Tissue Concentrations of Vancomycin Achieved by Regional Perfusion Versus Intravenous Prophylaxis in Upper Extremity Surgery: A Randomized Controlled Trial.

Abstract

Purpose: Prior studies on intraosseous administration of vancomycin in the lower extremity have demonstrated higher tissue drug concentrations using lower doses compared with systemic intravenous administration. Our purpose was to quantify and compare vancomycin concentrations in bone and soft tissue of the hand and wrist after regional perfusion and after systemic administration.

Methods: Twenty patients undergoing an upper extremity reconstructive procedure requiring removal of bone were randomized to regional intravenous perfusion of vancomycin (125 mg in 50 mL normal saline) or systemic intravenous administration of vancomycin (1 g). Samples of subcutaneous fat and bone were collected 5-10 minutes after skin incision and 20-25 minutes after skin incision, and fat was collected at closure. The primary outcome was the difference in bone and fat tissue concentrations between groups. The secondary outcome was complications related to the method of delivery of vancomycin in each group.

Results: Mean tissue concentrations in fat at each time point were 114.9 μg/g (range, 25.0-333.8), 117.2 μg/g (range, 57.1-220.3), and 150.1 μg/g (range, 4.6-386.4) in the regional perfusion group and 3.9 μg/g (range, 1.5-8.4), 5.2 μg/g (range, 1.6-18.6), and 4.5 μg/g (range, 1.4-8.1) in the systemic group, respectively. Mean bone concentrations were 107.0 μg/g (range, 27.4-269.1) and 117.4 μg/g (range, 57.1-220.3) in the regional perfusion group and 13.0 μg/g (range, 6.1-20.3) (P = .002) and 14.9 μg/g (range, 8.7-22.9) in the systemic group, respectively. A fitted linear mixed model showed the average tissue concentration was 109 μg/g higher in the regional group compared with systemic administration. There were no complications requiring reoperation in either group within the 12-week follow-up period.

Conclusions: Regional intravenous perfusion of vancomycin in the upper extremity achieves higher levels of antibiotic concentration than systemic intravenous administration of a much greater dose. These preliminary results warrant further evaluation of this method for the prevention and treatment of infections in the upper extremity.

Type of study/level of evidence: Therapeutic II.