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Hassanzadeh H, Ferro A, Woods K, Baring T. Review of the national usage of antibiotics in arthroplasty surgery: a need for evidence-based prescribing. Ann R Coll Surg Engl 2024; 106:628-632. [PMID: 37381757 PMCID: PMC11365728 DOI: 10.1308/rcsann.2022.0145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2022] [Indexed: 06/30/2023] Open
Abstract
INTRODUCTION Surgical site infections (SSI) remain one of the most serious complications of arthroplasty surgery. The role of antibiotic prophylaxis in preventing SSI post-arthroplasty is well established. However, there is considerable heterogeneity in prophylactic prescribing across the United Kingdom (UK), which is contradicted by the contemporaneous evidence. This descriptive study aimed to compare the current first-line antibiotic recommendations across hospitals in the UK and The Republic of Ireland for elective arthroplasty procedures. METHODS The MicroGuide mobile phone application was used to access hospital antibiotic guidelines. First-line antibiotic recommendation and dosing regimen for primary elective arthroplasties were recorded. FINDINGS A total of nine distinct antibiotic regimens were identified through our search. The most frequently used first-line antibiotic was cefuroxime. This was recommended by 30 of the 83 (36.1%) hospitals in the study. This was followed by a combination of flucloxacillin and gentamicin, which was used by 38 of 124 (31%) hospitals. There was also significant heterogeneity in dosing regimens. A single prophylactic dose was most commonly recommended (52%); 4% of hospitals recommended two prophylactic doses, 19% three doses and 23% four doses. CONCLUSIONS Single-dose prophylaxis is recognised as at least noninferior to multiple-dose prophylaxis in primary arthroplasty. There is considerable variation in the local antibiotic recommendations for surgical site prophylaxis post-primary arthroplasty surgery, with respect to both recommended first-line antibiotic and dosing regimens. With increasing emphasis on the importance of antibiotic stewardship and the emergence of antibiotic resistance, this study highlights the need for an evidence-based approach to prophylactic dosing across the UK.
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Affiliation(s)
- H Hassanzadeh
- Homerton University Hospital NHS Foundation Trust, UK
| | - A Ferro
- Homerton University Hospital NHS Foundation Trust, UK
| | - K Woods
- Homerton University Hospital NHS Foundation Trust, UK
| | - T Baring
- Homerton University Hospital NHS Foundation Trust, UK
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Abedi AA, Varnum C, Pedersen AB, Gromov K, Hallas J, Iversen P, Jakobsen T, Jimenez-Solem E, Kidholm K, Kjerulf A, Lange J, Odgaard A, Rosenvinge FS, Solgaard S, Sperling K, Stegger M, Christensen R, Overgaard S. Effect of single versus multiple prophylactic antibiotic doses on prosthetic joint infections following primary total hip arthroplasty in patients with osteoarthritis at public and private hospitals in Denmark: protocol for a nationwide cross-over, cluster randomised, non-inferiority trial [The Pro-Hip-Quality Trial]. BMJ Open 2023; 13:e071487. [PMID: 37604637 PMCID: PMC10445366 DOI: 10.1136/bmjopen-2022-071487] [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: 12/30/2022] [Accepted: 06/21/2023] [Indexed: 08/23/2023] Open
Abstract
INTRODUCTION A feared complication after total hip arthroplasty (THA) is prosthetic joint infection (PJI), associated with high morbidity and mortality. Prophylactic antibiotics can reduce the risk of PJI. However, there is no consensus on the dosages and current recommendations are based on a low evidence level. The objective is to compare the effect of a single versus multiple doses of prophylactic antibiotics administered within 24 hours on PJI. METHODS AND ANALYSIS The study is designed as a cross-over, cluster randomised, non-inferiority trial. All clinical centres use both antibiotic practices (1 year of each intervention). All Danish orthopaedic surgery departments will be involved: Based on quality databases, 2-year cohorts of approximately 20 000 primary THAs conducted at 39 public and private hospitals, will be included. INCLUSION CRITERIA age ≥18 years, all indications for THA except patients operated due to acute or sequelae from proximal femoral or pelvic fractures or bone tumour or metastasis. The primary outcome is PJI within 90 days after primary THA. Secondary outcomes include (1) serious adverse events, (2) potential PJI, (3) length of hospitalisation stay, (4) cardiovascular events, (5) hospital-treated infections, (6) community-based antibiotic use, (7) opioid use and (8) use of acetaminophen and non-steroidal anti-inflammatory drugs. All outcome measures will be extracted from national databases. Analyses will be based on the intention-to-treat population. Non-inferiority will be shown if the upper limit of the two-sided 95% CI for the OR is less than 1.32 for the single dose as compared with multiple doses. The results will establish best practice on antibiotic prophylaxis dosages in the future. ETHICS AND DISSEMINATION This study has been approved by Committees on Health Research Ethics for The Capital Region of Denmark (21069108) and The Danish Medicines Agency (2021091723). All results will be presented in peer-reviewed medical journals and international conferences. TRIAL REGISTRATION NUMBER NCT05530551.
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Affiliation(s)
- Armita Armina Abedi
- Department of Orthopedic Surgery and Traumatology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Claus Varnum
- Department of Orthopedics, Lillebaelt Hospital - University Hospital Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Alma Becic Pedersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Kirill Gromov
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre Hospital, Hvidovre, Denmark
| | - Jesper Hallas
- Department of Public Health, Clinical Pharmacology, Pharmacy, and Environmental Medicine, University of Southern Denmark, Odense, Denmark
| | - Pernille Iversen
- The Danish Clinical Quality Program- National Clinical Registries (RKKP), Copenhagen, Denmark
| | - Thomas Jakobsen
- Department of Orthopedics, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Espen Jimenez-Solem
- Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Kristian Kidholm
- Centre for Innovative Medical Technology, Odense Universitetshospital, Odense, Denmark
| | - Anne Kjerulf
- Infectious Disease Epidemiology & Prevention, Statens Serum Institut, Copenhagen, Denmark
| | - Jeppe Lange
- Department of Orthopedic Surgery, Regional Hospital Horsens, Horsens, Denmark
- Department of Clinical Medicine, Århus Universitet Klinisk Institut, Aarhus, Denmark
| | - Anders Odgaard
- Department of Orthopaedic Surgery, Rigshospitalet, Copenhagen, Denmark
| | | | - Søren Solgaard
- Department of Hip and Knee Surgery, Copenhagen University Hospital, Herlev-Gentofte University Hospital, Hellerup, Denmark
| | - Kim Sperling
- Department of Orthopedic Surgery, Nastved Hospital, Nastved, Denmark
| | - Marc Stegger
- Department of Microbiological Surveillance and Research, Statens Serum Institut, Copenhagen, Denmark
| | - Robin Christensen
- Parker Institute, Frederiksberg and Bispebjerg Hospital, Copenhagen, Denmark
| | - Søren Overgaard
- Department of Orthopedic Surgery and Traumatology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
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3
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Leta TH, Fenstad AM, Lygre SHL, Lie SA, Lindberg-Larsen M, Pedersen AB, W-Dahl A, Rolfson O, Bülow E, Ashforth JA, Van Steenbergen LN, Nelissen RGHH, Harries D, De Steiger R, Lutro O, Hakulinen E, Mäkelä K, Willis J, Wyatt M, Frampton C, Grimberg A, Steinbrück A, Wu Y, Armaroli C, Molinari M, Picus R, Mullen K, Illgen R, Stoica IC, Vorovenci AE, Dragomirescu D, Dale H, Brand C, Christen B, Shapiro J, Wilkinson JM, Armstrong R, Wooster K, Hallan G, Gjertsen JE, Chang RN, Prentice HA, Paxton EW, Furnes O. The use of antibiotic-loaded bone cement and systemic antibiotic prophylactic use in 2,971,357 primary total knee arthroplasties from 2010 to 2020: an international register-based observational study among countries in Africa, Europe, North America, and Oceania. Acta Orthop 2023; 94:416-425. [PMID: 37565339 PMCID: PMC10416222 DOI: 10.2340/17453674.2023.17737] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/02/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND AND PURPOSE Antibiotic-loaded bone cement (ALBC) and systemic antibiotic prophylaxis (SAP) have been used to reduce periprosthetic joint infection (PJI) rates. We investigated the use of ALBC and SAP in primary total knee arthroplasty (TKA). PATIENTS AND METHODS This observational study is based on 2,971,357 primary TKAs reported in 2010-2020 to national/regional joint arthroplasty registries in Australia, Denmark, Finland, Germany, Italy, the Netherlands, New Zealand, Norway, Romania, South Africa, Sweden, Switzerland, the UK, and the USA. Aggregate-level data on trends and types of bone cement, antibiotic agents, and doses and duration of SAP used was extracted from participating registries. RESULTS ALBC was used in 77% of the TKAs with variation ranging from 100% in Norway to 31% in the USA. Palacos R+G was the most common (62%) ALBC type used. The primary antibiotic used in ALBC was gentamicin (94%). Use of ALBC in combination with SAP was common practice (77%). Cefazolin was the most common (32%) SAP agent. The doses and duration of SAP used varied from one single preoperative dosage as standard practice in Bolzano, Italy (98%) to 1-day 4 doses in Norway (83% of the 40,709 TKAs reported to the Norwegian arthroplasty register). CONCLUSION The proportion of ALBC usage in primary TKA varies internationally, with gentamicin being the most common antibiotic. ALBC in combination with SAP was common practice, with cefazolin the most common SAP agent. The type of ALBC and type, dose, and duration of SAP varied among participating countries.
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Affiliation(s)
- Tesfaye H Leta
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Norway; Faculty of Health Science, VID Specialized University, Norway; Department of Population Health Sciences, Weill Medical College of Cornell University, USA; Department of Medical Device Surveillance & Assessment, Kaiser Permanente, USA.
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Norway
| | - Stein Håkon L Lygre
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Norway; Department of Occupational Medicine, Haukeland University Hospital, Norway
| | - Stein Atle Lie
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Norway; Institutes of Dentistry, University of Bergen, Norway
| | - Martin Lindberg-Larsen
- The Danish Knee Arthroplasty Register, Denmark; Department of Orthopedic Surgery and Traumatology, Odense University Hospital, Denmark
| | - Alma B Pedersen
- The Danish Knee Arthroplasty Register, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Denmark
| | - Annette W-Dahl
- The Swedish Arthroplasty Register, Sweden; Department of Clinical Sciences Lund, Division of Orthopedics, Lund University, Lund, Sweden
| | - Ola Rolfson
- The Swedish Arthroplasty Register, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Bülow
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Centre of Registers Västra Götaland, Gothenburg, Sweden
| | | | | | - Rob G H H Nelissen
- The Dutch Arthroplasty Register, the Netherlands; Department of Orthopedics, Leiden University Medical Center, the Netherlands
| | - Dylan Harries
- South Australian Health and Medical Research Institute, Australia
| | - Richard De Steiger
- The Australian Orthopaedic Association National Joint Replacement Registry, Australia
| | - Olav Lutro
- Department of Medicine, Stavanger University Hospital, Norway
| | | | - Keijo Mäkelä
- The Finnish Arthroplasty Register, Finland; Turku University Hospital and University of Turku, Turku, Finland
| | | | | | | | | | | | - Yinan Wu
- The Germany Arthroplasty Registry, Germany
| | - Cristiana Armaroli
- Arthroplasty Registry of the Autonomous Province of Trento (PATN), Clinical Epidemiology Service, Provincial Agency for Health Services of Trento (APSS), Italy
| | - Marco Molinari
- Orthopedics and Traumatology Operative Unit, Cavalese Hospital, Provincial Agency for Health Services of Trento (APSS), Italy
| | - Roberto Picus
- Arthroplasty Register of Autonomous Province of Bolzano (PABZ), Observatory of Health, Health Department AP of Bolzano, Italy
| | | | - Richard Illgen
- American Joint Replacement Registry, USA; University of Wisconsin-Madison School of Medicine and Public Health, Department of Orthopedic Surgery and Rehabilitation, USA
| | - Ioan C Stoica
- Romanian Arthroplasty Registry, Romania; University of Medicine and Pharmacy - Carol Davila - Bucharest - UMFCD Bucharest, Romania; Foisor Orthopedic Hospital, Romania
| | - Andreea E Vorovenci
- Romanian Arthroplasty Registry, Romania; Economic Cybernetics and Statistics Doctoral School, Bucharest University of Economic Studies, Romania
| | - Dan Dragomirescu
- Romanian Arthroplasty Registry, Romania; Economic Cybernetics and Statistics Doctoral School, Bucharest University of Economic Studies, Romania
| | - Håvard Dale
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Norway; Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Norway
| | - Christian Brand
- Swiss National Hip & Knee Joint Registry, Switzerland; Institute of Social and Preventive Medicine, SwissRDL, University of Bern; Switzerland
| | - Bernhard Christen
- Swiss National Hip & Knee Joint Registry, Switzerland; Articon, Bern, Switzerland
| | - Joanne Shapiro
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, UK; NEC Software Solutions, Hemel Hempstead, UK
| | - J Mark Wilkinson
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, UK; Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Richard Armstrong
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, UK; NEC Software Solutions, Hemel Hempstead, UK
| | - Kate Wooster
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, UK; NEC Software Solutions, Hemel Hempstead, UK
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Norway; Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Norway
| | - Jan-Erik Gjertsen
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Norway; Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Norway
| | - Richard N Chang
- Medical Device Surveillance & Assessment, Kaiser Permanente, USA
| | | | | | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Norway; Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Norway
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Allen J, Abdelmonem M, Fieraru G, Guyver P. Introducing A Day-Case Shoulder Arthroplasty Pathway In The UK - How We Did It. Shoulder Elbow 2023; 15:311-320. [PMID: 37325384 PMCID: PMC10268136 DOI: 10.1177/17585732221079582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/10/2022] [Accepted: 01/13/2022] [Indexed: 09/20/2023]
Abstract
Background As the demand for elective orthopaedics grows, day-case arthroplasty is gaining popularity. The aim of this study was to create a safe and reproducible pathway for day-case shoulder arthroplasty (DCSA) based upon a literature review and discussion with the local multidisciplinary team (MDT). Methods A literature review was performed using OVID MEDLINE and Embase databases reporting 90-day complication and admission rates following DCSA. Minimum follow-up was 30 days. Day-case was defined as discharge on the same day of surgery. Results The literature review revealed a mean 90-day complication rate of 7.7% [range, 0-15.9%] and mean 90-day readmission rate of 2.5% [range 0-9.3%]. A pilot protocol was devised based upon the literature review and consisted of 5 phases: (1) pre-operative assessment, (2) intra-operative phase, (3) post-operative phase, (4) follow-up, and (5) readmission protocol. This was presented, discussed, amended, and ultimately ratified by the local MDT. In May 2021 the unit successfully completed its first day-case shoulder arthroplasty. Discussion This study proposes a safe and reproducible pathway for DCSA. Patient selection, well-defined protocols and communication within the MDT are important factors to achieve this. Further studies with extended follow-up will be needed to gauge long-term success within our unit.
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Affiliation(s)
- James Allen
- Derriford Hospital, University Hospitals Plymouth NHS Trust, Huddersfield, UK
- Huddersfield Royal Infirmary, Huddersfield, UK
| | - Mohamed Abdelmonem
- Derriford Hospital, University Hospitals Plymouth NHS Trust, Huddersfield, UK
| | - Gabriel Fieraru
- Derriford Hospital, University Hospitals Plymouth NHS Trust, Huddersfield, UK
| | - Paul Guyver
- Derriford Hospital, University Hospitals Plymouth NHS Trust, Huddersfield, UK
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5
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Homsy P, Romo I, Kauhanen S. Antibiotic prophylaxis in clean and clean-contaminated plastic surgery: A critical review. J Plast Reconstr Aesthet Surg 2023; 83:233-245. [PMID: 37285776 DOI: 10.1016/j.bjps.2023.04.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 04/07/2023] [Accepted: 04/19/2023] [Indexed: 06/09/2023]
Abstract
Antibiotic prophylaxis is frequently used in plastic surgery procedures, despite the generally low rates of infection and few guidelines on the practice. The increasing prevalence of bacterial resistance to antibiotics calls for a reduction in unnecessary antibiotic use. The aim of this review was to create an updated summary of the available data on the effectiveness of antibiotic prophylaxis in reducing the postoperative infection in clean and clean-contaminated plastic surgery. A systematic literature search was performed on the databases Medline, Web of Science, and Scopus, limited to articles published January 2000 onward. Randomized controlled trials (RCTs) were included in the primary review, whereas older RCTs and other studies were sought if 2 or fewer relevant RCTs were identified. Overall, 28 relevant RCTs, 2 nonrandomized trials, and 15 cohort studies were identified. Although the number of studies for each type of surgery is limited, the data suggest that prophylactic systemic antibiotic may be unnecessary in noncontaminated facial plastic surgery, reduction mammaplasty, and breast augmentation. In addition, no benefit is apparent from extending the antibiotic prophylaxis over 24 h in rhinoplasty, aerodigestive tract reconstruction, and breast reconstruction. No studies assessing the necessity of antibiotic prophylaxis in abdominoplasty, lipotransfer, soft tissue tumor surgery, or gender affirmation surgery were identified. In conclusion, limited data are available on the effectiveness of antibiotic prophylaxis in clean and clean-contaminated plastic surgery. More studies on this topic are needed before strong recommendations can be made on the use of antibiotics in this setting.
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Affiliation(s)
- Pauliina Homsy
- Department of Plastic Surgery, Puistosairaala, University of Helsinki and Helsinki University Central Hospital, P.O. Box 281, 00029 HUS, Finland.
| | - Inka Romo
- Department of Infectious Diseases, Meilahden Kolmiosairaala, University of Helsinki and Helsinki University Central Hospital, P.O. Box 372, 00029 HUS, Finland
| | - Susanna Kauhanen
- Department of Plastic Surgery, Puistosairaala, University of Helsinki and Helsinki University Central Hospital, P.O. Box 281, 00029 HUS, Finland
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Prevention Techniques Have Had Minimal Impact on the Population Rate of Prosthetic Joint Infection for Primary Total Hip and Knee Arthroplasty: A National Database Study. J Arthroplasty 2023; 38:1131-1140. [PMID: 36858132 DOI: 10.1016/j.arth.2023.02.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Several studies over the years have offered modalities that may greatly decrease the rate of periprosthetic joint infection when implemented. As a result, one would expect a drastic decrease in infection rate among the implementing population with its widespread use. The purpose of this study was to assess whether there exists a decrease in infection rate over time, after accounting for available confounding variables, within a large national database. METHODS A large national database from 2005 to 2019 was queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). In total, 221,416 THAs and 354,049 TKAs were performed over the study period. Differences in 30-day infection rate were assessed with time and available preoperative risk factors using multinominal logistic regressions. RESULTS Rate of infection overall trended downward for both THA and TKA. After accounting for confounding variables, odds of THA infection marginally decreased over time (odds ratio 0.968 [0.952-0.985], P < .0001), while the odds of a TKA infection marginally increased with time (odds ratio 1.037 [1.020-1.054], P < .0001). CONCLUSION Individual peer-reviewed publications have presented infection control modalities demonstrating dramatic decreases in infection rate while analysis at a population level shows almost no changes in infection rate over a 15-year time period. This study supports continued investigation for influential modalities in preventing periprosthetic joint infection and care in patient selection for primary hip and knee arthroplasty.
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Berberich C, Josse J, Ruiz PS. Patients at a high risk of PJI: Can we reduce the incidence of infection using dual antibiotic-loaded bone cement? ARTHROPLASTY 2022; 4:41. [PMID: 36068617 PMCID: PMC9450350 DOI: 10.1186/s42836-022-00142-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/26/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractProsthetic joint infection (PJI) is one of the most devastating complications of orthopedic surgery. However, not all patients are equally at the risk of severe infection. The incidences of PJI vary with the host and surgery-related risk factors. It is now generally accepted that some important medical comorbidities may predispose the patients to a high risk of PJI. Time-consuming and invasive surgical procedures, such as revision arthroplasties, are also associated with a high incidence of PJI, presumably due to the increased risk of surgical site contamination. Effective infection-preventing strategies should begin with identifying and optimizing the patients at a high risk of infection prior to surgery. Optimizing the operating room environment and antibiotic prophylaxis are also essential strategies that help minimize the overall incidence of infection in orthopedic surgery. The ideal antibiotic prophylaxis is still under debate, and discussions have emerged about whether variations or adjustments to the standard protocol are justified in patients at a high risk of infection. This also includes evaluating the possible benefits and risks of using high-dose dual antibiotic-loaded bone cement instead of low-dose single antibiotic-loaded bone cement in arthroplasty. This review summarizes the evidence showing that the combination of two local antibiotics in bone cement exerts a strong and longer-lasting antimicrobial effect against PJI-associated pathogens. This conclusion is consistent with the preliminary clinical studies showing a low incidence of PJI in high-risk patients undergoing cemented hemiarthroplasty, cemented revision, and primary arthroplasty if dual ALBC is used. These results may encourage clinicians to consolidate this hypothesis in a wider clinical range.
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Spangehl M. Preoperative Prophylactic Antibiotics in Total Hip and Knee Arthroplasty: What, When, and How. J Arthroplasty 2022; 37:1432-1434. [PMID: 35051610 DOI: 10.1016/j.arth.2022.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/27/2021] [Accepted: 01/10/2022] [Indexed: 02/02/2023] Open
Abstract
Although there are numerous nonpatient-related factors that may help reduce infection risk, the proper use of prophylactic antibiotics is most responsible for reducing infection. The role of prophylactic antibiotics is to reduce early periprosthetic joint replacement, which is accomplished by having adequate antibiotic tissue levels at the time of skin incision. The goal of this section of the symposium is to review current antibiotic recommendations, how to manage patients with a self-reported penicillin allergy, review the use of dual antibiotics, discuss the use of antibiotics in the outpatient total joint setting, as well as very briefly discuss the administration of intraosseous antibiotics in knee arthroplasty.
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Affiliation(s)
- Mark Spangehl
- Mayo Clinic College of Medicine and Science, Phoenix, Arizona
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9
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Tøstesen SK, Stilling M, Hanberg P, Thillemann TM, Falstie-Jensen T, Tøttrup M, Knudsen M, Petersen ET, Bue M. High Cefuroxime Concentrations and Long Elimination in an Orthopaedic Surgical Deadspace—A Microdialysis Porcine Study. Antibiotics (Basel) 2022; 11:antibiotics11020208. [PMID: 35203810 PMCID: PMC8868149 DOI: 10.3390/antibiotics11020208] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/27/2022] [Accepted: 02/04/2022] [Indexed: 02/04/2023] Open
Abstract
Deadspace is the tissue and bony defect in a surgical wound after closure. This space is presumably poorly perfused favouring bacterial proliferation and biofilm formation. In arthroplasty surgery, an obligate deadspace surrounding the prosthesis is introduced and deadspace management, in combination with obtaining therapeutic prophylactic antibiotic concentrations, is important for limiting the risk of acquiring a periprosthetic joint infection (PJI). This study aimed to investigate cefuroxime distribution to an orthopaedic surgical deadspace in comparison with plasma and bone concentrations during two dosing intervals (8 h × 2). In a setup imitating shoulder arthroplasty surgery, but without insertion of a prosthesis, microdialysis catheters were placed for cefuroxime sampling in a deadspace in the glenohumeral joint and in cancellous bone of the scapular neck in eighteen pigs. Blood samples were collected as a reference. Cefuroxime was administered according to weight (20 mg/kg). The primary endpoint was time above the cefuroxime minimal inhibitory concentration of the free fraction of cefuroxime for Staphylococcus aureus (fT > MIC (4 μg/mL)). During the two dosing intervals, mean fT > MIC (4 μg/mL) was significantly longer in deadspace (605 min) compared with plasma (284 min) and bone (334 min). For deadspace, the mean time to reach 4 μg/mL was prolonged from the first dosing interval (8 min) to the second dosing interval (21 min), while the peak drug concentration was lower and half-life was longer in the second dosing interval. In conclusion, weight-adjusted cefuroxime fT > MIC (4 μg/mL) and elimination from the deadspace was longer in comparison to plasma and bone. Our results suggest a deadspace consolidation and a longer diffusions distance, resulting in a low cefuroxime turn-over. Based on theoretical targets, cefuroxime appears to be an appropriate prophylactic drug for the prevention of PJI.
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Affiliation(s)
- Sara Kousgaard Tøstesen
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark; (M.S.); (P.H.); (M.B.)
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
- Correspondence:
| | - Maiken Stilling
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark; (M.S.); (P.H.); (M.B.)
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
- AutoRSA Research Group, Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Pelle Hanberg
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark; (M.S.); (P.H.); (M.B.)
| | - Theis Muncholm Thillemann
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
| | - Thomas Falstie-Jensen
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
| | - Mikkel Tøttrup
- Department of Orthopaedic Surgery, Aalborg University Hospital, 9640 Farsoe, Denmark;
| | - Martin Knudsen
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
| | - Emil Toft Petersen
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
- AutoRSA Research Group, Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Mats Bue
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark; (M.S.); (P.H.); (M.B.)
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
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García-Rey E. CORR Insights®: Intraosseous Regional Prophylactic Antibiotics Decrease the Risk of Prosthetic Joint Infection in Primary TKA: A Multicenter Study. Clin Orthop Relat Res 2021; 479:2513-2515. [PMID: 34460441 PMCID: PMC8509909 DOI: 10.1097/corr.0000000000001963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/11/2021] [Indexed: 01/31/2023]
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11
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Population pharmacokinetic model of cefazolin in total hip arthroplasty. Sci Rep 2021; 11:19763. [PMID: 34611213 PMCID: PMC8492877 DOI: 10.1038/s41598-021-99162-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 09/13/2021] [Indexed: 02/02/2023] Open
Abstract
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.
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