Methicillin-resistant Staphylococcus aureus in TKA treated with revision and direct intra-articular antibiotic infusion.
BACKGROUND
Resistant organisms are difficult to eradicate in infected total knee arthroplasty. While most surgeons use antibiotic-impregnated cement in these revisions, the delivery of the drug in adequate doses is limited in penetration and duration. Direct infusion is an alternate technique.


OBJECTIVE
We asked whether single-stage revision and direct antibiotic infusion for infected TKA would control infection in patients with methicillin-resistant Staphylococcus aureus (MRSA) infections.


METHODS
We retrospectively reviewed 18 patients (18 knees) with MRSA with one-stage revision protocol that included débridement, uncemented revision of total knee components, and intraarticular infusion of 500 mg vancomycin via Hickman catheter once or twice daily for 6 weeks; we used no intravenous antibiotics after the first 24 hours. We monitored serum vancomycin levels to maintain levels between 3 and 10 microg/mL. Minimum followup was 27 months (range, 27–75 months). Mean followup was 62 months, (range, 27–96 months).


RESULTS
Infection was controlled at last followup in all but one patient with a recurrence of the MRSA. The patient was reoperated at 5 months; a necrotic bone fragment was removed, the knee was débrided and revised, and the antibiotic infusion protocol readministered. The patient remained free of infection 42 months postoperatively. At 2-year followup, the mean Knee Society score was 83. We observed no radiographic evidence of implant migration.


CONCLUSIONS
One-stage revision and 6 weeks of intraarticular vancomycin administration controlled infection in MRSA infected TKA with no apparent complications.


METHODS
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Whiteside
Leo A
LA
Missouri Bone and Joint Center, St.Louis, MO, USA
Peppers
Michael
M
Nayfeh
Tariq A
TA
Roy
Marcel E
ME
D000368:Aged; D000369:Aged, 80 and over; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects*; D002408:Catheters, Indwelling; D002908:Chronic Disease; D003646:Debridement; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007270:Injections, Intra-Articular; D008297:Male; D055624:Methicillin-Resistant Staphylococcus aureus; D008875:Middle Aged; D011446:Prospective Studies; D012086:Reoperation; D012189:Retrospective Studies; D013203:Staphylococcal Infections / Q000188:drug therapy* / Q000382:microbiology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D014640:Vancomycin / Q000008:administration & dosage*
D014640:Vancomycin
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