Prophylactic antibiotics in elective hip and knee arthroplasty: an analysis of organisms reported to cause infections and National survey of clinical practice

Review of the national usage of antibiotics in arthroplasty surgery: a need for evidence-based prescribing

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.

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.

Antibiotic prophylaxis in alloplastic temporomandibular joint replacement surgery: A multi-national survey of temporomandibular joint surgeons

Temporomandibular disorders include a wide spectrum of extra-articular and intra-articular conditions affecting the temporomandibular joint (TMJ). In salvage cases involving intra-articular end-stage disease, alloplastic temporomandibular joint replacement (TMJR) is a management option which can be utilised to rehabilitate a disabled joint's function and form. Whilst post-TMJR infection is rare, it is one of the most serious complications. The principles governing TMJR surgery antibiotic prophylaxis have been based on those established in orthopaedic surgery literature. Antibiotic resistance due to antibiotic over-use is a significant concern, therefore antibiotic stewardship has been developed to deal with this world-wide public health concern. The TMJ's anatomical proximity to the external auditory canal and oral cavity creates the potential for bacterial contamination. The aim of this study was to explore the views of 39 sub-specialist TMJ surgeons across nine nations usual approach to antibiotic prophylaxis and their management of TMJR infection. To accomplish this, an international survey was developed and conducted using Google Forms. The results demonstrated that 97.4% of the respondents employ prophylactic antibiotics at TMJR surgery, 83.8% on discharge. Variability in antibiotic choice with additional antimicrobial perioperative practices were also reported. Opinions on the management of a TMJR infection also varied. This survey establishes there is an agreement on the use of antibiotic prophylaxis, However the variability in choice, timing, course, duration of antibiotic use as well as the management of a postoperative TMJR infection demonstrates the need for further study leading to development of standardised antibiotic prophylaxis and infection management protocols for TMJR surgery.

Preventive strategies to reduce the rate of periprosthetic infections in total joint arthroplasty; a comprehensive review

The increasing frequency of total hip (THA) and knee arthroplasties (TKA) is marred by the rise in periprosthetic joint infections (PJIs) and surgical site infections (SSIs), with PJIs incurring costs over $1.62 billion as of 2020 and individual case management averaging $90,000. SSIs additionally burden the U.S. healthcare economy with billions in expenses annually. PJI prevalence in primary THA and TKA ranges from 0.5% to 2.4%, spiking to 20% in revisions and representing 25% of TKA revision causes. Projections estimate up to 270,000 annual PJI cases by 2030. Often caused by gram-positive bacteria, particularly methicillin-resistant staphylococci, these infections demand preventive measures. This review dissects PJI prevention across preoperative, intraoperative, and perioperative phases, aligning with evidence-based CDC and WHO guidelines. Preoperative measures include managing diabetes, obesity, tobacco use, Staphylococcus aureus screening and nasal decolonization, nutritional optimization, and management of inflammatory arthropathies. Intraoperatively, antibiotic prophylaxis, skin preparation, operative room environmental controls, surgical technique precision, and irrigation options are scrutinized. Perioperative concerns focus on anticoagulation, blood management, and infection risk mitigation. Integrating these strategies promotes a patient-centric care model, aiming to reduce PJI incidence, improve patient outcomes, and increase care cost-effectiveness in joint arthroplasty.

Second-Line Antibiotic Agents in Patient-Reported Penicillin or Cephalosporin Allergy Have No Negative Impact on Antibiotic Resistance After Hip and Knee Arthroplasty

BACKGROUND

The aim of the present study was to compare causative bacteria and their antibiotic resistance profiles in patients developing a periprosthetic joint infection (PJI) based on preoperative prophylactic antibiotic regimens in primary total hip (THA) and primary total and unicompartmental knee arthroplasty (TKA/UKA).

METHODS

We reviewed all cases of PJI occurring after primary THA and primary TKA/UKA, between 2011 and 2020 in a tertiary referral hospital. The standard preoperative prophylactic antibiotic for primary joint arthroplasty was cefuroxime and recommended second-line agent was clindamycin. Patients were divided by the replaced joint and analyzed independently.

RESULTS

In the THA group, culture-positive PJI was detected in 61 of 3,123 (2.0%) cefuroxime-administered cases and 6 of 206 (2.9%) noncefuroxime-administered cases. In the TKA/UKA group, culture positive PJI was identified in 21 of 2,455 (0.9%) cefuroxime-administered cases and in 3 of 211 (1.4%) noncefuroxime administered cases. The most commonly isolated bacteria in both groups were coagulase negative staphylococci (CNS). There were no statistically significant differences of pathogen spectrum depending on the preoperative antibiotic regimen detected. Antibiotic resistance of isolated bacteria was significantly different in 4 of 27 (14.8%) analyzed antibiotics in THA and in 3 of 22 (13.6%) analyzed antibiotics in TKA/UKA. In all cohorts, a high occurrence of oxacillin-resistant CNS (50.0 to 100.0%) and clindamycin-resistant CNS (56.3 to 100.0%) has been observed.

CONCLUSION

The use of the second-line antibiotic did not influence the pathogen spectrum or antibiotic resistance. However, an alarmingly high proportion of CNS strains was resistant to clindamycin.

Variation of Practice in Prophylactic Protocol to Reduce Prosthetic Joint Infection in Primary Hip and Knee Arthroplasty: A National Survey in the United Kingdom

Purpose

Prosthetic joint infection (PJI) has an enormous physiological and psychological burden on patients. Surgeons rightly wish to minimise this risk. It has been shown that a standardised, evidence-based approach to perioperative care leads to better patient outcomes. A review of current practice was conducted using a cross-sectional survey among surgeons at multiple centers nationwide.

Materials and Methods

An 11-question electronic survey was circulated to hip and knee arthroplasty consultants nationally via the BOA (British Orthopaedic Association) e-newsletter.

Results

The respondents included 56 consultants working across 19 different trusts. Thirty-four (60.7%) screen patients for asymptomatic bacteriuria (ASB) preoperatively, with 19 (55.9%) would treating with antibiotics. Fifty-six (100%) screen for methicillin-resistant Staphylococcus aureus and treat if positive. Only 15 (26.8%) screen for methicillin-sensitive S. aureus (MSSA) or empirically eradicate. Zero (0%) routinely catheterise patients perioperatively. Forty-one (73.2%) would give intramuscular or intravenous gentamicin for a perioperative catheterisation. All surgeons use laminar flow theatres. Twenty-six (46.4%) use only an impervious gown, 6 (10.7%) exhaust pipes, and 24 (42.3%) surgical helmet system. Five different antimicrobial prophylaxis regimens are used 9 (16.1%) cefuroxime, 2 (3.6%) flucloxacillin, 19 (33.9%) flucloxacillin and gentamicin, 10 (17.9%) teicoplanin, 16 (28.6%) teicoplanin and gentamicin. Twenty-two (39.3%) routinely give further doses.

Conclusion

ASB screening, treatment and intramuscular gentamicin for perioperative catheterisation is routinely practiced despite no supporting evidence base. MSSA screening and treatment is underutilised. Multiple antibiotic regimens exist despite little variation in organisms in PJI. Practice varies between surgeons and centers, we should all be practicing evidence-based medicine.

National variation in prophylactic antibiotic use for elective primary total joint replacement

Aims

Prophylactic antibiotic regimens for elective primary total hip and knee arthroplasty vary widely across hospitals and trusts in the UK. This study aimed to identify antibiotic prophylaxis regimens currently in use for elective primary arthroplasty across the UK, establish variations in antibiotic prophylaxis regimens and their impact on the risk of periprosthetic joint infection (PJI) in the first-year post-index procedure, and evaluate adherence to current international consensus guidance.

Methods

The guidelines for the primary and alternative recommended prophylactic antibiotic regimens in clean orthopaedic surgery (primary arthroplasty) for 109 hospitals and trusts across the UK were sought by searching each trust and hospital's website (intranet webpages), and by using the MicroGuide app. The mean cost of each antibiotic regimen was calculated using price data from the British National Formulary (BNF). Regimens were then compared to the 2018 Philadelphia Consensus Guidance, to evaluate adherence to international guidance.

Results

The primary choice and dosing of the prophylactic antimicrobial regimens varied widely. The two most used regimens were combined teicoplanin and gentamicin, and cefuroxime followed by two or three doses of cefuroxime eight-hourly, recommended by 24 centres (22.02%) each. The alternative choice and dosing of the prophylactic antimicrobial regimen also varied widely across the 83 centres with data available. Prophylaxis regimens across some centres fail to cover the likeliest causes of surgical site infection (SSI). Five centres (4.59%) recommend co-amoxiclav, which confers no Staphylococcus coverage, while 33 centres (30.28%) recommend cefuroxime, which confers no Enterococcus coverage. Limited adherence to 2018 Philadelphia Consensus Guidance was observed, with 67 centres (61.50%) not including a cephalosporin in their guidance.

Conclusion

This analysis of guidance on antimicrobial prophylaxis in primary arthroplasty across 109 hospitals and trusts in the UK has identified widespread variation in primary and alternative antimicrobial regimens currently recommended.

A Low Rate of Periprosthetic Infections after Aseptic Knee Prosthesis Revision Using Dual-Antibiotic-Impregnated Bone Cement

AIM

The incidence of periprosthetic joint infections (PJI) following aseptic knee revision arthroplasty lies between 3% and 7.5%. The aim of this study was to verify the hypothesis that the use of dual-antibiotic-impregnated cement in knee revision arthroplasty leads to a lower rate of periprosthetic joint infections.

METHODS

We retrospectively reviewed 403 aseptic revision knee arthroplasties performed between January 2013 and March 2021 (148 revisions of a unicompartmental prosthesis, 188 revisions of a bicondylar total knee arthroplasty (TKA), 41 revisions of an axis-guided prosthesis, and 26 revisions of only one component of a surface replacement prosthesis). The bone cement Copal G+C (Heraeus Medical, Wertheim, Germany) with two antibiotics-gentamycin and clindamycin-was used for the fixation of the new implant. The follow-up period was 53.4 ± 27.9 (4.0-115.0) months.

RESULTS

Five patients suffered from PJI within follow-up (1.2%). The revision rate for any reason was 8.7%. Survival for any reason was significantly different between the types of revision (p = 0.026, Log-Rank-test), with lower survival rates after more complex surgical procedures. The 5-year survival rate with regard to revision for any reason was 91.3% [88.2-94.4%] and with regard to revision for PJI 98.2% [98.7-99.9%], respectively.

CONCLUSION

The use of the dual-antibiotic-impregnated bone cement Copal G+C results in a lower rate of periprosthetic infections after aseptic knee prosthesis replacement than that reported in published prosthesis revisions using only one antibiotic in the bone cement.

Bacterial Contamination in Total Joint Replacement: Should We Change into a New Set of Clean Scrub Suits Whenever Entering the Operating Room?

BACKGROUND

The aims of this study are as follows: (1) to investigate the level and probability of bacterial contamination on scrub suits over time for medical personnel working inside and/or outside the operating room (OR) area; (2) to discuss the protective role of cover gowns against bacterial contamination; and (3) to consider the necessity of changing into clean suits whenever entering the OR in terms of preventing periprosthetic joint infection (PJI) in total joint replacement (TJR).

METHODS

The bacterial colony count was examined on the chest area of the scrub suits worn during various daily clinical practices. The genus/species of the contaminants were identified by matrix-assisted laser deposition ionization-time of flight mass spectrometry (MALDI-TOF MS).

RESULTS

The scrub suits worn outside the OR area showed a greater level of bacterial contamination than those worn inside the OR area, although the colony counts tended to increase over time both in and out of the area. The probability of contamination involving coagulase-negative staphylococci (CNS) (known as the primary cause of PJI) did not increase significantly in the scrubs worn inside the OR area, but did increase significantly after a long-time departure from the OR area.

CONCLUSIONS

Our results suggest that wearing scrub suits outside and/or the long duration of wearing the same suits can significantly increase the level and probability of any bacterial contamination (including CNS) on scrub suits. We also found that wearing a cover gown over scrub suits outside the OR area may have only a limited protective role against bacterial contamination.

Does addition of gentamicin for antibiotic prophylaxis in total knee arthroplasty reduce the rate of periprosthetic joint infection?

BACKGROUND

First-generation cephalosporins are used as antibiotic prophylaxis in total joint arthroplasty patients. However, this regimen does not address Gram-negative bacteria causing periprosthetic joint infection (PJI). Previous studies have suggested that the addition of an aminoglycoside as antibiotic prophylaxis in THA reduces surgical site infection (SSI), and less is known on its effect in TKA. This study aimed to investigate if the addition of a single-dose gentamicin, administered pre-operatively, is associated with lower rates of infection in TKA patients.

PATIENTS AND METHODS

This is a retrospective study of patients who underwent primary TKA as treatment for osteoarthritis between January 2011 and April 2021, with a minimum 1-year follow-up. The mean age was 69.9 (± 9.8), the mean BMI was 29.7 (± 5.5), and most patients had American Society of Anaesthesiology (ASA) score of 2-3 (92.9%). Patients were stratified based on the peri-operative antibiotic prophylaxis they received: cefazolin with addition of gentamicin (case group) or cefazolin (control group). Our primary study endpoints were rates of PJI and SSI, which were compared between groups using the chi-square test. Statistical significance was set as p < 0.05.

RESULTS

The final study population consisted of 1590 patients, 1008 (63.4%) in the control group and 582 (36.6%) patients in the case group. The total infection rate for patients that received gentamicin dropped by 34%; however, this finding did not reach statistical significance (1.3% (control) vs. 0.86% (case), p = 0.43). The same drop was seen after subdivision of infections to PJI (0.5% vs. 0.34%, 32% drop, p = 0.66) and SSI (0.8% vs. 0.52%, 35% drop, p = 0.52).

CONCLUSIONS

A single dose of gentamicin administered pre-operatively to a standard antibiotic prophylaxis was not associated with a statistically significant lower rate of PJI. Although the difference in infection rate did not reach statistical significance, the current study noted a drop in the rate of infection by 1/3 in the gentamicin cohort. Further investigation to evaluate the potential benefit of adding gentamicin to a peri-operative antibiotic regimen is warranted.

Quantifying the primary and secondary effects of antimicrobial resistance on surgery patients: Methods and data sources for empirical estimation in England

Antimicrobial resistance (AMR) may negatively impact surgery patients through reducing the efficacy of treatment of surgical site infections, also known as the "primary effects" of AMR. Previous estimates of the burden of AMR have largely ignored the potential "secondary effects," such as changes in surgical care pathways due to AMR, such as different infection prevention procedures or reduced access to surgical procedures altogether, with literature providing limited quantifications of this potential burden. Former conceptual models and approaches for quantifying such impacts are available, though they are often high-level and difficult to utilize in practice. We therefore expand on this earlier work to incorporate heterogeneity in antimicrobial usage, AMR, and causative organisms, providing a detailed decision-tree-Markov-hybrid conceptual model to estimate the burden of AMR on surgery patients. We collate available data sources in England and describe how routinely collected data could be used to parameterise such a model, providing a useful repository of data systems for future health economic evaluations. The wealth of national-level data available for England provides a case study in describing how current surveillance and administrative data capture systems could be used in the estimation of transition probability and cost parameters. However, it is recommended that such data are utilized in combination with expert opinion (for scope and scenario definitions) to robustly estimate both the primary and secondary effects of AMR over time. Though we focus on England, this discussion is useful in other settings with established and/or developing infectious diseases surveillance systems that feed into AMR National Action Plans.

Quantifying the primary and secondary effects of antimicrobial resistance on surgery patients: Methods and data sources for empirical estimation in England

Antimicrobial resistance (AMR) may negatively impact surgery patients through reducing the efficacy of treatment of surgical site infections, also known as the “primary effects” of AMR. Previous estimates of the burden of AMR have largely ignored the potential “secondary effects,” such as changes in surgical care pathways due to AMR, such as different infection prevention procedures or reduced access to surgical procedures altogether, with literature providing limited quantifications of this potential burden. Former conceptual models and approaches for quantifying such impacts are available, though they are often high-level and difficult to utilize in practice. We therefore expand on this earlier work to incorporate heterogeneity in antimicrobial usage, AMR, and causative organisms, providing a detailed decision-tree-Markov-hybrid conceptual model to estimate the burden of AMR on surgery patients. We collate available data sources in England and describe how routinely collected data could be used to parameterise such a model, providing a useful repository of data systems for future health economic evaluations. The wealth of national-level data available for England provides a case study in describing how current surveillance and administrative data capture systems could be used in the estimation of transition probability and cost parameters. However, it is recommended that such data are utilized in combination with expert opinion (for scope and scenario definitions) to robustly estimate both the primary and secondary effects of AMR over time. Though we focus on England, this discussion is useful in other settings with established and/or developing infectious diseases surveillance systems that feed into AMR National Action Plans.

Significant Difference in Antimicrobial Resistance of Coagulase Negative Periprosthetic Joint Infection in Septic Revision Total Knee Arthroplasty Between Two Major Orthopedic Centers

BACKGROUND

Antimicrobial resistance is recognized as a major public health threat. It occurs naturally; however, an excessive antibiotic use and misuse of antibiotics accelerate the process. Periprosthetic joint infections (PJI) are becoming harder to treat as the efficacy of antibiotics is becoming lower. The aim of this study was to compare the resistance of coagulase-negative staphylococci (CNS) to antibiotics identified after revision TKAs for PJI between two major orthopedic centers.

METHODS

A review of all revision TKAs, undertaken between 2006 and 2018 in two orthopedic centers, was performed, including all those meeting the consensus criteria for PJI, in which CNS were identified. There were no major differences in surgical approach and tissue sampling between both centers. Thirteen commonly used antibiotics were tested at both centers.

RESULTS

The 132 strains were analyzed for their resistance to 13 different antibiotics. Staphylococcus epidermidis was identified in 70.5% cultures, followed by Staphylococcus capitis in 8.3% cultures. The comparison of antibiotic resistance between two centers was statistically significant to penicillin (P = .001), oxacillin (P = .011), cefuroxime (P = .044), levofloxacin (P = .006), moxifloxacin (P = .008), tetracycline (P < .001), rifampicin (P < .001) and vancomycin (P < .001). The difference of resistance of CNS was not statistically significant to fosfomycin, clindamycin, teicoplanin, erythromycin and ampicillin.

CONCLUSIONS

The resistance of CNS to antibiotics differs significantly between two major orthopedic centers that are geographically fairly close. Monitoring of bacteriological analyses in each referral center should be continuously performed. Close monitoring is needed for more efficient antibiotic treatment of and prophylaxis against PJI.

Antibiotic Combination Therapy: A Strategy to Overcome Bacterial Resistance to Aminoglycoside Antibiotics

After the first aminoglycoside antibiotic streptomycin being applied in clinical practice in the mid-1940s, aminoglycoside antibiotics (AGAs) are widely used to treat clinical bacterial infections and bacterial resistance to AGAs is increasing. The bacterial resistance to AGAs is owed to aminoglycoside modifying enzyme modification, active efflux pump gene overexpression and 16S rRNA ribosomal subunit methylation, leading to modification of AGAs' structures and decreased concentration of drugs within bacteria. As AGAs's side effects and bacterial resistance, the development of AGAs is time-consuming and difficult. Because bacterial resistance may occur in a short time after application in clinical practice, it was found that the antibacterial effect of the combination was not only better than that of AGAs alone but also reduce the dosage of antibiotics, thereby reducing the occurrence of side effects. This article reviews the clinical use of AGAs, the antibacterial mechanisms, the molecular mechanisms of bacterial resistance, and especially focuses a recent development of the combination of AGAs with other drugs to exert a synergistic antibacterial effect to provide a new strategy to overcome bacterial resistance to AGAs.

Significant Difference in Antimicrobial Resistance of Bacteria in Septic Revision between Total Knee Arthroplasty and Total Hip Arthroplasty

Antimicrobial resistance (AMR) aggravates the already difficult treatment of periprosthetic joint infections (PJI). Due to many factors influencing AMR, the correct choice of antimicrobial management remains arguable. The primary purpose of this retrospective study was to identify and compare bacteria and their antibiotic resistance profile between septic revision total knee arthroplasty (TKA) and septic revision total hip arthroplasty (THA). A review of all revision TKAs and revision THAs, undertaken between 2007 and 2020 in a tertiary referral hospital, was performed. Included were cases meeting the consensus criteria for PJI, in which an organism has been identified. There were no major differences in tissue sampling between revision TKAs and revision THAs over time. A total of 228 bacterial strains, isolated after revision TKA and THA, were analysed for their resistance to 20 different antibiotics. There was a statistically significant higher occurrence of Gram-negative bacteria identified after revision THAs compared to TKA (p = 0.002). The comparison of antibiotic resistance between revision TKAs and revision THAs was statistically significant in 9 of 20 analysed antibiotics. This has implications for the choice of empirical antibiotic in revision surgery as well as prophylactic antibiotic in primary surgery, depending on the joint that is to be replaced.

Non-compliance with clinical guidelines increases the risk of complications after primary total hip and knee joint replacement surgery

BACKGROUND

Total hip and total knee replacement (THR/TKR) are common and effective surgeries to reduce the pain and disability associated with arthritis but are associated with small but significant risks of preventable complications such as surgical site infection (SSI) and venous-thrombo-embolism (VTE). This study aims to determine the degree to which hospital care was compliant with clinical guidelines for the prevention of SSI and VTE after THR/TKR; and whether non-compliant prophylaxis is associated with increased risk of complications.

METHODS AND FINDINGS

A prospective multi-centre cohort study was undertaken in consenting adults with osteoarthritis undergoing elective primary TKR/THR at one of 19 high-volume Australian public or private hospitals. Data were collected prior to surgery and for one-year post-surgery. Four adjusted logistic regression analyses were undertaken to explore associations between binary non-compliance and the risk of surgical complications: (1) composite (simultaneous) non-compliance with both (VTE and antibiotic) guidelines and composite complications [all-cause mortality, VTE, readmission/reoperation for joint-related reasons (one-year) and non-joint-related reasons (35-days)], (2) VTE non-compliance and VTE outcomes, (3) antibiotic non-compliance and any SSI, and (4) antibiotic non-compliance and deep SSI. Data were analysed for 1875 participants. Guideline non-compliance rates were high: 65% (VTE), 87% (antibiotics) and 95% (composite guideline). Composite non-compliance was not associated with composite complication (12.8% vs 8.3%, adjusted odds ratio [AOR] = 1.41, 95%CI 0.68-3.45, p = 0.40). Non-compliance with VTE guidelines was associated with VTE outcomes (5% vs 2.4%, AOR = 2.83, 95%CI 1.59-5.28,p < 0.001). Non-compliance with antibiotic guidelines was associated with any SSI (14.8% vs 6.1%, AOR = 1.98, 95%CI 1.17-3.62,p = 0.02) but not deep infection (3.7% vs 1.2%,AOR = 2.39, 95%CI 0.85-10.00, p = 0.15).

CONCLUSIONS

We found high rates of clinical variation and statistically significant associations between non-compliance with VTE and antibiotic guidelines and increased risk of VTE and SSI, respectively. Complications after THR/TKR surgery may be decreased by improving compliance with clinical guidelines.

Development of antibiotic resistance in periprosthetic joint infection after total knee arthroplasty

AIMS

The management of periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is challenging. The correct antibiotic management remains elusive due to differences in epidemiology and resistance between countries, and reports in the literature. Before the efficacy of surgical treatment is investigated, it is crucial to analyze the bacterial strains causing PJI, especially for patients in whom no organisms are grown.

METHODS

A review of all revision TKAs which were undertaken between 2006 and 2018 in a tertiary referral centre was performed, including all those meeting the consensus criteria for PJI, in which organisms were identified. Using a cluster analysis, three chronological time periods were created. We then evaluated the antibiotic resistance of the identified bacteria between these three clusters and the effectiveness of our antibiotic regime.

RESULTS

We identified 129 PJIs with 161 culture identified bacteria in 97 patients. Coagulase-negative staphylococci (CNS) were identified in 46.6% cultures, followed by Staphylococcus aureus in 19.8%. The overall resistance to antibiotics did not increase significantly during the study period (p = 0.454). However, CNS resistance to teicoplanin (p < 0.001), fosfomycin (p = 0.016), and tetracycline (p = 0.014) increased significantly. Vancomycin had an 84.4% overall sensitivity and 100% CNS sensitivity and was the most effective agent.

CONCLUSION

Although we were unable to show an overall increase in antibiotic resistance in organisms that cause PJI after TKA during the study period, this was not true for CNS. It is concerning that resistance of CNS to new antibiotics, but not vancomycin, has increased in a little more than a decade. Our findings suggest that referral centres should continuously monitor their bacteriological analyses, as these have significant implications for prophylactic treatment in both primary arthroplasty and revision arthroplasty for PJI. Cite this article: Bone Joint J 2021;103-B(6 Supple A):171-176.

Intraosseous Regional Administration of Vancomycin in Primary Total Knee Arthroplasty Does Not Increase the Risk of Vancomycin-Associated Complications

BACKGROUND

Periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is a rare but major complication. Owing to an increasing antibiotic resistance in bacteria causing PJI, vancomycin has been investigated as a prophylactic agent. Intraosseous regional administration (IORA) of vancomycin achieves significantly higher local tissue concentrations than systemic administration. There are limited data on IORA of vancomycin with respect to vancomycin-associated complications.

METHODS

Single-surgeon retrospective review of primary TKA was performed between January 2015 and May 2019. All patients received 500 mg of IORA of vancomycin after tourniquet inflation and 3 × 1 g intravenous cefazolin in 24 hrs. Preoperative data collected included age, gender, body mass index, American Society of Anesthesiologists (ASA) score, diabetes, and chronic kidney disease (CKD). We documented in-hospital complications and complications requiring readmission within 12 months. Primary outcome measures were the incidence of acute kidney injury (AKI), 'red man syndrome' (RMS), and neutropenia. The secondary outcome measure was PJI incidence.

RESULTS

We identified 631 primary TKAs in 556 patients, of which 331 received IORA. The mean age was 67.7 ± 8.7 years, and 57.8% were women. CKD was prevalent in 17.2% of the cohort. AKI occurred in 25 (3.9%) cases. After controlling for covariates, CKD was the only significant predictor of AKI (odds ratio = 3.035, P = .023). RMS and neutropenia were not observed in this cohort. The 90-day PJI rate was 0%, and the 1-year PJI rate was 0.2%.

CONCLUSIONS

Low-dose IORA of vancomycin in addition to standard intravenous systemic cefazolin prophylaxis in TKA is safe without significant adverse effects of vancomycin such as AKI, RMS, or neutropenia.

Dual antibiotic loaded bone cement in patients at high infection risks in arthroplasty: Rationale of use for prophylaxis and scientific evidence

In view of the demographic changes and projected increase of arthroplasty procedures worldwide, the number of prosthetic joint infection cases will naturally grow. Therefore, in order to counteract this trend more rigid rules and a stricter implementation of effective preventive strategies is of highest importance. In the absence of a “miracle weapon” priorities should lie in evidence-based measures including preoperative optimization of patients at higher infection risks, the fulfilment of strict hygiene rules in the operating theatre and an effective antibiotic prophylaxis regimen. Instead of a “one size fits all” philosophy, it has been proposed to adjust the antibiotic prophylaxis protocol to major infection risks taking into account important patient- and procedure-related risk factors. A stronger focus on the local application mode via use of high dose dual antibiotic-loaded bone cement in such risk situations may have its advantages and is easy to apply in the theatre. The more potent antimicrobial growth inhibition in vitro and the strong reduction of the prosthetic joint infection rate in risk for infection patients with aid of dual antibiotic-loaded bone cement in clinical studies align with this hypothesis.

Is Preoperative Identification of the Infecting Organism Essential Before Single-Stage Revision Hip Arthroplasty for Periprosthetic Infection?

BACKGROUND

It is commonly stated that identification of the infecting organism is a prerequisite to single-stage revision arthroplasty of the hip for deep infection. We have performed single-stage revision in a series of patients where the organism was not identified preoperatively. The aim of this study is to investigate whether the rate of infection eradication following single-stage revision was affected by preoperative knowledge of the infecting organism.

METHODS

We identified all patients who had undergone a single-stage revision for a deep infection at our hospital between 2006 and 2015. One hundred five patients were assigned into 2 groups based upon whether the infecting organism had been identified preoperatively (group A = 28) or not (group B = 77).

RESULTS

The reinfection rates were 3.6% in group A and 9.1% for group B (P = .679). Re-revision rates were 7.1% and 9.1%, respectively (P = 1.00). Overall, the implant survival rate at 6 years was 87.9% (95% confidence interval, 97.4-78.4). In group B, preoperative aspiration was performed in 36.4% (28/77) of cases. Staphylococci species were the predominant causative organisms, with gram-negative involvement in 19.0% (20/105) of cases.

CONCLUSION

The rate of infection eradication and overall survivorship with single-stage revision was similar in our series to that reported in the literature. While desirable, we did not find identification of the infecting organism before surgery influenced the outcome. Given the functional and economic benefits of single-stage revision, we suggest that failure to identify an organism is not an absolute contraindication to this approach.

Trends and patterns of antibiotic prescribing at orthopedic inpatient departments of two private-sector hospitals in Central India: A 10-year observational study

Background

Frequent antibiotic prescribing in departments with high infection risk like orthopedics prominently contributes to the global increase of antibiotic resistance. However, few studies present antibiotic prescribing patterns and trends among orthopedic inpatients.

Aim

To compare and present the patterns and trends of antibiotic prescription over 10 years for orthopedic inpatients in a teaching (TH) and a non-teaching hospital (NTH) in Central India.

Methods

Data from orthopedic inpatients (TH-6446; NTH-4397) were collected using a prospective cross-sectional study design. Patterns were compared based on the indications and corresponding antibiotic treatments, mean Defined Daily Doses (DDD)/1000 patient-days, adherence to the National List of Essential Medicines India (NLEMI) and the World Health Organization Model List of Essential Medicines (WHOMLEM). Antibiotic prescriptions were analyzed separately for the operated and the non-operated inpatients. Linear regression was used to analyze the time trends of antibiotic prescribing; in total through DDD/1000 patient-days and by antibiotic groups.

Results

Third generation cephalosporins were the most prescribed antibiotic class (TH-39%; NTH-65%) and fractures were the most common indications (TH-48%; NTH-48%). Majority of the operated inpatients (TH-99%; NTH-97%) were prescribed pre-operative prophylactic antibiotics. The non-operated inpatients were also prescribed antibiotics (TH-40%; NTH-75%), although few of them had infectious diagnoses (TH-8%; NTH-14%). Adherence to the NLEMI was lower (TH-31%; NTH-34%) than adherence to the WHOMLEM (TH-65%; NTH-62%) in both hospitals. Mean DDD/1000 patient-days was 16 times higher in the TH (2658) compared to the NTH (162). Total antibiotic prescribing increased over 10 years (TH-β = 3.23; NTH-β = 1.02).

Conclusion

Substantial number of inpatients were prescribed antibiotics without clear infectious indications. Adherence to the NLEMI and the WHOMLEM was low in both hospitals. Antibiotic use increased in both hospitals over 10 years and was higher in the TH than in the NTH. The need for developing and implementing local antibiotic prescribing guidelines is emphasized.

Similar risk of complete revision for infection with single-dose versus multiple-dose antibiotic prophylaxis in primary arthroplasty of the hip and knee: results of an observational cohort study in the Dutch Arthroplasty Register in 242,179 patients

Background and purpose - The optimal type and duration of antibiotic prophylaxis for primary arthroplasty of the hip and knee are subject to debate. We compared the risk of complete revision (obtained by a 1- or 2-stage procedure) for periprosthetic joint infection (PJI) after primary total hip or knee arthroplasty between patients receiving a single dose of prophylactic antibiotics and patients receiving multiple doses of antibiotics for prevention of PJI. Patients and methods - A cohort of 130,712 primary total hip and 111,467 knee arthroplasties performed between 2011 and 2015 in the Netherlands was analyzed. We linked data from the Dutch arthroplasty register to a survey collected across all Dutch institutions on hospital-level antibiotic prophylaxis policy. We used restricted cubic spline Poisson models adjusted for hospital clustering to compare the risk of revision for infection according to type and duration of antibiotic prophylaxis received. Results - For total hip arthroplasties, the rates of revision for infection were 31/10,000 person-years (95% CI 28-35), 39 (25-59), and 23 (15-34) in the groups that received multiple doses of cefazolin, multiple doses of cefuroxime, and a single dose of cefazolin, respectively. The rates for knee arthroplasties were 27/10,000 person-years (95% CI 24-31), 40 (24-62), and 24 (16-36). Similar risk of complete revision for infection among antibiotic prophylaxis regimens was found when adjusting for confounders. Interpretation - In a large observational cohort we found no apparent association between the type or duration of antibiotic prophylaxis and the risk of complete revision for infection. This does question whether there is any advantage to the use of prolonged antibiotic prophylaxis beyond a single dose.

Bacterial adhesion on orthopedic implants

Orthopedic implants are routinely used for fixation of fractures, correction of deformities, joint replacements, and soft tissue anchorage. Different biomaterials have been engineered for orthopedic implants. Previously, they were designed merely as mechanical devices, now new strategies to enhance bone healing and implant osteointegration via local delivery of molecules and via implant coatings are being developed. These biological coatings should enhance osteointegration and reduce foreign body response or infection. This article reviews current and future orthopedic implants, materials and surface characteristics, biocompatibility, and mechanisms of bacterial adhesion. Additionally, the review is addressing implant-related infection, the main strategies to prevent it and suggest possible future research that may control implant related-infection.

Antibiotics and cement: what I need to know?

We conducted a systematic review about antibiotic-loaded bone cement (ALBC) with a focus on clinical evidence about ALBC in general, concerns about ALBC and ALBC cost.

Synergistic antibacterial effects of analgesics and antibiotics against Staphylococcus aureus

The local use of analgesics and antibiotics is common during the treatment of periprosthetic joint infection (PJI). The effect of nonantimicrobial drugs on antibacterial activity is underappreciated in clinical practice. This study focuses on the novel assessment of the combined antibacterial effects of commonly used analgesics and antibiotics against methicillin-sensitive Staphylococcus aureus (MSSA)-pathogen associated with most PJIs. We identified that bupivacaine/lidocaine and ketorolac/gentamicin combinations yielded fractional inhibitory concentration indices below 0.4, indicative of synergistic antibacterial effect. Time-kill curves were used for in-depth characterization of the synergy, and the obtained results demonstrated pronounced synergistic effects of bupivacaine/lidocaine and ketorolac/gentamicin combinations against MSSA.

2018 International Consensus Meeting on Musculoskeletal Infection: Research Priorities from the General Assembly Questions

Musculoskeletal infections (MSKI) remain the bane of orthopedic surgery, and result in grievous illness and inordinate costs that threaten healthcare systems. As prevention, diagnosis, and treatment has remained largely unchanged over the last 50 years, a 2nd International Consensus Meeting on Musculoskeletal Infection (ICM 2018, https://icmphilly.com) was completed. Questions pertaining to all areas of MSKI were extensively researched to prepare recommendations, which were discussed and voted on by the delegates using the Delphi methodology. The questions, including the General Assembly (GA) results, have been published (GA questions). However, as critical outcomes include: (i) incidence and cost data that substantiate the problems, and (ii) establishment of research priorities; an ICM 2018 research workgroup (RW) was assembled to accomplish these tasks. Here, we present the result of the RW consensus on the current and projected incidence of infection, and the costs per patient, for all orthopedic subspecialties, which range from 0.1% to 30%, and $17,000 to $150,000. The RW also identified the most important research questions. The Delphi methodology was utilized to initially derive four objective criteria to define a subset of the 164 GA questions that are high priority for future research. Thirty-eight questions (23% of all GA questions) achieved the requisite > 70% agreement vote, and are highlighted in this Consensus article within six thematic categories: acute versus chronic infection, host immunity, antibiotics, diagnosis, research caveats, and modifiable factors. Finally, the RW emphasizes that without appropriate funding to address these high priority research questions, a 3rd ICM on MSKI to address similar issues at greater cost is inevitable.

Improving surgical antibiotic prophylaxis adherence and reducing hospital readmissions: a bundle of interventions including health information technologies

OBJECTIVES

Infection following orthopaedic surgery is a feared complication and an indicator of the quality of the hospital. Surgical antibiotic prophylaxis (SAP) guidelines are not always properly followed. Our aim was to describe and evaluate the impact of a multidisciplinary intervention on antibiotic prophylaxis adherence to hospital guidelines and 30-day postoperative outcomes.

METHODS

The study was carried out from January to May 2016 and consisted of creating a multidisciplinary team, updating institutional guidelines and embedding the recommendations in the computerised physician order entry system which is linked to dose and renal function alerts, educational activities and pharmaceutical bedside care of patients in the orthopaedic department. A prospective pre-post study was carried out in accordance with the Declaration of Helsinki. The following information was recorded: patient and surgery characteristics, adherence to SAP guidelines, surgical site infections, length of hospital stay and rate of readmission 30 days after discharge. Statistical analyses were performed using SPSS 18.0.

RESULTS

Eighty three orthopaedic patients of mean±SD age 68.2±17.0 years (44.6% male, 40 in the pre-intervention group and 43 in the intervention group) were included. Cefazolin was the recommended and most commonly administered antibiotic agent. In the intervention group, an improvement in global adherence to guidelines was achieved (76.7% vs 89.9%; p=0.039): antibiotic duration (75.0% vs 97.7%), correct dosage post-surgery (55.0% vs 76.7%), timing of administration (57.5% vs 72.1%), antibiotic pre-surgery prescription (92.5% vs 97.7%). Three surgical site infections were detected in the pre-intervention group and none in the intervention group (p>0.05). Length of hospital stay was reduced by 1 day and readmission decreased by 15% (p=0.038).

CONCLUSIONS

SAP is used in daily practice in most orthopaedic patients. The implementation of a multidisciplinary programme based on health technology improved the adherence to guidelines and appeared to reduce the readmission rate.

One- and two-stage surgical revision of peri-prosthetic joint infection of the hip: a pooled individual participant data analysis of 44 cohort studies

One-stage and two-stage revision strategies are the two main options for treating established chronic peri-prosthetic joint infection (PJI) of the hip; however, there is uncertainty regarding which is the best treatment option. We aimed to compare the risk of re-infection between the two revision strategies using pooled individual participant data (IPD). Observational cohort studies with PJI of the hip treated exclusively by one- or two-stage revision and reporting re-infection outcomes were retrieved by searching MEDLINE, EMBASE, Web of Science, The Cochrane Library, and the WHO International Clinical Trials Registry Platform; as well as email contact with investigators. We analysed IPD of 1856 participants with PJI of the hip from 44 cohorts across four continents. The primary outcome was re-infection (recurrence of infection by the same organism(s) and/or re-infection with a new organism(s)). Hazard ratios (HRs) for re-infection were calculated using Cox proportional frailty hazards models. After a median follow-up of 3.7 years, 222 re-infections were recorded. Re-infection rates per 1000 person-years of follow-up were 16.8 (95% CI 13.6-20.7) and 32.3 (95% CI 27.3-38.3) for one-stage and two-stage strategies respectively. The age- and sex-adjusted HR of re-infection for two-stage revision was 1.70 (0.58-5.00) when compared with one-stage revision. The association remained consistently absent after further adjustment for potential confounders. The HRs did not vary importantly in clinically relevant subgroups. Analysis of pooled individual patient data suggest that a one-stage revision strategy may be as effective as a two-stage revision strategy in treating PJI of the hip.

[Local antibiotic therapy]

The treatment of superficial wound infections with local antibiotics is considered to be problematic as it is accompanied by an increased risk of resistance development and ineffectiveness in deeper regions. On the contrary, the local application of antibiotics is useful in arthroplasty and necessary if implants are utilized. The reason for this is the prevention of a rapid biofilm formation on foreign implants and a resulting infection may remain undiscovered until it becomes chronic. Apart from exogenous material, necrotic tissue (e. g. bone sequestra) provides suitable retreat areas for pathogens in the body. Because of the characteristics of bone and joint infections and an exceptional infection recurrence rate, a combined approach is required. Systemic antibiotic prophylaxis is able to reduce the number of pathogens acquired by perioperative contamination or hematogenic spread from another focus of infection; however, systemically applied antibiotics often fail to form an effective colonization barrier around the implant because their ability to penetrate the bone is relatively low. On the other hand, the high concentration of locally released antibiotics leads to an effective protection of the implant from bacteria in situ. Thus, for the treatment of implant-associated infections, systemic and local application of anti-infective agents is a reliable adjuvant measure that improves the therapeutic success. Polymethylmethacrylate (PMMA) bone cement is the most commonly used local drug carrier. Based on clinical and microbiological results, microbiologists and infectious disease experts together with the surgeon and pharmacist determine which anti-infective agents are indicated for systemic and local, PMMA cement-related application. Because there is no evident concept for the local application, unlike the recommendation for systemic use of anti-infective agents, this review article describes which aspects should be taken into account.

Assessment and management of infected total knee replacements

Infection following total knee replacement surgery is a challenging and devastating complication. Clinical assessment including history, examination, radiographs, blood tests and knee aspirations helps to establish the diagnosis. Revision surgery is typically required to eradicate infection and restore function. This has traditionally been performed through two-stage revision surgery, although single-stage revision surgery is gaining popularity with comparable results in carefully selected patients. This article reviews the clinical assessment and principles of surgical management of infected total knee replacements.

Acute Kidney Injury After Prophylactic Cefuroxime and Gentamicin in Patients Undergoing Primary Hip and Knee Arthroplasty-A Propensity Score-Matched Study

BACKGROUND

Perioperative acute kidney injury (AKI) can be associated with lower limb arthroplasty and increases morbidity, length of stay, and mortality. AKI is more prevalent in some antibiotic regimes compared with others. The aim of the present study is to assess the impact of cefuroxime (CEF), with or without gentamicin (±G), on AKI rates.

METHODS

A prospective cohort study involving patients undergoing hip or knee arthroplasty was performed, between September 1, 2015 and November 30, 2016. Prophylactic intravenous antibiotics were administered according to local policy. AKI was graded according to the validated Acute Kidney Injury Network criteria based on the changes from baseline serum creatinine values. Propensity score matching was performed to identify risk factors. The local audit department approved the study. Appropriate statistical analyses were performed.

RESULTS

A total of 2560 met the inclusion criteria, with a female preponderance (1447/2560; 56.5%). The mean age was 67.5 ± 10.7 years, with males being significantly younger (65.9 ± 10.9 vs 68.7 ± 10.4 years). AKI developed in 32 cases (1.25%). There was no difference in AKI rates between CEF alone and CEF in combination with gentamicin (1.07% vs 1.36%; P = .524). Overall 31/32 cases were Acute Kidney Injury Network stage I. AKI did not affect the length of stay. Postoperative infection rate was 7/2560 (0.27%). There were no incidences of Clostridium difficile-associated diarrhea. Multivariate analysis demonstrated an increased AKI risk with the use of intravenous gentamicin.

CONCLUSION

C ± G yields low rates of infection and AKI compared with high-dose penicillin-based regimes. It is a safe and effective choice for lower limb arthroplasty.

Use of regional administration of prophylactic antibiotics in total knee arthroplasty

Prosthetic joint infection after total knee arthroplasty is an infrequent, yet serious complication. Antimicrobial prophylaxis plays an important role in reducing the rate of surgical site infections. To be effective as an antimicrobial prophylaxis, the serum, tissue and bone concentrations of the antibiotic must be greater than the target organism's minimum inhibitory concentration. As antibiotic resistance increases current intravenous prophylactic dosing has been shown to be subtherapeutic for some patients. Intravenous regional administration and intraosseous regional administration of prophylactic antibiotics are novel methods used to increase the antibiotic tissue concentrations, which may enhance the efficacy of prophylactic antibiotics in total knee arthroplasty. Currently, literature has shown both intravenous regional administration and intraosseous regional administration to be safe and effective techniques. However, there is no clinical evidence to show that it results in a reduction of prosthetic joint infection rates. This study summarizes the current knowledge base on the use of regional administration of prophylactic antibiotics in total knee arthroplasty.

Dual-Agent Antibiotic Prophylaxis Using a Single Preoperative Vancomycin Dose Effectively Reduces Prosthetic Joint Infection Rates With Minimal Renal Toxicity Risk

BACKGROUND

We performed this study to compare prosthetic joint infection (PJI) and renal toxicity rates following hip and knee total joint arthroplasty (TJA) when a first-generation cephalosporin was administered either alone or in combination with a single preoperative vancomycin dose, whether vancomycin administration timing potentially influenced dual-antibiotic PJI prophylaxis approach effectiveness, and whether single-dose vancomycin use increased risk of renal impairment.

METHODS

This was a retrospective study of 1997 consecutive primary TJAs (1871 patients) treated with cefazolin alone (1044 TJAs) or cefazolin with single-dose vancomycin (953 TJAs). The vancomycin group included 476 TJAs (450 patients) with infusion started at least 45 minutes before the skin incision and 477 TJAs (464 patients) with infusion started less than 45 minutes before the skin incision.

RESULTS

The addition of a single dose of vancomycin did not significantly reduce PJI rates when compared with cefazolin alone (1.6% vs 2.1%, P = .32). However, the PJI rate was significantly lower following primary TJA when vancomycin administration was initiated at least 45 minutes before incision (0.2%) when compared with other TJA procedures performed using cefazolin and vancomycin (2.9%, P < .01) or cefazolin alone (2.1%, P < .01). We observed no difference in renal toxicity between treatment groups.

CONCLUSION

In our institution, the addition of vancomycin to cefazolin at least 45 minutes before incision reduced PJI infection rates in primary hip and knee TJA with a low risk of renal impairment.

Ten-Year Trends in Medical Complications Following 540,623 Primary Total Hip Replacements from a National Database

BACKGROUND

More than 75,000 total hip replacements were performed in England and Wales in 2014, and this figure is predicted to increase. Trends in mortality and complications following total hip replacement from 2005 to 2014 were evaluated to quantify risk and to identify "at-risk" groups to better inform recommendations for patient care.

METHODS

Our primary analysis estimated 90-day inpatient mortality following total hip replacement using Hospital Episode Statistics data from 2005 to 2014. Secondary analyses explored 30-day rates of lower respiratory tract infection, renal failure, myocardial infarction, pulmonary embolism, deep-vein thrombosis, cerebrovascular accident, and Clostridium difficile. Hierarchical logistic regression was used to estimate population averages, adjusting for time and prognostic covariates.

RESULTS

From January 2005 to July 2014, a total of 540,623 total hip replacements were reported. The 90-day mortality rate dropped steadily, from 0.60% in 2005 to 0.15% in 2014. Reported postoperative complications (with the exception of lower respiratory tract infection and renal failure) reduced year-on-year, despite a steady rise in the average Charlson Comorbidity Index score. The 30-day rate of lower respiratory tract infection and renal failure increased from 0.54% to 0.84% and 0.21% to 1.09%, respectively. The risk of mortality was significantly higher for those who developed a lower respiratory tract infection (odds ratio [OR] = 42.3) or renal failure (OR = 36.5) than for those who developed pulmonary embolism (OR = 10.9) or deep-vein thrombosis (OR = 2.6).

CONCLUSIONS

Despite a population with increasing levels of comorbidity, indicators of quality of care improved from 2005 to 2014, with the exception of the rates of lower respiratory tract infection and renal failure. Postoperative care should focus on reducing the risk of lower respiratory tract infection and renal failure, both of which increased and were strongly associated with mortality. Moreover, they appeared to occur in identifiable high-risk groups; modifications to routine care should be considered for these patients.

LEVEL OF EVIDENCE

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

A cost-effectiveness modelling study of strategies to reduce risk of infection following primary hip replacement based on a systematic review

BACKGROUND

A deep infection of the surgical site is reported in 0.7% of all cases of total hip arthroplasty (THA). This often leads to revision surgery that is invasive, painful and costly. A range of strategies is employed in NHS hospitals to reduce risk, yet no economic analysis has been undertaken to compare the value for money of competing prevention strategies.

OBJECTIVES

To compare the costs and health benefits of strategies that reduce the risk of deep infection following THA in NHS hospitals. To make recommendations to decision-makers about the cost-effectiveness of the alternatives.

DESIGN

The study comprised a systematic review and cost-effectiveness decision analysis.

SETTING

77,321 patients who had a primary hip arthroplasty in NHS hospitals in 2012.

INTERVENTIONS

Nine different treatment strategies including antibiotic prophylaxis, antibiotic-impregnated cement and ventilation systems used in the operating theatre.

MAIN OUTCOME MEASURES

Change in the number of deep infections, change in the total costs and change in the total health benefits in quality-adjusted life-years (QALYs).

DATA SOURCES

Literature searches using MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Central Register of Controlled Trials were undertaken to cover the period 1966-2012 to identify infection prevention strategies. Relevant journals, conference proceedings and bibliographies of retrieved papers were hand-searched. Orthopaedic surgeons and infection prevention experts were also consulted.

REVIEW METHODS

English-language papers only. The selection of evidence was by two independent reviewers. Studies were included if they were interventions that reported THA-related deep surgical site infection (SSI) as an outcome. Mixed-treatment comparisons were made to produce estimates of the relative effects of competing infection control strategies.

RESULTS

Twelve studies, six randomised controlled trials and six observational studies, involving 123,788 total hip replacements (THRs) and nine infection control strategies, were identified. The quality of the evidence was judged against four categories developed by the National Institute for Health and Care Excellence Methods for Development of NICE Public Health Guidance ( http://publications.nice.org.uk/methods-for-the-development-of-nice-public-health-guidance-third-edition-pmg4 ), accessed March 2012. All evidence was found to fit the two highest categories of 1 and 2. Nine competing infection control interventions [treatments (Ts) 1-9] were used in a cohort simulation model of 77,321 patients who had a primary THR in 2012. Predictions were made for cases of deep infection and total costs, and QALY outcomes. Compared with a baseline of T1 (no systemic antibiotics, plain cement and conventional ventilation) all other treatment strategies reduced risk. T6 was the most effective (systemic antibiotics, antibiotic-impregnated cement and conventional ventilation) and prevented a further 1481 cases of deep infection, and led to the largest annual cost savings and the greatest gains to QALYs. The additional uses of laminar airflow and body exhaust suits indicate higher costs and worse health outcomes.

CONCLUSIONS

T6 is an optimal strategy for reducing the risk of SSI following THA. The other strategies that are commonly used among NHS hospitals lead to higher cost and worse QALY outcomes. Policy-makers, therefore, have an opportunity to save resources and improve health outcomes. The effects of laminar air flow and body exhaust suits might be further studied if policy-makers are to consider disinvesting in these technologies.

LIMITATIONS

A wide range of evidence sources was synthesised and there is large uncertainty in the conclusions.

FUNDING

The National Institute for Health Research Health Technology Assessment programme and the Queensland Health Quality Improvement and Enhancement Programme (grant number 2008001769).

The association between cement type and the subsequent risk of revision surgery in primary total hip replacement

Background and purpose - To further improve the success of joint replacement surgery, attention needs to be paid to variations associated with improved or worsened outcomes. We investigated the association between the type of bone cement used and the risk of revision surgery after primary total hip replacement. Methods - We conducted a prospective study of data from the National Joint Registry for England and Wales between April 1, 2003 and December 31, 2013. 199,205 primary total hip replacements performed for osteoarthritis where bone cement was used were included. A multilevel over-dispersed piecewise Poisson model was used to estimate differences in the rate of revision by bone cement type adjusted for implant type, head size, age, sex, ASA grade, and surgical approach. Results - The rate of revision was higher in DePuy CMW3 medium viscosity with gentamicin (IRR 2.0, 95% CI 1.5-2.7) and DePuy SmartSet high viscosity plain (IRR 2.7, 95% CI 1.1-5.5), and lower in DePuy CMW1 high viscosity plain (IRR 0.44, 95% CI 0.19-0.89) bone cements compared with Heraeus Palacos high viscosity with gentamicin. Revision rates were similar between plain and antibiotic-loaded bone cement. Interpretation - The majority of bone cements performed similarly well, excluding DePuy SmartSet high viscosity and CMW3 high viscosity with gentamicin, which both had higher revision rates. We found no clear differences by viscosity or antibiotic content.

Antibiotic Prophylaxis and DAIR Treatment in Primary Total Hip and Knee Arthroplasty, A National Survey in The Netherlands

BACKGROUND

To prevent postoperative infection the use of systemic antibiotic prophylaxis is common ground. Type of antibiotic used and duration of prophylaxis are subject to debate. In case of suspected early periprosthetic infection a debridement, antibiotics and implant retention (DAIR) procedure is treatment of first choice. This study evaluated the antibiotic prophylaxis and DAIR treatment protocols nationwide as well as reporting of these DAIR procedures to the national joint registry.

METHODS

All institutions that performed total hip or knee arthroplasty were contacted to complete a 16-question online survey. Questions included availability of a protocol, type and duration of antibiotic prophylaxis used and tendency to register infectious complications in the Dutch Arthroplasty Register.

RESULTS

All ninety-nine consulted institutions responded to this survey. All but one institutions have a standardized hospital based protocol for antibiotic prophylaxis in primary total hip or knee arthroplasty. Cefazolin was antibiotic prophylaxis of choice in ninety-four institutions for both primary hip and knee arthroplasty. In ten institutions one preoperative gift of antibiotic prophylaxis was administered. A protocol describing treatment when suspecting early periprosthetic joint infection was present in seventy-one institutions. When performing a DAIR procedure modular parts were exchanged in seventy institutions in case of a hip prosthesis and in eighty-one institutions in case of a knee prosthesis. Sixty-three institutions register DAIR procedures in the Dutch Arthroplasty Register.

INTERPRETATION

In contradiction to the results of a recent study in Great Britain, we have found only little variety in availability of protocols and in the type of antibiotic used as prophylaxis in primary total hip and knee arthroplasty in The Netherlands. Not every institution has a protocol for treatment in suspicion of early infection. Although mobile parts are exchanged in the majority of cases, there appears to be an underreporting of DAIR procedures in the Dutch Arthroplasty Register.

Higher risk of revision for infection using systemic clindamycin prophylaxis than with cloxacillin

Background and purpose - Clindamycin has not been compared with other antibiotics for prophylaxis in arthroplasty. Since 2009, the Swedish Knee Arthroplasty Register (SKAR) has been collecting information on the prophylactic antibiotic regime used at every individual operation. In Sweden, when there is allergy to penicillin, clindamycin has been the recommended alternative. We examined whether there were differences in the rate of revision due to infection depending on which antibiotic was used as systemic prophylaxis. Patients and methods - Patients who had a total knee arthroplasty (TKA) performed due to osteoarthritis (OA) during the years 2009-2015 were included in the study. Information on which antibiotic was used was available for 80,018 operations (55,530 patients). Survival statistics were used to calculate the rate of revision due to infection until the end of 2015, comparing the group of patients who received cloxacillin with those who received clindamycin as systemic prophylaxis. Results - Cloxacillin was used in 90% of the cases, clindamycin in 7%, and cephalosporins in 2%. The risk of being revised due to infection was higher when clindamycin was used than when cloxacillin was used (RR =1.5, 95% CI: 1.2-2.0; p = 0.001). There was no significant difference in the revision rate for other causes (p = 0.2). Interpretation - We advise that patients reporting allergic reaction to penicillin should have their allergic history explored. In the absence of a clear history of type-I allergic reaction (e.g. urticaria, anaphylaxis, or bronchospasm), we suggest the use of a third-generation cephalosporin instead of clindamycin as perioperative prophylaxis when undergoing a TKR. No recommendation can be given regarding patients with type-1 allergy.

Prevention of periprosthetic joint infection: new guidelines

The World Health Organization (WHO) and the Centre for Disease Control and Prevention (CDC) recently published guidelines for the prevention of surgical site infection. The WHO guidelines, if implemented worldwide, could have an immense impact on our practices and those of the CDC have implications for healthcare policy in the United States. Our aim was to review the strategies for prevention of periprosthetic joint infection in light of these and other recent guidelines. Cite this article: Bone Joint J 2017;99-B(4 Supple B):3-10.

Impact of national policies on the microbial aetiology of surgical site infections in acute NHS hospitals in England: analysis of trends between 2000 and 2013 using multi-centre prospective cohort data

Our study aimed to evaluate changes in the epidemiology of pathogens causing surgical site infections (SSIs) in England between 2000 and 2013 in the context of intensified national interventions to reduce healthcare-associated infections introduced since 2006. National prospective surveillance data on target surgical procedures were used for this study. Data on causative organism were available for 72% of inpatient-detected SSIs meeting the standard case definitions for superficial, deep and organ-space infections (9767/13 531) which were analysed for trends. A multivariable logistic linear mixed model with hospital random effects was fitted to evaluate trends by pathogen. Staphylococcus aureus was the predominant cause of SSI between 2000 (41%) and 2009 (24%), decreasing from 2006 onwards reaching 16% in 2013. Data for 2005-2013 showed that the odds of SSI caused by S. aureus decreased significantly by 14% per year [adjusted odds ratio (aOR) 0·86, 95% confidence interval (CI) 0·83-0·89] driven by significant decreases in methicillin-resistant S. aureus (MRSA) (aOR 0·71, 95% CI 0·68-0·75). However a small significant increase in methicillin-sensitive S. aureus was identified (aOR 1·06, 95% CI 1·02-1·10). Enterobacteriaceae were stable during 2000-2007 (12% of cases overall), increasing from 2008 (18%) onwards, being present in 25% of cases in 2013; the model supported these increasing trends during 2007-2013 (aOR 1·12, 95% CI 1·07-1·18). The decreasing trends in S. aureus SSIs from 2006 and the increases in Enterobacteriaceae SSIs from 2008 may be related to intensified national efforts targeted at reducing MRSA bacteraemia combined with changes in antibiotic use aimed at controlling C. difficile infections.