Efficacy of a single dose of cefazolin as a prophylactic antibiotic in primary arthroplasty

Additional doses of prophylactic antibiotics post-arthroplasty: Are there any benefits?

Guidelines for prophylactic antibiotic administration in total joint replacement vary considerably in terms of drug, dosage, route of administration and duration of cover. Despite the range of treatment options available, infection remains the most common reason for arthroplasty failure in the decades following a procedure, simultaneously increasing health care costs and lowering patient satisfaction considerably. This work aims to evaluate whether there are benefits to administering further doses of antibiotic post-arthroplasty, in addition to the recommendations of current protocols. We present a review of evidence surrounding infection rates in a variety of prophylactic regimens, and weigh this against further considerations such as cost to the patient and risks of nephrotoxicity. In summary, the available evidence does not suggest a benefit to administering additional doses post-arthroplasty in most cases. However, further doses may benefit those deemed at high risk of infection, or those in areas of high methicillin-resistant Staphylococcus aureus prevalence.

Not so Fast: Extended Oral Antibiotic Prophylaxis Does Not Reduce 90-Day Infection Rate Following Joint Arthroplasty

BACKGROUND

Periprosthetic joint infection (PJI) is a devastating complication following both total hip (THA) and knee (TKA) arthroplasty. Extended oral antibiotic (EOA) prophylaxis has been reported to reduce PJI following TJA in high-risk patients. The purpose of this study was to determine if EOA reduces PJI in all-comers and high-risk THA and TKA populations.

METHODS

This is a retrospective cohort study, including 4,576 patients undergoing primary THA or TKA at a single institution from 2018 to 2022. Beginning in 2020, EOA prophylaxis was administered for 10 days following THA or TKA at our institution. Patients were separated into 2 cohorts (1,769 EOA, 2,807 no EOA) based on whether they received postoperative EOA. The 90-day and 1-year outcomes, with a focus on PJI, were then compared between groups. A subgroup analysis of high-risk patients was also performed.

RESULTS

There was no difference in 90-day PJI rates between cohorts (EOA 1 versus no EOA 0.8%; P = .6). The difference in the rate of PJI remained insignificant at 1 year (EOA 1 versus no EOA 1%; P = .9). Similarly, our subgroup analysis of high-risk patients demonstrated no difference in postoperative PJI between EOA (n = 254) and no EOA (n = 396) (0.8 versus 2.3%, respectively; P = .2). Reassuringly, we also found no differences in the incidence of Clostridium difficile infection (EOA 0.1 versus no EOA 0.1%; P > .9) or in antibiotic resistance among those who developed PJI within 90 days (EOA 59 versus no EOA 83%; P = .2).

CONCLUSIONS

With the numbers available for analysis, EOA prophylaxis was not associated with PJI risk reduction following primary TJA when universally deployed. Furthermore, among high-risk patients, there was no statistically significant difference. While we did not identify increased antibiotic resistance or Clostridium difficile infection, we cannot recommend wide-spread adoption of EOA prophylaxis, and clarification regarding the role of EOA, even in high-risk patients, is needed.

Assessment of the effectiveness of weight-adjusted antibiotic administration, for reduced duration, in surgical prophylaxis of primary hip and knee arthroplasty

BACKGROUND

Prophylactic antibiotics have significantly led to a reduction in the risk of post-operative surgical site infections (SSI) in orthopaedic surgery. The aim of using antibiotics for this purpose is to achieve serum and tissue drug levels that exceed, for the duration of the operation, the minimum inhibitory concentration of the likely organisms that are encountered. Prophylactic antibiotics reduce the rate of SSIs in lower limb arthroplasty from between 4% and 8% to between 1% and 3%. Controversy, however, still surrounds the optimal frequency and dosing of antibiotic administration.

AIM

To evaluate the impact of introduction of a weight-adjusted antibiotic prophylaxis regime, combined with a reduction in the duration of administration of post-operative antibiotics on SSI incidence during the 2 years following primary elective total hip and knee arthroplasty.

METHODS

Following ethical approval, patients undergoing primary total hip arthroplasty (THA)/total knee arthroplasty (TKA) with the old regime (OR) of a preoperative dose [cefazolin 2 g intravenously (IV)], and two subsequent doses (2 h and 8 h), were compared to those after a change to a new regime (NR) of a weight-adjusted preoperative dose (cefazolin 2 g IV for patients < 120 kg; cefazolin 3g IV for patients > 120 kg) and a post-operative dose at 2 h. The primary outcome in both groups was SSI rates during the 2 years post-operatively.

RESULTS

A total of n = 1273 operations (THA n = 534, TKA n = 739) were performed in n = 1264 patients. There was no statistically significant difference in the rate of deep (OR 0.74% (5/675) vs NR 0.50% (3/598); fishers exact test P = 0.72), nor superficial SSIs (OR 2.07% (14/675) vs NR 1.50% (9/598); chi-squared test P = 0.44) at 2 years post-operatively. With propensity score weighting and an interrupted time series analysis, there was also no difference in SSI rates between both groups [RR 0.88 (95%CI 0.61 to 1.30) P = 0.46].

CONCLUSION

A weight-adjusted regime, with a reduction in number of post-operative doses had no adverse impact on SSI incidence in this population.

CEFAZOLIN PROPHYLACTIC EFFICACY ON PROSTHETIC JOINT INFECTION AFTER PRIMARY HIP ARTHROPLASTY

Objective

Perioperative deep prosthetic joint infection (PJI) is a serious postoperative complication of total hip arthroplasty (THA). We aimed to compare the efficacy of cefazolin administered within 24 and 48 h of primary THA for PJI prophylaxis.

Methods

In this retrospective study, 720 patients were divided into two groups depending on whether cefazolin was administered as a single injection of 2 g twice daily within 24 (24-h group) or 48 h of surgery and the following day (48-h group). Sex, age at surgery, body mass index, co-existing diseases, blood test data, and PJI risk factors were evaluated.

Results

The 24- and 48-h groups included 364 and 356 patients, respectively. Diabetes mellitus was the most common risk factor for PJI in both groups. The corresponding incidence of perioperative deep PJI following primary THA was 0.55% and 0.28% in the 24- and 48-h groups, respectively. There was no significant difference in patient background characteristics between the groups.

Conclusions

Cefazolin administration within 24 h of primary THA may be appropriate for perioperative deep PJI. Level of Evidence II; Retrospective study .

International Survey of Practice for Prophylactic Systemic Antibiotic Therapy in Hip and Knee Arthroplasty

(1) Background: Prophylactic systemic antibiotics are acknowledged to be an important part of mitigating prosthetic joint infections. Controversy persists regarding optimal antibiotic regimes. We sought to evaluate current international antibiotics guidelines for total joint arthroplasty (TJA) of the hip and knee. (2) Methods: 42 arthroplasty societies across 6 continents were contacted and their published literature reviewed. (3) Results: 17 societies had guidelines; of which 11 recommended an antibiotic agent or antibiotic class (10—cephalosporin; 1—cloxacillin); 15 recommended antibiotic infusion within an hour of incision and 10 advised for post-operative doses (8—up to 24 h; 1—up to 36 h; 1—up to 48 h). (4) Conclusions: Prophylactic antibiotic guidelines for TJA are often absent or heterogenous in their advice.

Meta-Analysis of Clinical Trials Comparing Cefazolin to Cefuroxime, Ceftriaxone, and Cefamandole for Surgical Site Infection Prevention

Surgical site infections are among the most prevalent and costly healthcare-associated infections, resulting in poor patient outcomes and even death. Cefazolin is a first-generation cephalosporin antibiotic that is widely used for surgical prophylaxis in a variety of surgical disciplines. Although previous studies showed that cefazolin is effective in preventing surgical site infections, other agents, such as cefuroxime and ceftriaxone, were used excessively for surgical patients. The present analysis included only clinical trials comparing the efficacy of cefazolin to cefuroxime, ceftriaxone, and cefamandole in lowering SSIs using PubMed, Google Scholar, and ClinicalTrials.gov. Review Manager software (RevMan version 5.4) was used to conduct the meta-analyses. A total of 12,446 patients were included in the study. Among these patients, 6327 patients received cefazolin and 6119 patients received cefamandole, cefuroxime, or ceftriaxone. Our analysis showed that cefazolin is as effective as cefuroxime, cefamandole, and ceftriaxone in preventing surgical site infections. Hence, our findings have provided evidence for the use of cefazolin before surgeries because of its efficacy, as previous studies showed that it is inexpensive and safer than other agents.

Antibiotic prophylaxis in total joint arthroplasty – the usual practice and variability among joint replacement surgeons in Hong Kong

Background

Perioperative antibiotics is a well established measure to prevent periprosthetic joint infection (PJI). However, the usual practice of prescription vary from surgeon to surgeon. This study aims to investigate and compare the usual practice and variability of prescribing antibiotic prophylaxis among different joint replacement surgeons in Hong Kong.

Methods

An online questionnaire was prepared and sent to members of the Adult Joint Reconstruction (AJR) Chapter of the Hong Kong Orthopaedic Association (HKOA). The questionnaire consists of a total of 15 questions in 3 categories: choice of antibiotics, dose of antibiotics and duration of antibiotics prescribed by the surgeon.

Results

A total of 25 responses were received and data collected. Participants were from a diverse background from different hospitals with variable years of experience. Results showed a general consensus on the choice of antibiotics, but also a wide variability on the actual prescription, particularly about the weight-adjusted dose and total duration of antibiotics given.

Conclusion

There is a wide variability among surgeons regarding the actual prescription of antibiotic prophylaxis. Correlation between rate of PJI and specific aspects of antibiotic prescription is needed to give recommendations to surgeons regarding perioperative antibiotic usage in total joint arthroplasties.

Population pharmacokinetic model of cefazolin in total hip arthroplasty

Cefazolin is an antibiotic recommended for infection prevention in total hip arthroplasty (THA). However, the dosing regimen necessary to achieve therapeutic concentrations in obese patients remains unclear. The aim of this study was to conduct a population analysis of cefazolin pharmacokinetics (PK) and assess whether cefazolin administration should be weight adapted in THA. Adult patients undergoing THA surgery received an injection of 2000 mg of cefazolin, doubled in the case of BMI > 35 kg/m² and total body weight > 100 kg. A population PK study was conducted to quantify cefazolin exposure over time compared to the therapeutic concentration threshold. A total of 484 cefazolin measurements were acquired in 100 patients, of whom 29% were obese. A 2-compartment model best fitted the data, and creatinine clearance determined interpatient variability in elimination clearance. Our PK simulations using a 2000 mg cefazolin bolus showed that cefazolin concentrations remained above the threshold throughout surgery, regardless of weight or renal function. A 2000 mg cefazolin single injection without adaptation to weight or renal function and without intraoperative reinjection was efficient in maintaining therapeutic concentrations throughout surgery. The optimal target concentration and necessary duration of its maintenance remain unclear.

Perioperative Antibiotic Prophylaxis: Single and 24-Hour Antibiotic Dosages are Equally Effective at Preventing Periprosthetic Joint Infection in Total Joint Arthroplasty

BACKGROUND

Perioperative antibiotic prophylaxis is used to prevent surgical site infection and periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). Secondary to a national shortage of cefazolin, patients at our institution began receiving a single preoperative prophylactic antibiotic dose for primary TJA and no 24-hour postoperative antibiotic prophylaxis. The purpose of the study was to compare the efficacy of single-dose antibiotic use versus 24-hour dosing of prophylactic antibiotics in the prevention of acute PJI and short-term complications after primary TJA.

METHODS

A retrospective review of 3317 patients undergoing primary TJA performed from January 2015 to December 2019 identified 554 patients who received a single dose of preoperative antibiotic prophylaxis during the antibiotic shortage and 2763 patients who received post-TJA 24-hour antibiotic prophylaxis before the shortage. Patient records were evaluated for acute PJI, superficial infection, 90-day reoperation, and 90-day complications.

RESULTS

There were no significant differences in patient characteristics between single-dose and 24-hour antibiotic groups. Similarly, there were no significant differences in rates of acute PJI (0.7% vs 0.2%; P = .301), superficial infection (2.4% vs 1.4%; P = .221), 90-day reoperation (2.1% vs 1.1%; P = .155), and 90-day complications (9.9% vs 7.9%; P = .169) between single and 24-hour antibiotic dose. Post hoc power analysis demonstrated adequate sample size, beta = 93%.

CONCLUSION

Single-dose prophylactic antibiotics did not lead to an increased risk of acute PJI or short-term complications after TJA. Our study suggests that administration of a single antibiotic dose may be safely considered in patients undergoing routine primary TJA.

The AAHKS Clinical Research Award: Extended Oral Antibiotics Prevent Periprosthetic Joint Infection in High-Risk Cases: 3855 Patients With 1-Year Follow-Up

BACKGROUND

Surgical and host factors predispose patients to periprosthetic joint infection (PJI) after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). While surgical factors are modifiable, host factors can be challenging, and there are limited data demonstrating that preoperative patient optimization decreases risk of PJI. The goal of this study was to evaluate whether extended oral antibiotic prophylaxis reduces the one-year infection rate in high-risk patients.

METHODS

A total of 3855 consecutive primary THAs and TKAs performed between 2011 and 2019 at a suburban academic hospital with modern perioperative and infection-prevention protocols were retrospectively reviewed. Beginning in January 2015, a 7-day oral antibiotic prophylaxis protocol was implemented after discharge for patients at high risk for PJI. The percentage of high-risk patients diagnosed with PJI within 1 year was compared between groups that did and did not receive extended antibiotic prophylaxis. Univariate and logistic regression analyses were performed, with P ≤ .05 denoting statistical significance.

RESULTS

Overall 1-year infection rates were 2.26% and 0.85% after THA and TKA, respectively. High-risk patients with extended antibiotic prophylaxis had a significantly lower rate of PJI than high-risk patients without extended antibiotic prophylaxis (0.89% vs 2.64%, respectively; P < .001). There was no difference in the infection rate between high-risk patients who received antibiotics and low-risk patients (0.89% vs 1.29%, respectively; P = .348) with numbers available.

CONCLUSION

Extended postoperative oral antibiotic prophylaxis for 7 days led to a statistically significant and clinically meaningful reduction in 1-year infection rates of patients at high risk for infection. In fact, the PJI rate in high-risk patients who received antibiotics was less than the rate seen in low-risk patients. Thus, extended oral antibiotic prophylaxis may be a simple measure to effectively counteract poor host factors. Moreover, the findings of this study may mitigate the incentive to select healthier patients in outcome-based reimbursement models. Further study with a multicenter randomized control trial is needed to further validate this protocol.

LEVEL OF EVIDENCE

Therapeutic level III.

Postoperative Prophylactic Antibiotics in Spine Surgery: A Propensity-Matched Analysis

BACKGROUND

Surgical site infections are common and costly complications after spine surgery. Prophylactic antibiotics are the standard of care; however, the appropriate duration of antibiotics has yet to be adequately addressed. We sought to determine whether the duration of antibiotic administration (preoperatively only versus preoperatively and for 24 hours postoperatively) impacts postoperative infection rates.

METHODS

All patients undergoing inpatient spinal procedures at a single institution from 2011 to 2018 were evaluated for inclusion. A minimum of 1 year of follow-up was used to adequately capture postoperative infections. The 1:1 nearest-neighbor propensity score matching technique was used between patients who did and did not receive postoperative antibiotics, and multivariable logistic regression analysis was conducted to control for confounding.

RESULTS

A total of 4,454 patients were evaluated and, of those, 2,672 (60%) received 24 hours of postoperative antibiotics and 1,782 (40%) received no postoperative antibiotics. After propensity-matched analysis, there was no difference between patients who received postoperative antibiotics and those who did not in terms of the infection rate (1.8% compared with 1.5%). No significant decrease in the odds of postoperative infection was noted in association with the use of postoperative antibiotics (odds ratio = 1.17; 95% confidence interval, 0.620 to 2.23; p = 0.628). Additionally, there was no observed increase in the risk of Clostridium difficile infection or in the short-term rate of infection with multidrug-resistant organisms.

CONCLUSIONS

There was no difference in the rate of surgical site infections between patients who received 24 hours of postoperative antibiotics and those who did not. Additionally, we found no observable risks, such as more antibiotic-resistant infections and C. difficile infections, with prolonged antibiotic use.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Characteristics of Antibiotic Prophylaxis and Risk of Surgical Site Infections in Primary Total Hip and Knee Arthroplasty

BACKGROUND

Despite numerous antibiotic prophylaxis options for total hip arthroplasty (THA) and total knee arthroplasty (TKA), an assessment of practice patterns and comparative effectiveness is lacking. We aimed to characterize antibiotic utilization patterns and associations with infection risk and hypothesized differences in infection risk based on regimen.

METHODS

A retrospective cohort study was performed using data from 436,724 THA and 862,918 TKA (Premier Healthcare Database; 2006-2016). Main exposures were antibiotic type and duration: day of surgery only (day 0) or through postoperative day 1 (day 1). The primary outcome was surgical site infection (SSI) <30 days postoperation. Mixed-effect models measured associations between prophylaxis regimen and SSI as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

SSI prevalence was 0.21% (n = 914) for THA and 0.22% (n = 1914) for TKA. Among THA procedures, the most commonly used antibiotics were cefazolin (74.1%), vancomycin (8.4%), "other" antibiotic combinations (7.1%), vancomycin + cefazolin (5.1%), and clindamycin (3.3%). Here, 51.8% received prophylaxis on day 0 only, whereas 48.2% received prophylaxis through day 1. Similar patterns existed for TKA. Relative to cefazolin, higher SSI odds were seen with vancomycin (OR = 1.36; CI 1.09-1.71) in THA and with vancomycin (OR = 1.29; CI = 1.10-1.52), vancomycin + cefazolin (OR = 1.35; CI = 1.12-1.64), clindamycin (OR = 1.38; CI = 1.11-1.71), and "other" antibiotic combinations (OR = 1.28; CI = 1.07-1.53) in TKA. Prophylaxis duration did not alter SSI odds. Results were corroborated in sensitivity analyses.

CONCLUSION

Antibiotic prophylaxis regimens other than cefazolin were associated with increased SSI risk among THA/TKA patients. These findings emphasize a modifiable intervention to mitigate infection risk.

Evaluation of Antibacterial and Cytotoxic Properties of a Fluorinated Diamond-Like Carbon Coating for the Development of Antibacterial Medical Implants

Peri-implant infection is a serious complication in surgical procedures involving implants. We conducted an in vitro study to determine whether the use of a fluorinated diamond-like carbon (F-DLC) coating on a titanium alloy surface can prevent peri-implant infection. After applying the F-DLC, we evaluated its antibacterial and cytotoxic properties. The coating groups, containing controlled fluorine concentrations of 5.44%, 17.43%, 24.09%, and 30%, were examined for the presence of Staphylococcus aureus and Escherichia coli according to ISO 22196 for the measurement of antibacterial activity on plastics and other nonporous surfaces. Biological toxicity was evaluated using Chinese hamster V79 cells according to ISO 10993-5 for the biological evaluation of medical devices. In the control group, populations of S. aureus and E. coli substantially increased from 2.4 × 10⁴ to (1.45 ± 1.11) × 10⁶ colony-forming units (CFUs) and from 2.54 × 10⁴ to (4.04 ± 0.44) × 10⁶ CFUs, respectively. However, no bacteria colonies were detected in any F-DLC group with a fluorine concentration of ≥ 17.43%. In the biological toxicity study, an F-DLC coating with a fluorine concentration of 30% showed a colony formation rate of 105.8 ± 24.1%, which did not differ significantly from the colony formation rate of 107.5 ± 31.1% in the nontoxic control group. An F-DLC coating on titanium alloy discs showed excellent in vitro antibacterial activity with no biological toxicity.

A comparative study of 5 different antibiotic prophylaxis regimes in 4500 total knee replacements

AIM

To compare the incidence of surgical site infection with different antibiotic regimes in elective total knee arthroplasty. We hypothesise that a single high dose of Teicoplanin and Gentamicin is as effective as other regimes.

METHODS

A retrospective study of prospectively collected data on a total of 4500 elective knee replacements over a 9-year period was conducted in a district general hospital. Data were collected on antibiotic regime, patient characteristics, infection (treatment, infective agents, sensitivities) and complications.

RESULTS

Five different antibiotic regimes that have been used in elective knee arthroplasty were identified in our institution. 40 patients in total were identified who had a deep infection. Rates of deep surgical site infection were not significantly different between the five groups (p = 0.83).

CONCLUSION

A single pre-operative dose of Teicoplanin and Gentamicin has similar efficacy of prophylaxis to other regimes for patients undergoing primary elective total knee replacements. We recommend the choice of prophylaxis regimen is made locally based on pathogen virulence, drug resistance and cost.

Dual prophylaxis with teicoplanin and cefazolin in the prevention of prosthetic joint infection

INTRODUCTION

There is a growing increase in prosthetic joint infection (PJI) incidence due to cephalosporin-resistant bacteria, used in surgical prophylaxis. The replacement of these with glycopeptides has not been shown to improve the results, but they have been shown to improve with their combination.

METHODS

Comparative study of combination of teicoplanin and cefazolin before arthroplasty surgery against cefazolin alone from a previous control group.

RESULTS

During the control period, there were 16 PJIs from 585 surgeries, while in the intervention group there were 6 from 579 (incidence 2.7% vs. 1.03%, RR 0.4, P=.04). In control group, 11 of the infections were caused by Gram-positive bacteria versus 4 in the intervention group (1.8% vs. 0.7%, P=.08).

CONCLUSIONS

The addition of teicoplanin to cefazolin in the prophylaxis of arthroplasty surgery was associated with a reduction in the incidence of PJI, thanks to a decrease in infections caused by Gram-positive bacteria.

Perioperative Antibiotic Prophylaxis in Total Joint Arthroplasty: A Single Dose Is as Effective as Multiple Doses

BACKGROUND

Recent surgical site infection prevention guidelines recommend that no additional prophylactic antibiotics be administered after the surgical incision is closed in clean-contaminated procedures. Although there is ample evidence to support this recommendation in non-arthroplasty surgery, there is concern about extending these guidelines to surgical procedures with an implant such as total joint arthroplasty (TJA). The aim of this study was to compare the efficacy of a single dose of prophylactic antibiotics with that of multiple doses of antibiotics for prevention of periprosthetic joint infection (PJI) in patients undergoing TJA.

METHODS

A retrospective study of 20,682 primary TJAs carried out from 2006 to 2017 was performed. Patients who received a single dose of prophylactic antibiotics (n = 4,523) were compared with patients who received multiple doses of antibiotics (n = 16,159). A previously validated PJI risk score was assigned to each patient. Patients who developed PJI within 1 year were identified, and a multivariate logistic regression analysis was performed to control for potential confounders. Analyses using propensity score matching and regression adjustment were also performed.

RESULTS

The overall PJI rate was 0.60% (27 of 4,523) for patients who received a single dose of antibiotics compared with 0.88% (142 of 16,159) for those who received multiple doses. There was no difference in the PJI rate between patients who received a single dose of antibiotics and those who received multiple doses in the univariate (adjusted odds ratio [OR] = 0.674, p = 0.064), multivariate (OR = 0.755, p = 0.205), or propensity score matched analysis (OR = 0.746, p = 0.277). Furthermore, multiple doses did not demonstrate any additional benefit for patients with a high preoperative risk of PJI (p = 0.136).

CONCLUSIONS

This study supports the notion that the administration of additional antibiotics following skin closure may not be required for primary TJA, regardless of the patient's preoperative risk of PJI. The findings of this large retrospective study highlight the need for a randomized, prospective study on which to base guidelines.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Extended Oral Antibiotic Prophylaxis in High-Risk Patients Substantially Reduces Primary Total Hip and Knee Arthroplasty 90-Day Infection Rate

BACKGROUND

Total joint arthroplasty (TJA) episodic payment models shift risk and cost of periprosthetic joint infection (PJI) to surgeons and hospitals, causing some to avoid treating high-risk patients. Furthermore, there are little data to support optimization of host factors preoperatively to decrease PJI, and recent literature supports using extended antibiotic prophylaxis following reimplantation TJA. The purpose of this study was to evaluate whether extended oral antibiotic prophylaxis minimized PJI after primary TJA in high-risk patients.

METHODS

A retrospective cohort study was performed of 2,181 primary total knee arthroplasties (TKAs) and primary total hip arthroplasties (THAs) carried out from 2011 through 2016 at a suburban academic hospital with modern perioperative and infection-prevention protocols. Beginning in January 2015, extended oral antibiotic prophylaxis for 7 days after discharge was implemented for patients at high risk for PJI. The percentages of patients diagnosed with PJI within 90 days were identified and compared between groups that did and did not receive extended oral antibiotic prophylaxis, with p ≤ 0.05 indicating significance.

RESULTS

The 90-day infection rates were 1.0% and 2.2% after the TKAs and THAs, respectively. High-risk patients without extended antibiotic prophylaxis were 4.9 (p = 0.009) and 4.0 (p = 0.037) times more likely to develop PJI after TKA and THA, respectively, than high-risk patients with extended antibiotic prophylaxis.

CONCLUSIONS

Extended postoperative antibiotic prophylaxis led to a statistically significant and clinically meaningful reduction in the 90-day infection rate of selected patients at high risk for infection. We encourage further study and deliberation prior to adoption of a protocol involving extended oral antibiotic prophylaxis after high-risk TJA, with the benefits weighed appropriately against potential adverse consequences such as increasing the development of antimicrobial resistance.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Antibiotic Prophylaxis and Prevention of Surgical Site Infection in Shoulder and Elbow Surgery

Infection after orthopedic procedures is a devastating and serious complication associated with significant clinical and financial challenges to the health care system and unfortunate patient. The time and resource-intensive nature of treating infection after orthopedic procedures has turned attention toward enhancing prevention and establishing quality improvement measures. Prevention strategies throughout the perioperative period include host optimization, risk mitigation, reducing bacterial burden and proper wound management. Understanding the most common offending organisms of the shoulder, Propionibacterium acnes and coagulase negative Staphylococcus species, and their hypothesized mechanism of infection is crucial to selecting appropriate preventative measures.

Antibiotic prophylaxis in orthopaedic surgery: difficult decisions in an era of evolving antibiotic resistance

Prophylactic antibiotics can decrease the risk of wound infection and have been routinely employed in orthopaedic surgery for decades. Despite their widespread use, questions still surround the selection of antibiotics for prophylaxis, timing and duration of administration. The health economic costs associated with wound infections are significant, and the judicious but appropriate use of antibiotics can reduce this risk. This review examines the evidence behind commonly debated topics in antibiotic prophylaxis and highlights the uses and advantages of some commonly used antibiotics. Cite this article: Bone Joint J 2016;98-B:1014-19.

Quality Measures That Address the Upper Limb

PURPOSE

Physicians, health care systems, and payers use quality measures to judge performance and monitor the outcomes of interventions. Practicing upper-limb surgeons desire quality measures that are important to patients and feasible to use, and for which it is fair to hold them accountable.

METHODS

Nine academic upper-limb surgeons completed a RAND/University of California-Los Angeles Delphi Appropriateness process to evaluate the importance, feasibility, and accountability of 134 quality measures identified from systematic review. Panelists rated measures on an ordinal scale between 1 (definitely not valid) and 9 (definitely valid) in 2 rounds (preliminary round and final round) with an intervening face-to-face discussion. Ratings from 1 to 3 were considered not valid, 4 to 6 were equivocal or uncertain, and 7 to 9 were valid. If no more than 2 of the 9 ratings were outside the 3-point range that included the median (1-3, 4-6, or 7-9), panelists were considered to be in agreement. If 3 or more ratings of a measure were within the 1 to 3 range whereas 3 or more ratings were in the 7 to 9 range, panelists were considered to be in disagreement.

RESULTS

There was agreement that 58 of the measures are important (43%), 74 are feasible (55%), and surgeons can be held accountable for 39 (29%). All 3 thresholds were met for 33 measures (25%). A total of 36 reached agreement for being unimportant (48%) and 57 were not suited for surgeon accountability (43%).

CONCLUSIONS

A minority of upper-limb quality measures were rated as important for care, feasible to complete, and suitable for upper-limb surgeon accountability.

CLINICAL RELEVANCE

Before health systems and payers implement quality measures, we recommend ensuring their importance and feasibility to safeguard against measures that may not improve care and might misappropriate attention and resources.

Periprosthetic joint infections at a teaching hospital in 1990-2007

BACKGROUND

Periprosthetic joint infections (PJIs) are major complications associated with high costs and substantial morbidity. We sought to evaluate hip and knee arthroplasty infection rates at our hospital, compare them in periods before and after implementation of measures to reduce PJIs (1990-2002 and 2003-2007) and identify associated risk factors.

METHODS

We retrospectively reviewed records of patients who received primary hip or knee total joint prostheses at our centre between Jan. 1, 1990, and Dec. 31, 2007, and were readmitted for the treatment of infection related to their surgery. We also reviewed data from a prospective surveillance protocol of total hip (THA) and knee arthroplasty (TKA) infections that started in November 2005. We ascertained the annual rates of deep, superficial and hematogenous infections.

RESULTS

During the periods studied, 2403 THAs and 1220 TKAs were performed. For THA, the average rates of deep, superficial and hematogenous infections were 2.0%, 0.8% and 0.3%, respectively. For TKA, the rates were 1.6%, 0.7% and 0.2%, respectively. Of 106 infected joints, 84 (79.2%) presented risk factors for infection. Efforts to reduce the infection rate at our institution began in 2003. We achieved a 44% decrease in the deep infection rate for THA (2.5% v. 1.4%; p = 0.06) and a 45% decrease for TKA (2.0% v. 1.1%, p = 0.20) between the periods studied.

CONCLUSION

Knowing the actual infection rate associated with different procedures in specific settings is essential to identify unexpected problems and seek solutions to improve patient care. Although we do not know what specific improvements were successful, we were able to decrease our infection rates to levels comparable to those reported by similar care centres.

One-day antibiotic infusion for the prevention of postoperative infection following arthroplasty: a case control study

Intravenous antibiotics effectively reduce the prevalence of postoperative infection. However, Japanese orthopaedic surgeons have no consensus with regard to the optimal duration of prophylaxis. The aim of this study is to compare the outcome of one-day intravenous antibiotic administration with that of long-term intravenous antibiotic administration. Patients who underwent total hip or knee arthroplasty were divided into 2 groups to receive one of 2 prophylactic protocols retrospectively. Group A (223 patients) received intravenous antibiotics twice only on the day of surgery, whereas Group B (104 patients) received intravenous antibiotics for at least 3 days after surgery. We analyzed the wound infection rate and monitored liver and renal functions. None of these patients had a postoperative infection. No liver dysfunction and renal dysfunction were observed. One-day antibiotic infusion was as effective as long-term antibiotics in preventing infection after arthroplasty and achieved greater cost effectiveness.

Outcome of infected total joint replacement

Numerous protocols are used to treat an infected total joint arthroplasty. We evaluated survival outcomes of patients with infected total joint arthroplasties over 35 years to determine if one treatment is more effective than others.Of 17,561 total joint arthroplasties performed at our facility, 116 (0.66%) were diagnosed with deep infection, 22 of which (18.97%) were hematogenous. Success rates among resection, 1-stage, and 2-stage reimplantation arthroplasty were compared in each joint, as were organism types. After excluding 8 patients (6.9%) who died within 1 year of final treatment and 8 lost to follow-up, 30 hips and 70 knees were studied. Seventeen hips were treated with 2-stage arthroplasty; 70.6% succeeded after the first attempt, and 82.4% succeeded after the second. Fifty-one 2-stage knees had 54.9% success after the first attempt and 66.7% success after the second. Five of 5 hips treated with 1-stage arthroplasty succeeded after the first attempt, while 1 of 3 one-stage knees succeeded after the first attempt; none of these 8 joints had a hematogenous infection. No joints requiring a third treatment were successful after the third attempt. There were no differences in survival between different bacteria.Treatment of deep prosthetic joint infection is difficult once the first attempt has failed and becomes more so after failure of the second attempt. Two-stage arthroplasty provides good results in most cases (82% in hips, 67% in knees), but a third attempt does not increase these percentages. The organism type does not significantly affect success in infected joint treatment.

Safety and Efficacy of Cefazolin Sodium in the Management of Bacterial Infection and in Surgical Prophylaxis

Cefazolin sodium is a first-generation cephalosporin antibiotic and has been used worldwide since the early 1970s. It is used for the treatment of bacterial infections in various organs, such as the respiratory tract, skin and skin structure, genital tract, urinary tract, biliary tract, and bone and joint infections. It has also been used for septicemia due to susceptible gram-positive cocci (except Enterococcus), some gram-negative bacilli including E. coli, Proteus, and Klebsiella may be susceptible, and for perioperative prophylaxis. After the introduction of penicillins and other cephalosporins, occasional outbreaks of methicillin-resistant Staphylococcus aureus were noted. As a result, vancomycin use was increased; however, very recently and most alarmingly, vancomycin-resistant strains have been described. In this setting, to avoid the risk of the development of vancomycin-resistant strains further, vancomycin use should be curtailed. In consideration of this historical background, the appropriate use of antibiotics, such as dosage, dosage intervals, and the duration of administration is required not only for the protection of patients’ health but also for the prevention of the development of drug resistance. Cefazolin has been used in clinical practice for about 40 years, and a large body of evidence has been accumulated, and its efficacy and safety are well established compared with other antibiotics. Therefore, cefazolin has been chosen as a first-line anti-microbial for prophylaxis after various surgical procedures, including cardiovascular surgery, hysterectomy, arthroplasty and so on. Based on these facts, especially for the prophylaxis of surgical site infections, the first-generation cephalosporin, cefazolin, is now being “re-visited”.

Non-compliance with recommendations for the practice of antibiotic prophylaxis and risk of surgical site infection: results of a multilevel analysis from the INCISO Surveillance Network

OBJECTIVES

The aim of this study was to determine which surgical antibiotic prophylaxis (SAP) practices alter surgical site infection (SSI) risk.

METHODS

Data were collected during a 7 year surveillance period (2001-07) from volunteer surgery wards participating in the INCISO Surveillance Network in Northern France. Main SAP practices, i.e. antibiotic choice, timing of first dose and total SAP duration, were evaluated and compliance checked based on French recommendations. The study focused on selected procedures in digestive, orthopaedic, gynaecological and cardiovascular surgery, for which standard SAP is recommended. Multilevel logistic regression analysis (a two-level random effect model) was carried out to identify SAP-, patient- and procedure-specific factors associated with SSI.

RESULTS

Of 8029 patients who underwent the selected surgeries, 91.3% received SAP and 2.5% developed SSI. Among those receiving SAP, 83.3% received appropriate antibiotic agents and 76.6% had an optimal timing of administration. SAP duration was considered to be appropriate in 35.0%, too long (SAP unnecessarily prolonged) in 45.2% and too short (lack of intra-operative redosing when recommended) in 19.8%. In the multivariate analysis, a too-short SAP duration remained the only inappropriate practice associated with higher SSI risk (odds ratio = 1.8, 95% confidence interval: 1.14-2.81), after adjustment for surgery procedure group, the National Nosocomial Infections Surveillance System risk index, age and infection risk variability among hospitals. No significant relationships were observed between SSI and the other SAP parameters.

CONCLUSIONS

A too-short SAP duration was the most important SAP malpractice associated with an increased risk of SSI. Information directed at practitioners should be reinforced based on standard recommendations.

Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates

The study aims to delineate the deep infection rates and infection risk factors for primary total knee and total hip arthroplasty patients. A retrospective review was conducted on 6108 patients from 1991 to 2004. The deep infection cases were compared to the noninfected cohort whereby infection risk factors were identified. Of the 8494 joint arthroplasties, 43 (0.51%) developed a deep infection (30 total knee arthroplasties, 13 total hip arthroplasties). Patients with a body mass index greater than 50 had an increased odds ratio of infection of 21.3 (P < .0001). Diabetic patients were 3 times as likely to become infected compared to nondiabetic patients (P = .0027). Simultaneous bilateral total joint arthroplasties were found to have developed infection 3 times less frequently than those performed as unilateral procedures (P = .0024). The average age in our infection cohort was 64.3 and 68.4 in the noninfected cohort. In this retrospective review study, obesity, diabetes, and younger age were found to be risk factors for joint arthroplasty infection.

Myths and legends in orthopaedic practice: are we all guilty?

Over years of practice, many beliefs and practices become entrenched as tried and tested, and we subconsciously believe they are based on scientific evidence. We identified nine such beliefs by interviewing orthopaedic surgeons in which studies (or lack thereof) apparently do not support such practices. These are: changing the scalpel blade after the skin incision to limit contamination; bending the patient's knee when applying a thigh tourniquet; bed rest for treatment of deep vein thrombosis; antibiotics in irrigation solution; routine use of hip precautions; routine use of antibiotics for the duration of wound drains; routine removal of hardware in children; correlation between operative time and infection; and not changing dressings on the floor before scrubbing. A survey of 186 practicing orthopaedic surgeons in academic and community settings was performed to assess their routine practice patterns. We present the results of the survey along with an in-depth literature review of these topics. Most surgeon practices are based on a combination of knowledge gained during training, reading the literature, and personal experience. The results of this survey hopefully will raise the awareness of the selected literature for common practices.

Single- versus multiple-dose antibiotic prophylaxis in the surgical treatment of closed fractures: a meta-analysis

OBJECTIVES

The use of prophylactic antibiotics in the surgical treatment of closed long bone fractures is well established. The duration and dosage of prophylaxis, however, vary significantly among surgeons. A systematic review and meta-analysis were performed to determine if multiple-dose perioperative antibiotic prophylaxis is more effective than a single preoperative dose in the prevention of surgical wound infections during the treatment of closed long bone fractures.

DATA SOURCES

Articles were identified by searching the following medical databases: Medline, Medline In Process & Other Non-indexed Citations, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews. Relevant conference proceedings and the reference section of selected manuscripts were also searched for additional studies.

STUDY SELECTION

Studies were included if they were prospective randomized controlled trials of patients with closed fractures treated with surgical fixation or arthroplasty. The interventions must have directly compared a single preoperative prophylactic dose to a multiple-dose perioperative strategy. Studies were excluded if they involved open fractures.

DATA EXTRACTION

The demographic information, prophylaxis strategy, wound infection rate, and risk ratio were extracted from each article.

DATA SYNTHESIS

Seven trials and 3,808 patients were pooled using a random effects model. When compared to a regimen of multiple doses of prophylactic antibiotics, administration of a single preoperative dose has a risk ratio of 1.24 (95% CI 0.60-2.60). The pooled risk difference between the 2 strategies is 0.005 (95% CI -0.011-0.021). Neither result is significant.

CONCLUSIONS

In the setting of closed long bone fractures, the pooled results failed to demonstrate superiority of multiple-dose prophylaxis over a single-dose strategy. The pooled estimates suggest that surgical wound infections are relatively rare events and that any potential difference in infection rates between prophylaxis strategies is likely quite small. However, because the confidence interval surrounding the pooled risk ratio spans 1.0 by such a large amount, we are unable to definitively recommend a preferred dosing regimen to prevent surgical wound infections. Although future research is required to ensure our prophylaxis decisions continue to be evidence based and cost-effective, it is unlikely that a single clinical trial will be able to provide the answer. The use of other quantitative methods, such as cost-effectiveness analysis, may be helpful in modeling an optimal prophylaxis strategy.

Hip and Knee Arthroplasty in the Geriatric Population

Osteoarthritis is the leading cause of hip and knee pathology in the geriatric population. Hip and knee arthroplasty are the definitive interventions to alleviate pain and restore physical functioning. Complications related to these procedures do occur: the most com-mon of these are infection, thromboembolism, dislocations, and periprosthetic fractures. New improvements related to minimally invasive and computer-assisted navigation surgery techniques are promising and already have shown excellent outcomes in patients exposed to joint arthroplasty.