Timely Explantation of Tobramycin-impregnated Beads and Bone Cement to Avoid Haemodialysis in a Patient with Worsening Renal Failure

Overview

Journal BMJ Case Rep

Specialty General Medicine

Date 2022 Feb 8

PMID 35131767

Authors

Joseph Jeffry Borick

Shuba Balan

Paola Lichtenberger

Lauren Bjork

Affiliations

Soon will be listed here.

Abstract

A male patient with right total knee arthroplasty complicated by prosthetic joint infection on intravenous antimicrobials developed an acute kidney injury (AKI) with creatinine up to 7.3 mg/dL ('normal' range (0.5-1.2 mg/dL)) after hardware removal and tobramycin loaded polymethylmethacrylate beads and spacer placement. The AKI was initially attributed to intravenous vancomycin. Despite discontinuing vancomycin, the AKI worsened. A tobramycin level was collected and resulted at 5.5 µg/mL. Due to high suspicion for aminoglycoside-induced renal toxicity and to prevent haemodialysis, the antibiotic cement spacer with tobramycin-impregnated beads was removed. After the removal, tobramycin level rapidly decreased and renal functions improved. AKI is an increasingly recognised complication related to antibiotic-loaded bone cement (ALBC) due to the systemic absorption of antibiotics. With this case we highlight the early recognition of ALBC-induced renal toxicity necessitating explantation of ALBC and beads in order to prevent haemodialysis and emphasise monitoring aminoglycoside levels in the early postoperative period.

References

Anagnostakos K . Therapeutic Use of Antibiotic-loaded Bone Cement in the Treatment of Hip and Knee Joint Infections. J Bone Jt Infect. 2017; 2(1):29-37. PMC: 5423576. DOI: 10.7150/jbji.16067. View

Evans R . Successful treatment of total hip and knee infection with articulating antibiotic components: a modified treatment method. Clin Orthop Relat Res. 2004; (427):37-46. DOI: 10.1097/01.blo.0000143739.07632.7c. View

Geller J, Cunn G, Herschmiller T, Murtaugh T, Chen A . Acute Kidney Injury After First-Stage Joint Revision for Infection: Risk Factors and the Impact of Antibiotic Dosing. J Arthroplasty. 2017; 32(10):3120-3125. DOI: 10.1016/j.arth.2017.04.054. View

Mounasamy V, Fulco P, Desai P, Adelaar R, Bearman G . The successful use of vancomycin-impregnated cement beads in a patient with vancomycin systemic toxicity: a case report with review of literature. Eur J Orthop Surg Traumatol. 2013; 23 Suppl 2:S299-302. DOI: 10.1007/s00590-012-1062-4. View

King J, Hamilton D, Jacobs C, Duncan S . The Hidden Cost of Commercial Antibiotic-Loaded Bone Cement: A Systematic Review of Clinical Results and Cost Implications Following Total Knee Arthroplasty. J Arthroplasty. 2018; 33(12):3789-3792. DOI: 10.1016/j.arth.2018.08.009. View

Mingeot-Leclercq M, Tulkens P . Aminoglycosides: nephrotoxicity. Antimicrob Agents Chemother. 1999; 43(5):1003-12. PMC: 89104. DOI: 10.1128/AAC.43.5.1003. View

Masri B, Duncan C, Beauchamp C . Long-term elution of antibiotics from bone-cement: an in vivo study using the prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) system. J Arthroplasty. 1998; 13(3):331-8. DOI: 10.1016/s0883-5403(98)90179-6. View

Koo K, Yang J, Cho S, Song H, Park H, Ha Y . Impregnation of vancomycin, gentamicin, and cefotaxime in a cement spacer for two-stage cementless reconstruction in infected total hip arthroplasty. J Arthroplasty. 2001; 16(7):882-92. DOI: 10.1054/arth.2001.24444. View

Van Vugt T, Arts J, Geurts J . Antibiotic-Loaded Polymethylmethacrylate Beads and Spacers in Treatment of Orthopedic Infections and the Role of Biofilm Formation. Front Microbiol. 2019; 10:1626. PMC: 6671866. DOI: 10.3389/fmicb.2019.01626. View

10.

Menge T, Koethe J, Jenkins C, Wright P, Shinar A, Miller G . Acute kidney injury after placement of an antibiotic-impregnated cement spacer during revision total knee arthroplasty. J Arthroplasty. 2012; 27(6):1221-7.e1-2. DOI: 10.1016/j.arth.2011.12.005. View

11.

Schiavone Panni A, Corona K, Giulianelli M, Mazzitelli G, Del Regno C, Vasso M . Antibiotic-loaded bone cement reduces risk of infections in primary total knee arthroplasty? A systematic review. Knee Surg Sports Traumatol Arthrosc. 2016; 24(10):3168-3174. DOI: 10.1007/s00167-016-4301-0. View

12.

Adams K, Couch L, Cierny G, Calhoun J, Mader J . In vitro and in vivo evaluation of antibiotic diffusion from antibiotic-impregnated polymethylmethacrylate beads. Clin Orthop Relat Res. 1992; (278):244-52. View

13.

Luu A, Syed F, Raman G, Bhalla A, Muldoon E, Hadley S . Two-stage arthroplasty for prosthetic joint infection: a systematic review of acute kidney injury, systemic toxicity and infection control. J Arthroplasty. 2013; 28(9):1490-8.e1. DOI: 10.1016/j.arth.2013.02.035. View

14.

Aeng E, Shalansky K, Lau T, Zalunardo N, Li G, Bowie W . Acute Kidney Injury With Tobramycin-Impregnated Bone Cement Spacers in Prosthetic Joint Infections. Ann Pharmacother. 2015; 49(11):1207-13. DOI: 10.1177/1060028015600176. View

15.

Salim S, Everitt J, Schwartz A, Agarwal M, Castenada J, Fulop T . Aminoglycoside impregnated cement spacer precipitating acute kidney injury requiring hemodialysis. Semin Dial. 2017; 31(1):88-93. DOI: 10.1111/sdi.12639. View

16.

Springer B, Lee G, Osmon D, Haidukewych G, Hanssen A, Jacofsky D . Systemic safety of high-dose antibiotic-loaded cement spacers after resection of an infected total knee arthroplasty. Clin Orthop Relat Res. 2004; (427):47-51. DOI: 10.1097/01.blo.0000144476.43661.10. View

17.

Zhou Y, Li L, Zhou Q, Yuan S, Wu Y, Zhao H . Lack of efficacy of prophylactic application of antibiotic-loaded bone cement for prevention of infection in primary total knee arthroplasty: results of a meta-analysis. Surg Infect (Larchmt). 2015; 16(2):183-7. DOI: 10.1089/sur.2014.044. View

18.

Patel R, Baker H, Smith S . Acute Renal Failure due to a Tobramycin and Vancomycin Spacer in Revision Two-Staged Knee Arthroplasty. Case Rep Nephrol. 2018; 2018:6579894. PMC: 6051127. DOI: 10.1155/2018/6579894. View

19.

Turhan S . Does the Use of Antibiotic-Loaded Bone Cement Have an Effect on Deep Infection in Primary Total Knee Arthroplasty Practice?. Surg Infect (Larchmt). 2019; 20(3):244-246. DOI: 10.1089/sur.2018.123. View

20.

Hinarejos P, Guirro P, Puig-Verdie L, Torres-Claramunt R, Leal-Blanquet J, Sanchez-Soler J . Use of antibiotic-loaded cement in total knee arthroplasty. World J Orthop. 2015; 6(11):877-85. PMC: 4686435. DOI: 10.5312/wjo.v6.i11.877. View