JOA - 2026-09-01 - Journal Article; Randomized Controlled Trial
Concentration, Antibacterial Effect, and Safety of Combining Intra-articular Epsilon-Aminocaproic Acid and Vancomycin in Primary Total Knee Arthroplasty: A Randomized Study.
Zhang Y, Wei J, Su C, Hu M, Xu H, Xiang S
Topics
Key Takeaway
Intra-articular vancomycin combined with EACA maintained higher local vancomycin concentrations at 8 and 24 hours versus vancomycin alone while preserving EACA's antifibrinolytic effect, with no enhancement of antibacterial activity and no cases of AKI, ototoxicity, or anaphylaxis across 141 TKAs.
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Summary
This study evaluated whether combining intra-articular vancomycin (1,000 mg/30 mL) with EACA (20 mL) in primary TKA alters local drug concentration, hemostasis, antibacterial efficacy, or systemic safety compared to each agent alone. The VE group achieved higher intra-articular vancomycin levels at 8 and 24 hours than the V group with equivalent serum levels, and perioperative blood loss in VE was equivalent to E and significantly lower than V (P<0.01). Antibacterial effect was comparable between VE and V groups, both superior to E alone, with no AKI, ototoxicity, or anaphylaxis in any group.
Key Limitation
The study is underpowered to detect differences in actual PJI incidence, as no infections occurred in any group, making the clinical antibacterial superiority or inferiority of the combination impossible to assess.
Original Abstract
BACKGROUND
In this study, we aimed to investigate the intra-articular concentration, antibacterial effect, and safety of a combination of vancomycin and epsilon-aminocaproic acid (EACA) in primary total knee arthroplasty (TKA).
METHODS
There were 94 patients who underwent unilateral primary TKA and were randomized into the vancomycin plus EACA (VE) group and the vancomycin (V) group. There were 47 contemporary TKAs propensity score-matched to form the EACA (E) group. The VE group received vancomycin 30 mL (1,000 mg) plus EACA 20 mL, the V group received vancomycin plus saline, and the E group received saline plus EACA. Postoperative blood and drainage samples were collected for vancomycin analysis using liquid chromatography-tandem mass spectrometry. Perioperative blood loss, renal function, and bacterial tests for common periprosthetic joint infection pathogens were evaluated.
RESULTS
Perioperative blood loss in the VE group was equivalent to that in the E group and significantly lower than that in the V group (P < 0.01). The intra-articular vancomycin levels in the VE group were higher than those in the V group at eight and 24 hours, while the serum levels were similar. Antimicrobial effects were comparable in the VE and the V groups, both of which were superior to those in the E group. There were no cases of acute renal injury, ototoxicity, or anaphylaxis.
CONCLUSIONS
The combination of intra-articular vancomycin and EACA maintained the vancomycin concentration without impairing the antifibrinolytic function of EACA, although it did not enhance the antibacterial effect of vancomycin.