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Yendluri A, Park J, Singh P, Rako K, Stern BZ, Poeran J, Chen DD, Moucha CS, Hayden BL. Oral Postoperative Antibiotic Prophylaxis for Outpatient Total Hip and Knee Arthroplasty: Describing Current Practices. J Arthroplasty 2024; 39:1911-1916.e1. [PMID: 38657914 PMCID: PMC11262968 DOI: 10.1016/j.arth.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 04/07/2024] [Accepted: 04/08/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Despite an increase in outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA), large-scale data are lacking on current practice for antibiotic prophylaxis prescribing. We aimed to describe current oral antibiotic prophylaxis practices nationally for outpatient THA and TKA. METHODS This nationwide retrospective cohort study included primary outpatient THA or TKA procedures in patients aged 18 to 64 years from 2018 to 2021 using a national claims database. Oral antibiotic prescriptions filled perioperatively (defined as 5 days before to 3 days after surgery) were extracted; these were categorized and assumed to represent postoperative prophylaxis. Multivariable logistic regression measured associations between patient and surgery characteristics and perioperative oral antibiotic prophylaxis. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) are reported. RESULTS Oral antibiotic prescriptions were filled in 16.5% of 73,015 outpatient THA and TKA (18.4% of 24,857 THAs, 15.5% of 48,158 TKAs) procedures. Prescriptions were most often for cephalosporins (74.3%), with cephalexin (52.8%), and cefadroxil (19.1%) being the most common. Non-cephalosporin antibiotics prescribed were mainly clindamycin (6.8%), sulfamethoxazole-trimethoprim (6.7%), and doxycycline (6.2%). The odds of receiving oral antibiotic prophylaxis were higher for THA compared to TKA (OR 1.13, 95% CI 1.09 to 1.18, P < .001) and in the presence of obesity, diabetes, and autoimmune conditions (OR 1.08 to 1.13, P < .001 to .01). Ambulatory surgery center procedures also had significantly increased odds of prophylaxis compared to hospital-based outpatient surgeries (OR 2.62, 95% CI 2.51 to 2.73, P < .001). Additionally, regional and time-based variations were noted. CONCLUSIONS Perioperative oral antibiotic prophylaxis prescriptions were filled in only 16.5% of outpatient THA and TKA cases, with variation in the type of antibiotic prescribed. The receipt of any prophylaxis and specific medications was associated with demographic, clinical, and procedure-related characteristics. Follow-up research will evaluate associations with infection risk reduction.
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Affiliation(s)
- Avanish Yendluri
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai
| | - Jiwoo Park
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai
| | - Priya Singh
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai
| | - Kyle Rako
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai
| | - Brocha Z. Stern
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai
| | - Jashvant Poeran
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai
| | - Darwin D. Chen
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai
| | - Calin S. Moucha
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai
| | - Brett L. Hayden
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai
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Grossmann NC, Kersting Y, Affentranger A, Antonelli L, Aschwanden FJ, Baumeister P, Müllner G, Rossi M, Mattei A, Fankhauser CD. Prevalence of reported penicillin allergy and associations with perioperative complications, length of stay, and cost in patients undergoing elective cancer surgery. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e234. [PMID: 38156201 PMCID: PMC10753465 DOI: 10.1017/ash.2023.501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 10/26/2023] [Accepted: 11/01/2023] [Indexed: 12/30/2023]
Abstract
Objective Up to 10% of patients report penicillin allergy (PA), although only 1% are truly affected by Ig-E-mediated allergies. PA has been associated with worse postoperative outcomes, but studies on the impact of reported PA in cancer patients are lacking, and especially in these multimorbid patients, a non-complicated course is of utmost importance. Methods Retrospective analysis of patients undergoing elective oncological surgery at a tertiary reference center. Data on surgical site infections (SSI), postoperative complications (measured by Clavien-Dindo classification and Comprehensive Complication Index (CCI)), hospitalization duration, and treatment costs were collected. Results Between 09/2019 and 03/2020, 152 patients were identified. 16/152 patients (11%) reported PA, while 136/152 (89%) did not. There were no differences in age, BMI, Charlson Comorbidity Index, and smoking status between groups (p > 0.4). Perioperative beta-lactam antibiotics were used in 122 (89.7%) and 15 (93.8%) patients without and with reported PA, respectively. SSI and mean numbers of infections occurred non-significantly more often in patients with PA (p = 0.2 and p = 0.47). The median CCI was significantly higher in PA group (26 vs. 51; p = 0.035). The median hospitalization duration and treatment costs were similar between non-PA and PA groups (4 vs 3 days, p = 0.8; 16'818 vs 17'444 CHF, p = 0.4). Conclusions In patients undergoing cancer surgery, reported PA is common. Failure to question the unproven PA may impair perioperative outcomes. For this reason, patient and provider education on which reactions constitute a true allergy would also assist in allergy de-labeling. In addition, skin testing and oral antibiotic challenges can be performed to identify the safe antibiotics and to de-label appropriate patients.
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Affiliation(s)
| | - Yves Kersting
- Department of Urology, Kantonsspital Luzern, Lucerne, Switzerland
| | | | - Luca Antonelli
- Department of Urology, Kantonsspital Luzern, Lucerne, Switzerland
| | | | | | - Gerhard Müllner
- Department of Dermatology and Allergology, Kantonsspital Luzern, Lucerne, Switzerland
| | - Marco Rossi
- Department of Infectious Diseases, Kantonsspital Luzern, Lucerne, Switzerland
| | - Agostino Mattei
- Department of Urology, Kantonsspital Luzern, Lucerne, Switzerland
| | - Christian Daniel Fankhauser
- Department of Urology, Kantonsspital Luzern, Lucerne, Switzerland
- University of Zurich, Zurich, Switzerland
- University of Lucerne, Lucerne, Switzerland
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Young SW, Chen W, Clarke HD, Spangehl MJ. Intraosseous regional prophylaxis in total knee arthroplasty. Bone Joint J 2023; 105-B:1135-1139. [PMID: 37907081 DOI: 10.1302/0301-620x.105b11.bjj-2023-0708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Prophylactic antibiotics are important in reducing the risk of periprosthetic joint infection (PJI) following total knee arthroplasty. Their effectiveness depends on the choice of antibiotic and the optimum timing of their administration, to ensure adequate tissue concentrations. Cephalosporins are typically used, but an increasing number of resistant organisms are causing PJI, leading to the additional use of vancomycin. There are difficulties, however, with the systemic administration of vancomycin including its optimal timing, due to the need for prolonged administration, and potential adverse reactions. Intraosseous regional administration distal to a tourniquet is an alternative and attractive mode of delivery due to the ease of obtaining intraosseous access. Many authors have reported the effectiveness of intraosseous prophylaxis in achieving higher concentrations of antibiotic in the tissues compared with intravenous administration, providing equal or enhanced prophylaxis while minimizing adverse effects. This annotation describes the technique of intraosseous administration of antibiotics and summarizes the relevant clinical literature to date.
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Affiliation(s)
- Simon W Young
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - William Chen
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Henry D Clarke
- Department of Orthopaedics, Mayo Clinic, Scottsdale, Arizona, USA
| | - Mark J Spangehl
- Department of Orthopaedics, Mayo Clinic, Scottsdale, Arizona, USA
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Zhang J, Chen G, Yu X, Liu Y, Li Z, Zhang X, Zhong Q, Xu R. Higher cefazolin concentrations in synovial fluid with intraosseous regional prophylaxis in knee arthroplasty: a randomized controlled trial. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-05108-1. [PMID: 37902891 DOI: 10.1007/s00402-023-05108-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/09/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND Prophylactic antibiotics reduce the risk of periprosthetic joint infection. However, conventional systemic administration may not provide adequate tissue concentrations against more resistant organisms such as coagulase-negative staphylococci. Intraosseous regional administration is known to achieve significantly higher antibiotic tissue concentrations than systemic administration, but it is unclear how synovial fluid concentrations are affected. We aimed to compare synovial fluid cefazolin concentrations achieved by regional intraosseous versus systemic intravenous administration, and also to compare synovial fluid cefazolin concentrations with those in subcutaneous fat. METHODS A total of 60 patients undergoing primary knee arthroplasty were randomized into 2 groups: group IO received 2 g interosseous cefazolin in 100 mL saline through a tibial cannula after tourniquet inflation and before skin incision; group IV received 2 g cefazolin in 100 mL saline via the median basilic or median cephalic vein 30 min before tourniquet inflation. Subcutaneous fat and synovial fluid samples were collected immediately after skin incision, and cefazolin concentrations were measured by high-performance liquid chromatography. RESULTS The cefazolin concentration in synovial fluid was 391.3 ± 70.1 μg/ml in group IO and 17.6 ± 3.5 μg/ml in group IV. The cefazolin concentration in subcutaneous fat was 247.9 ± 64.9 μg/g in group IO and 11.4 ± 1.9 μg/g in group IV. CONCLUSION Intraosseous regional administration results in several times higher tissue concentrations than systemic administration, especially in the synovial fluid.
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Affiliation(s)
- Jingyu Zhang
- Department of Orthopaedics, Suzhou Municipal Hospital, The Affiliated Hospital of Nanjing Medical University, No 26, Daoqian Street, Suzhou, 215000, Jiangsu, People's Republic of China
| | - Guangxiang Chen
- Department of Orthopaedics, Suzhou Municipal Hospital, The Affiliated Hospital of Nanjing Medical University, No 26, Daoqian Street, Suzhou, 215000, Jiangsu, People's Republic of China
| | - Xiao Yu
- Department of Orthopaedics, Suzhou Municipal Hospital, The Affiliated Hospital of Nanjing Medical University, No 26, Daoqian Street, Suzhou, 215000, Jiangsu, People's Republic of China
| | - Yubo Liu
- Department of Orthopaedics, Suzhou Municipal Hospital, The Affiliated Hospital of Nanjing Medical University, No 26, Daoqian Street, Suzhou, 215000, Jiangsu, People's Republic of China
| | - Zhiqiang Li
- Department of Orthopaedics, Suzhou Municipal Hospital, The Affiliated Hospital of Nanjing Medical University, No 26, Daoqian Street, Suzhou, 215000, Jiangsu, People's Republic of China
| | - Xiangxin Zhang
- Department of Orthopaedics, Suzhou Municipal Hospital, The Affiliated Hospital of Nanjing Medical University, No 26, Daoqian Street, Suzhou, 215000, Jiangsu, People's Republic of China
| | - Qiao Zhong
- Department of Laboratory, Suzhou Municipal Hospital, The Affiliated Hospital of Nanjing Medical University, No 26, Daoqian Street, Suzhou, 215000, Jiangsu, People's Republic of China
| | - Renjie Xu
- Department of Orthopaedics, Suzhou Municipal Hospital, The Affiliated Hospital of Nanjing Medical University, No 26, Daoqian Street, Suzhou, 215000, Jiangsu, People's Republic of China.
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