n Review Article Instructions 1. Review the stated learning objectives at the beginning of the CME article and determine if these objectives match your individual learning needs. cme 2. Read the article carefully. Do not neglect the tables ARTICLE and other illustrative materials, as they have been selected to enhance your knowledge and understanding. 3. The following quiz questions have been designed to provide a useful link between the CME article in the issue and your everyday practice. Read each question, choose Vancomycin Prophylaxis of the correct answer, and record your answer on the CME Registration Form at the end of the quiz. 4. Type or print your full name and address and your date of birth in the space provided on the CME Registration Form. Surgical Site Infection in 5. Indicate the total time spent on the activity (reading article and completing quiz). Forms and quizzes cannot be processed if this section is incomplete. All participants are required by the accreditation agency to attest to the time spent Clean Orthopedic Surgery completing the activity. 6. Complete the Evaluation portion of the CME Regi stration Form. Forms and quizzes cannot be processed if the Evaluation Wajdi W. Kanj, BS; John M. Flynn, MD; David A. Spiegel, MD; portion is incomplete. The Evaluation portion of the CME Registration Form will be separated from the quiz upon receipt at John P. Dormans, MD; Keith D. Baldwin, MD, MPH, MSPT ORTHOPEDICS. Your evaluation of this activity will in no way affect the scoring of your quiz. 7. Send the completed form, with your $15 payment (check or money order in US dollars drawn on a US bank, or credit educational objectives card information) to: ORTHOPEDICS CME Quiz, PO Box 36, Thorofare, NJ 08086, OR take the quiz online. Visit www. As a result of reading this article, physicians should be able to: Healio.com/EducationLab/Orthopedics for details. 8. Your answers will be graded, and you will be advised 1. Identify the motivation for vancomycin prophylaxis in clean orthopedic whether you have passed or failed. Unanswered questions will be considered incorrect. A score of at least 80% is required to pass. surgery. If a passing score is achieved, Keck School of Medicine of USC will issue an AMA PRA Category 1™ certificate within 4-6 weeks. 2. Identify the complications and challenges surrounding vancomycin pro- 9. Be sure to mail the CME Registration Form on or before the deadline listed. After that date, the quiz will close. CME phylaxis in clean orthopedic surgery. Registration Forms received after the date listed will not be processed. 3. Describe the effectiveness of intravenous vancomycin in clean orthopedic CME ACCREDITATION This activity has been planned and implemented surgery. in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through 4. Describe the effectiveness of locally delivered vancomycin in clean ortho- the joint sponsorship of Keck School of Medicine of USC and ORTHOPEDICS. Keck School of Medicine of USC is accredited pedic surgery. by the ACCME to provide continuing medical education for physicians. Keck School of Medicine of USC designates this Journal- based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate entity using antibiotics known to be effec- with the extent of their participation in the activity. ABSTRACT This CME activity is primarily targeted to orthopedic tive against MRSA. The goal of this study surgeons, hand surgeons, head and neck surgeons, trauma Community-acquired methicillin-resistant was to assess the use of MRSA prophy- surgeons, physical medicine specialists, and rheumatologists. Staphylococcus aureus (MRSA) has been There is no specific background requirement for participants laxis to determine whether it is safe and taking this activity. recognized as a public health concern FULL DISCLOSURE POLICY effective. In accordance with the Accreditation Council for Continuing since the mid-1990s. Because of the in- Medical Education’s Standards for Commercial Support, all crease in reports of this pathogen, it has A systematic search of the literature was CME providers are required to disclose to the activity audience the relevant financial relationships of the planners, teachers, become increasingly tempting for clini- performed to identify articles that ex- and authors involved in the development of CME content. An individual has a relevant financial relationship if he or she has cians to provide prophylaxis against this amined the use of vancomycin in clean a financial relationship in any amount occurring in the last 12 months with a commercial interest whose products or services are discussed in the CME activity content over which the individual has control. Drs Kanj and Spiegel have no relevant financial relationships The authors are from the Department of Orthopaedic Surgery, the Children’s Hospital of to disclose. Dr Flynn receives royalties from Biomet. Dr Philadelphia, Philadelphia, Pennsylvania. Dormans is a board member of POSNA and receives royalties The material presented in any Keck School of Medicine of USC continuing education activity does not from Elsevier, Mosby, Brooke’s Publishing, and his department receives grants from AO Spine and OMEGA. Dr Baldwin is a necessarily reflect the views and opinions of ORTHOPEDICS or Keck School of Medicine of USC. Neither stock owner in Pfizer. Dr Aboulafia, CME Editor, has no relevant ORTHOPEDICS nor Keck School of Medicine of USC nor the authors endorse or recommend any tech- financial relationships to disclose. Dr D’Ambrosia, Editor-in- niques, commercial products, or manufacturers. The authors may discuss the use of materials and/or prod- Chief, has no relevant financial relationships to disclose. The staff of ORTHOPEDICS have no relevant financial relationships ucts that have not yet been approved by the US Food and Drug Administration. All readers and continuing to disclose. education participants should verify all information before treating patients or using any product. UNLABELED AND INVESTIGATIONAL USAGE Correspondence should be addressed to: Keith D. Baldwin, MD, MPH, MSPT, Department of The audience is advised that this continuing medical Orthopaedic Surgery, The Children’s Hospital of Philadelphia, 34th and Civic Center Blvd, 2 Wood education activity may contain references to unlabeled uses of FDA-approved products or to products not approved by the Bldg, Philadelphia, PA 19104 ([email protected]). FDA for use in the United States. The faculty members have doi: 10.3928/01477447-20130122-10 been made aware of their obligation to disclose such usage. 138 ORTHOPEDICS | Healio.com/Orthopedics VANCOMYCIN PROPHYLAXIS IN ORTHOPEDIC SURGERY | KANJ ET AL cme ARTICLE orthopedic surgery. Infection rates and its transmission and mode of antibiotic nously had effective serum and synovial adverse events were extracted, and the resistance.4 vancomycin levels intraoperatively and in data were aggregated and analyzed using Although the use of vancomycin pro- the knee for more than 20 hours postop- a DerSimonian and Laird random effects phylaxis has seemed to increase, debate eratively. model. Publication bias and study quality remains about whether the drug achieves The purpose of the current systematic were also assessed. No benefit of paren- adequate penetration of relevant tissues to literature review was to determine whether teral administration of vancomycin was justify prophylaxis. Parenteral vancomy- evidence exists supporting the routine use identified. Local, vancomycin-impreg- cin has variable absolute bone concentra- of vancomycin prophylaxis in the face of nated cement and powder are associated tions and lower bone:serum concentration increasing bacterial resistance in orthope- with lower infection rates. Few adverse ratios in uninfected bone than most other dic surgery. In addition, the study aimed to events occurred, and most of those that antistaphylococcal agents.5 In addition, determine which mode of administration, if occurred involved infusion rate. recent data have shown a concerning trend any, was effective, and what safety profile toward higher infection rates when using vancomycin has as a prophylactic drug in Cost, resistance, and side effects are con- vancomycin to prevent infections in the clean orthopedic surgery. cerns in using vancomycin therapy in ad- absence of the carrier state.6 dition to standard antibiotic prophylaxis. Although first-generation cephalospo- SEARCH STRATEGY AND METHODS Given the lack of efficacy of intravenous rins have been vetted in clinical trials for Medline and EMBASE databases were vancomycin, the authors do not recom- prophylaxis of surgical site infections, searched for articles containing the terms mend its routine use in clean orthopedic no such literature exists for vancomycin. vancomycin AND prophylaxis AND sur- surgery. However, local administration Despite this, vancomycin has been shown gery and vancomycin AND prophylaxis appears to be safe and effective. The data to be safe in the treatment of infections.7 AND orthopedics. References from the ar- are most compelling in orthopedic spine Incidence rates for adverse reactions con- ticles were reviewed to identify additional surgery in which a patient without prophy- sist of the following: an anaphylactoid studies of interest. Subspecialty abstract laxis is more than 4 times as likely to have reaction known as red man syndrome books from the past 3 years available on- a deep