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Aneizi A, Kovvur M, Chrencik M, Ng VY. Prolonged prophylactic antibiotic use following megaprosthesis surgery may reduce periprosthetic infection. J Orthop 2024; 57:40-43. [PMID: 38973968 PMCID: PMC11222898 DOI: 10.1016/j.jor.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 05/30/2024] [Accepted: 06/01/2024] [Indexed: 07/09/2024] Open
Abstract
Introduction Megaprostheses provide a reconstructive option for patients with bone loss after musculoskeletal tumor resection. However, the postoperative surgical site infection (SSI) risk is significant. This study aims to evaluate outcomes of extended postoperative antibiotic regimens in patients after megaprosthesis surgery and gather insight into strategies to minimize SSI. Methods This retrospective cohort study evaluated patients who underwent megaprosthesis surgery by a single surgeon at a single center from 2014 to 2022. Patient demographics, comorbidities, cancer treatment details, and antibiotic regimens were collected. Excluded were patients with less than 1 year of follow-up, active infection at time of surgery, non-healing wounds unrelated to SSI, and preoperative antibiotic regimens secondary to being immunocompromised. Measures of interest included the development of SSI within 1 year of surgery and development of antibiotic-related complications. Results Included were 49 patients, with a mean age of 61.2 ± 2.0 years and a mean BMI of 29.4 ± 7.0. The mean drain duration was 6.5 days (standard deviation [SD], 6.9 days), and the mean intravenous antibiotic administration duration was 6.4 days (SD, 6.9 days). The median time to drain removal was five days, and the median time for intravenous antibiotic cessation was five days. The mean total antibiotic administration duration (intravenous and oral) was 25.4 days (SD, 13.4 days). Only 1 patient in the included cohort (2.04 %) developed an SSI requiring operative intervention. No other patient within the cohort experienced an antibiotic-related complication. Discussion This study suggests that the site's current protocol for managing post-megaprosthesis antibiotic prophylaxis based on drain duration and incision healing status has resulted in a low rate of SSI and antibiotic-related complications. Further research is needed to validate these findings and gain additional insights into managing antibiotic prophylaxis after megaprosthesis surgery.
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Affiliation(s)
- Ali Aneizi
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, 21201, United States
| | - Murali Kovvur
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, 21201, United States
| | - Matthew Chrencik
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, 21201, United States
| | - Vincent Y. Ng
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, 21201, United States
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Hajdu KS, Chenard SW, Judice AD, Quirion JC, Mika AP, Gilbert WB, Hefley W, Johnson DJ, Wright PW, Kang H, Halpern JL, Schwartz HS, Holt GE, Lawrenz JM. Prophylactic Antibiotic Choice and Deep Infection in Lower Extremity Endoprosthetic Reconstruction: Comparison of Cefazolin, Cefazolin-Vancomycin, and Alternative Regimens. J Am Acad Orthop Surg 2024:00124635-990000000-01029. [PMID: 38968697 DOI: 10.5435/jaaos-d-24-00211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/28/2024] [Indexed: 07/07/2024] Open
Abstract
INTRODUCTION Infection is a common mode of failure in lower extremity endoprostheses. The Prophylactic Antibiotic Regimens in Tumor Surgery trial reported that 5 days of cefazolin had no difference in surgical site infection compared with 24 hours of cefazolin. Our purpose was to evaluate infection rates of patients receiving perioperative cefazolin monotherapy, cefazolin-vancomycin dual therapy, or alternative antibiotic regimens. METHODS A single-center retrospective review was conducted on patients who received lower extremity endoprostheses from 2008 to 2021 with minimum 1-year follow-up. Three prophylactic antibiotic regimen groups were compared: cefazolin monotherapy, cefazolin-vancomycin dual therapy, and alternative regimens. The primary outcome was deep infection, defined by a sinus tract, positive culture, or clinical diagnosis. Secondary outcomes were revision surgery, microorganisms isolated, and superficial wound issues. RESULTS The overall deep infection rate was 10% (30/294) at the median final follow-up of 3.0 years (IQR 1.7 to 5.4). The deep infection rates in the cefazolin, cefazolin-vancomycin, and alternative regimen groups were 8% (6/72), 10% (18/179), and 14% (6/43), respectively (P = 0.625). Patients not receiving cefazolin had an 18% deep infection rate (6/34) and 21% revision surgery rate (7/34) compared with a 9% deep infection rate (24/260) (P = 0.13) and 12% revision surgery rate (31/260) (P = 0.17) in patients receiving cefazolin. In those not receiving cefazolin, 88% (30/34) were due to a documented penicillin allergy, only two being anaphylaxis. All six patients in the alternative regimen group who developed deep infections did not receive cefazolin secondary to nonanaphylactic penicillin allergy. CONCLUSION The addition of perioperative vancomycin to cefazolin in lower extremity endoprosthetic reconstructions was not associated with a lower deep infection rate. Patients who did not receive cefazolin trended toward higher rates of deep infection and revision surgery, although not statistically significant. The most common reason for not receiving cefazolin was a nonanaphylactic penicillin allergy, highlighting the continued practice of foregoing cefazolin unnecessarily.
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Affiliation(s)
- Katherine S Hajdu
- From the Department of Orthopaedic Surgery, Division of Musculoskeletal Oncology, Vanderbilt University Medical Center, Nashville, TN (Hajdu, Chenard, Quirion, Mika, Gilbert, Hefley, Johnson, Halpern, Schwartz, Holt, and Lawrenz), Department of Orthopaedic Surgery, Rochester Regional Health, Rochester, NY (Judice)Department of Medicine, Division of Infectious Disease, Vanderbilt University Medical Center, Nashville, TN (Wright)Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN (Kang)
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Zelenitsky SA. Effective Antimicrobial Prophylaxis in Surgery: The Relevance and Role of Pharmacokinetics-Pharmacodynamics. Antibiotics (Basel) 2023; 12:1738. [PMID: 38136772 PMCID: PMC10741006 DOI: 10.3390/antibiotics12121738] [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: 11/19/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
Appropriate surgical antimicrobial prophylaxis (SAP) is an important measure in preventing surgical site infections (SSIs). Although antimicrobial pharmacokinetics-pharmacodynamics (PKPD) is integral to optimizing antibiotic dosing for the treatment of infections, there is less research on preventing infections postsurgery. Whereas clinical studies of SAP dose, preincision timing, and redosing are informative, it is difficult to isolate their effect on SSI outcomes. Antimicrobial PKPD aims to explain the complex relationship between antibiotic exposure during surgery and the subsequent development of SSI. It accounts for the many factors that influence the PKs and antibiotic concentrations in patients and considers the susceptibilities of bacteria most likely to contaminate the surgical site. This narrative review examines the relevance and role of PKPD in providing effective SAP. The dose-response relationship i.e., association between lower dose and SSI in cefazolin prophylaxis is discussed. A comprehensive review of the evidence for an antibiotic concentration-response (SSI) relationship in SAP is also presented. Finally, PKPD considerations for improving SAP are explored with a focus on cefazolin prophylaxis in adults and outstanding questions regarding its dose, preincision timing, and redosing during surgery.
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Affiliation(s)
- Sheryl A. Zelenitsky
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0T5, Canada;
- Department of Pharmacy, St. Boniface Hospital, Winnipeg, MB R2H 2A6, Canada
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Azamgarhi T, Warren S, Fouch S, Standing JF, Gerrand C. Prophylactic antibiotics for massive endoprostheses in orthopaedic oncology. Bone Joint J 2023; 105-B:850-856. [PMID: 37524359 DOI: 10.1302/0301-620x.105b8.bjj-2022-1418.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
The recently published Prophylactic Antibiotic Regimens In Tumor Surgery (PARITY) trial found no benefit in extending antibiotic prophylaxis from 24 hours to five days after endoprosthetic reconstruction for lower limb bone tumours. PARITY is the first randomized controlled trial in orthopaedic oncology and is a huge step forward in understanding antibiotic prophylaxis. However, significant gaps remain, including questions around antibiotic choice, particularly in the UK, where cephalosporins are avoided due to concerns of Clostridioides difficile infection. We present a review of the evidence for antibiotic choice, dosing, and timing, and a brief description of PARITY, its implication for practice, and the remaining gaps in our understanding.
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Affiliation(s)
- Tariq Azamgarhi
- Pharmacy Department, Royal National Orthopaedic Hospital NHS Trust, London, UK
| | - Simon Warren
- Bone Infection Unit, Royal National Orthopaedic Hospital NHS Trust, London, UK
| | - Sarah Fouch
- School of Pharmacy and Biomedical Sciences, Portsmouth, UK
| | - Joseph F Standing
- Infection, Inflammation and Rheumatology, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Craig Gerrand
- Division of Orthopaedic Oncology, Royal National Orthopaedic Hospital NHS Trust Sarcoma Unit, London, UK
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Ray GS, Werth P, Alexander JH, Eward WC, Bernthal NM, Jeys LM, Funovics P, Windhager R, Temple HT, Lozano-Calderon S, Avedian RS, Jutte PC, Ghert M, Ruggieri P, Henderson ER. Surgical Site Infection in Patients Managed with an Endoprosthesis for the Treatment of Cancer: Evaluation of Patient, Disease, and Index Surgical Factors. J Bone Joint Surg Am 2023; 105:87-96. [PMID: 37466585 DOI: 10.2106/jbjs.22.01376] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Surgical site infection (SSI) after segmental endoprosthetic reconstruction in patients treated for oncologic conditions remains both a devastating and a common complication. The goal of the present study was to identify variables associated with the success or failure of treatment of early SSI following the treatment of a primary bone tumor with use of a segmental endoprosthesis. METHODS The present study used the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) data set to identify patients who had been diagnosed with an SSI after undergoing endoprosthetic reconstruction of a lower extremity primary bone tumor. The primary outcome of interest in the present study was a dichotomous variable: the success or failure of infection treatment. We defined failure as the inability to eradicate the infection, which we considered as an outcome of amputation or limb retention with chronic antibiotic suppression (>90 days or ongoing therapy at the conclusion of the study). Multivariable models were created with covariates of interest for each of the following: surgery characteristics, cancer treatment-related characteristics, and tumor characteristics. Multivariable testing included variables selected on the basis of known associations with infection or results of the univariable tests. RESULTS Of the 96 patients who were diagnosed with an SSI, 27 (28%) had successful eradication of the infection and 69 had treatment failure. Baseline and index procedure variables showing significant association with SSI treatment outcome were moderate/large amounts of fascial excision ≥1 cm2) (OR, 10.21 [95% CI, 2.65 to 46.21]; p = 0.001), use of local muscle/skin graft (OR,11.88 [95% CI, 1.83 to 245.83]; p = 0.031), and use of a deep Hemovac (OR, 0.24 [95% CI, 0.05 to 0.85]; p = 0.041). In the final multivariable model, excision of fascia during primary tumor resection was the only variable with a significant association with treatment outcome (OR, 10.21 [95% CI, 2.65 to 46.21]; p = 0.018). CONCLUSIONS The results of this secondary analysis of the PARITY trial data provide further insight into the patient-, disease-, and treatment-specific associations with SSI treatment outcomes, which may help to inform decision-making and management of SSI in patients who have undergone segmental bone reconstruction of the femur or tibia for oncologic indications. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- G S Ray
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - P Werth
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - J H Alexander
- Department of Orthopaedic Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - W C Eward
- Duke Health Department of Orthopaedic Surgery, Duke Cancer Center, Duke, North Carolina
| | - N M Bernthal
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, California
| | - L M Jeys
- Department of Orthopaedics, Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - P Funovics
- Department of Orthopaedics, Medical University of Vienna, Austria
| | - R Windhager
- Department of Orthopaedics, Medical University of Vienna, Austria
| | - H T Temple
- Miller School of Medicine, University of Miami, Miami, Florida
| | - S Lozano-Calderon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - R S Avedian
- Department of Orthopaedic Surgery, Stanford Health Care, Redwood City, California
| | - P C Jutte
- Department of Orthopaedics, University of Groningen, Groningen, The Netherlands
| | - M Ghert
- Department of Orthopaedics, McMaster University, Hamilton, Ontario, Canada
| | - P Ruggieri
- Department of Orthopaedics and Orthopaedic Oncology, Padova University, Padova, Italy
| | - E R Henderson
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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