Abstract Background The standard treatment for periprosthetic joint infections (PJI) typically involves a two-stage resection arthroplasty using antibiotic-loaded bone cement (ALBC) spacers. This study hypothesizes that there is no significant correlation between antibiotic levels in blood and synovial fluid and the patient’s kidney function, and that the success rates of staged resection arthroplasty are comparable between groups, specifically targeting gram-positive bacterial infections. Methods This retrospective review included patients treated from 2017 to 2022 with two-stage arthroplasty using vancomycin-loaded ALBC spacers, selectively targeting gram-positive infections. Patients with non-gram-positive infections or those with allergies or treatments affecting serum antibiotic levels were excluded. The study assessed comorbidities, renal function, specifics of the spacers, and vancomycin concentrations in joint fluid and blood. Results Among 62 PJI cases analyzed (22 hips and 40 knees), 34 patients (54.8%) had renal insufficiency (RI), associated with significantly lower albumin (2.64 g/dL vs. 3.43 g/dL, p 0.05). Both groups exhibited high vancomycin levels in joint fluid, with peak blood vancomycin levels inversely correlated with eGFR (coefficient − 3.612, 95% CI -8.543 to -2.753, p