Antibiotic stewardship in orthopaedic surgery: principles and practice

Local vancomycin administration in Orthopaedic Surgery - A systematic review of comparative studies

Background

There is still controversy surrounding the routine use of vancomycin locally in primary orthopaedic surgery procedures. Therefore, the aim of this review is to assess how local vancomycin impacts the rates and microbiology of surgical site infections.

Methods

A systematic electronic search of MEDLINE, EMBASE, and Web of Science was carried out for all comparative studies comparing locally applied vancomycin to control for primary orthopaedic surgery procedures published before August 14, 2022.

Results

A total of 61 studies with 65,671 patients were included for analysis. Forty-six studies used vancomycin powder, 12 studies with grafts soaked in vancomycin, two studies used vancomycin irrigation, and one study administered vancomycin interosseously. There were 15 studies (of 26) in spine surgery, five (of 14) in arthroplasty, ten (of 11) in sports medicine, and two (of five) in trauma surgery that found statistically significant decreases in overall infection rates when applying local vancomycin. Only one study (in spine surgery) found significant increases in infection rates with local vancomycin application. For spine surgery, local vancomycin application had the greatest proportion of gram-negative bacteria (40.7%) isolated compared to S. aureus (42.4%) in controls. In arthroplasty and trauma surgery, there were increases in the proportions of gram-negative bacteria when vancomycin was added. There were no reported systemic adverse reactions associated with local vancomycin use in any of the studies.

Conclusion

Applying local vancomycin during primary orthopaedic surgery procedures may reduce the rates of infections in multiple different orthopaedic specialties, particularly in spine surgery and sports medicine. However, careful consideration should be applied when administering local vancomycin during specific orthopaedic procedures given the heterogeneity of included studies and breadth of surgeries included in this review.

Level of evidence

Level III. A systematic review of level I - III studies.

Prophylactic Antibiotic Choice and Deep Infection in Lower Extremity Endoprosthetic Reconstruction: Comparison of Cefazolin, Cefazolin-Vancomycin, and Alternative Regimens

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.

Non-cefazolin antibiotic prophylaxis is associated with higher rates of elbow periprosthetic joint infection

BACKGROUND

Periprosthetic joint infection (PJI) is a common source of failure following elbow arthroplasty. Perioperative prophylactic antibiotics are considered standard of care. However, there are no data regarding the comparative efficacy of various antibiotics in the prevention of PJI for elbow arthroplasty. Previous studies in shoulder, hip, and knee arthroplasty have demonstrated higher rates of PJI with administration of non-cefazolin antibiotics. The elbow has higher rates of PJI than other joints. Therefore, this study evaluated whether perioperative antibiotic choice affects rates of PJI in elbow arthroplasty.

MATERIALS AND METHODS

A single-institution, prospectively collected total joint registry database was queried to identify patients who underwent primary elbow arthroplasty between 2003 and 2021. Elbows with known infection prior to arthroplasty (25) and procedures with incomplete perioperative antibiotic data (7) were excluded, for a final sample size of 603 total elbow arthroplasties and 19 distal humerus hemiarthroplasties. Cefazolin was administered in 561 elbows (90%) and non-cefazolin antibiotics including vancomycin (32 elbows, 5%), clindamycin (27 elbows, 4%), and piperacillin/tazobactam (2 elbows, 0.3%) were administered in the remaining 61 elbows (10%). Univariate and multivariate analyses were conducted to determine the association between the antibiotic administered and the development of PJI. Infection-free survivorship was estimated using the Kaplan-Meier method.

RESULTS

Deep infection occurred in 47 elbows (7.5%), and 16 elbows (2.5%) were diagnosed with superficial infections. Univariate analysis demonstrated that patients receiving non-cefazolin alternatives were at significantly higher risk for any infection (hazard ratio [HR] 2.6, 95% confidence interval [CI] 1.4-5.0; P < .01) and deep infection (HR 2.7, 95% CI 1.3-5.5; P < .01) compared with cefazolin administration. Multivariable analysis, controlling for several independent predictors of PJI (tobacco use, male sex, surgical indication other than osteoarthritis, and American Society of Anesthesiologists score), showed that non-cefazolin administration had a higher risk for any infection (HR 2.8, 95% CI 1.4-5.3; P < .01) and deep infection (HR 2.9, 95% CI 1.3-6.3; P < .01). Survivorship free of infection was significantly higher at all time points for the cefazolin cohort.

DISCUSSION

In primary elbow arthroplasty, cefazolin administration was associated with significantly lower rates of PJI compared to non-cefazolin antibiotics, even in patients with a greater number of prior surgeries, which is known to increase the risk of PJI. For patients with penicillin or cephalosporin allergies, preoperative allergy testing or a cefazolin test dose should be considered before administering non-cefazolin alternatives.

When intravenous vancomycin prophylaxis is needed in shoulder arthroplasty, incomplete administration is associated with increased infectious complications

BACKGROUND

Vancomycin is often used as antimicrobial prophylaxis for shoulder arthroplasty (SA) either when first generation cephalosporins are contraindicated or colonization with resistant bacteria is anticipated. In general, vancomycin necessitates longer infusion times to mitigate potential side effects. When infusion is started too close to the time of the incision, administration may not be complete during surgery. This study evaluated whether incomplete administration of intravenous vancomycin prior to SA affects the rate of infectious complications.

METHODS

Between 2000 and 2019, all primary SA types (hemiarthroplasty, anatomic total SA, reverse SA) performed at a single institution for elective and trauma indications using intravenous vancomycin as the primary antibiotic prophylaxis and a minimum follow-up of 2 yr were identified. The time between the initiation of vancomycin and skin incision was calculated. Complete administration was defined as at least 30 min of infusion prior to incision. Demographic characteristics and infectious complications including survival free of prosthetic joint infection (PJI) were generated. Multivariable analyses were conducted to evaluate the association between vancomycin timing and the development of PJI.

RESULTS

A total of 461 primary SAs were included. Infusion was incomplete (< 30 minutes preoperatively) for 163 [35.4%] SA and complete (> 30 minutes preoperatively) for 298 [64.6%] SAs. The incomplete group demonstrated higher rates of any infectious complication (8% vs. 2.3%; P = .005), PJI (5.5% vs. 1%; P = .004), and reoperation inclusive of revision due to infectious complications (4.9% vs. 1%; P = .009). Survivorship free of PJI was worse in SA with incomplete compared to those with complete vancomycin administration. Survival rates for incomplete and complete administration were 97.6% and 99.3% at 1 mo, 95.7% and 99.0% at 2 yr, 95.1% and 99.0% at 5 yr, and 93.9% and 99.0% at 20 yr, respectively (P = .006). Multivariable analyses confirmed that incomplete vancomycin administration was an independent risk factor for PJI compared with complete administration (hazard ratio, 4.22 [95% confidence interval, 1.12-15.90]; P = .033), even when other independent predictors of PJI (age, male sex, prior surgery, methicillin-resistant Staphylococcus aureus colonization, and follow-up) were considered.

CONCLUSIONS

When vancomycin is the primary prophylactic agent used at the time of primary SA, incomplete administration (infusion to incision time under 30 min) seems to adversely increase the rates of infectious complications and PJI. Prophylaxis protocols should ensure that complete vancomycin administration is achieved to minimize infection after SA.

Antimicrobial Stewardship in Total Joint Arthroplasty: Outcomes of a Collaborative Program Implementation

INTRODUCTION

Antimicrobial stewardship has been cited as a crucial component of orthopaedic surgical care; however, limited high-quality data exist to guide antibiotic use across the total joint arthroplasty continuum. Antimicrobial stewardship program (ASP) implementation and evaluation is needed in this space.

METHODS

We pursued a prospective, sequential cohort study of an interprofessional ASP for total joint arthroplasty (TJA) formed in late 2017 at the study institution. Twelve total evidence-based recommendations for protocol change were issued, with 11 accepted and implemented across three project phases spanning March 2018 to December 2019. The primary study outcome was the rate of optimal preoperative intravenous antibiotic selection as assessed for Baseline versus Postintervention time periods. Secondary outcomes included individual antibiotic utilization rates. Descriptive statistics were pursued for institutional surgical site infection (SSI) and postoperative acute kidney injury (AKI) rates across the affected time frame. A cost-benefit analysis of the ASP was estimated from the institutional perspective.

RESULTS

The rate of optimal preoperative antibiotic selection increased from 64.9% in the Baseline Period (February 2018, n = 57) to 95.4% in the Postimplementation period (June 2018 to December 2019, n = 1,220) (P < 0.001). The rates of second-line preoperative antibiotics and total perioperative antibiotic exposures decreased. Total SSI and AKI rates in primary elective TJA seemed to decrease from calendar year 2018 to 2019 (deep SSI 1.00% to 0.22%, superficial SSI 0.66% to 0.00%, and AKI 1.97% to 1.03%). The institution realized an estimated $197,050 cost savings per 1000 TJA procedures.

DISCUSSION

A comprehensive ASP for TJA was associated with an increased use of optimal preoperative antibiotic selection, decreased total antibiotic exposures, and cost savings, without apparent detriment to SSI or AKI rates.

Perioperative Management in Shoulder Arthroplasty: A Review of Current Practice

Perioperative management for patients undergoing shoulder arthroplasty has evolved significantly over the years to reduce overt complications and improve patient outcomes. The groundwork for perioperative care encompasses initial patient selection and education strategies for achieving successful outcome. Multimodal pain management strategies have advanced patient care with the increased use of new regional/local anesthetics. In addition, complications resulting from blood loss and transfusions have been curtailed with the use of synthetic antifibrinolytic agents. It remains critical for shoulder arthroplasty surgeons to optimize patients during the perioperative period through various modalities to maximize functional progression, outcomes, and patient's satisfaction following shoulder arthroplasty.

The Open-Fracture Patient Evaluation Nationwide (OPEN) study : the management of open fracture care in the UK

AIMS

The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK.

METHOD

Patients admitted to hospital with an open fracture (excluding phalanges or isolated hand injuries) between 1 June 2021 and 30 September 2021 were included. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture software. All domains of the British Orthopaedic Association Standard for Open Fracture Management were recorded.

RESULTS

Across 51 centres, 1,175 patients were analyzed. Antibiotics were given to 754 (69.0%) in the emergency department, 240 (22.0%) pre-hospital, and 99 (9.1%) as inpatients. Wounds were photographed in 848 (72.7%) cases. Median time to first surgery was 16 hrs 14 mins (interquartile range (IQR) 8 hrs 29 mins to 23 hrs 19 mins). Complex injuries were operated on sooner (median 12 hrs 51 mins (IQR 4 hrs 36 mins to 21 hrs 14 mins)). Of initial procedures, 1,053 (90.3%) occurred between 8am and 8pm. A consultant orthopaedic surgeon was present at 1,039 (89.2%) first procedures. In orthoplastic centres, a consultant plastic surgeon was present at 465 (45.1%) first procedures. Overall, 706 (60.8%) patients required a single operation. At primary debridement, 798 (65.0%) fractures were definitively fixed, while 734 (59.8%) fractures had fixation and coverage in one operation through direct closure or soft-tissue coverage. Negative pressure wound therapy was used in 235 (67.7%) staged procedures. Following wound closure or soft-tissue cover, 509 (47.0%) patients received antibiotics for a median of three days (IQR 1 to 7).

CONCLUSION

OPEN provides an insight into care across the UK and different levels of hospital for open fractures. Patients are predominantly operated on promptly, in working hours, and at specialist centres. Areas for improvement include combined patient review and follow-up, scheduled operating, earlier definitive soft-tissue cover, and more robust antibiotic husbandry.Cite this article: Bone Joint J 2022;104-B(9):1073-1080.

Antibiotic Prophylaxis with Cefazolin Is Associated with Lower Shoulder Periprosthetic Joint Infection Rates Than Non-Cefazolin Alternatives

BACKGROUND

Although prophylactic antibiotics are considered the standard of care, data with regard to the comparative efficacy of specific antibiotics in the prevention of periprosthetic joint infection (PJI) have remained limited. This study evaluated whether perioperative antibiotic choice affects rates of PJI development in shoulder arthroplasty.

METHODS

From 2000 to 2019, all primary shoulder arthroplasty types (hemiarthroplasty, anatomic total shoulder arthroplasty, reverse shoulder arthroplasty) performed for elective and trauma indications with perioperative antibiotic data and a minimum follow-up of 2 years were identified from a single institution. Demographic characteristics, PJI risk factors, and PJI-free survivorship data were retrieved. Multivariable analyses were conducted to determine the association between the antibiotic administered and the development of PJI.

RESULTS

Of 7,713 shoulder arthroplasties, cefazolin was administered in 6,879 procedures (89.2%) and non-cefazolin antibiotics consisting of vancomycin (465 procedures [6.0%]), clindamycin (345 procedures [4.5%]), and alternative regimens (24 procedures [0.31%]) were administered in 834 procedures (10.8%). PJIs occurred in 101 shoulder arthroplasties (1.3%), with Cutibacterium acnes as the most common pathogen (44 procedures [43.6%]). PJI-free survivorship was greater in shoulder arthroplasties in which cefazolin was administered compared with those in which non-cefazolin antibiotics were administered, with 0.91% greater survival free of PJI at 1 month, 1.4% at 1 year, and 2.7% at 15 years (p < 0.001). Cefazolin administration, compared with non-cefazolin administration, was associated with a 69% reduction in all-cause PJI risk and a 78% reduction in C. acnes PJI risk (p < 0.001). A higher risk of PJI for both groups was observed with vancomycin; the hazard ratio [HR] was 2.32 (95% confidence interval [CI], 1.22 to 4.40; p = 0.010) for all-cause PJI and 2.94 (95% CI, 1.12 to 7.49; p = 0.028) for C. acnes PJI. A higher risk of PJI was also observed for both groups for clindamycin; the HR was 5.07 (95% CI, 2.83 to 9.05; p < 0.001) for all-cause PJI and 8.01 (95% CI, 3.63 to 17.42; p < 0.001) for C. acnes PJI.

CONCLUSIONS

In primary shoulder arthroplasty, cefazolin administration was associated with a significantly lower rate of PJI compared with non-cefazolin alternatives, including both vancomycin and clindamycin. These risk discrepancies were observed across all infectious pathogens and may be considered even greater when C. acnes was the infecting bacterium.

LEVEL OF EVIDENCE

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

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.

Impact of a hospital-wide computerised approach to optimise the quality of antimicrobial prescriptions in patients with severe obesity: a quasi-experimental study

Background

Rates of adherence to available recommendations for dose adjustments in patients with severe obesity are generally low. Hence, antimicrobials are often underdosed in these patients. Antimicrobial stewardship programmes can improve the use of antimicrobials in hospitalised patients. The aim of the study was to analyse the impact of an antimicrobial stewardship programme based on a computerised clinical decision support system for optimal dosing and antimicrobial use in inpatients with severe obesity.

Methods

This quasi-experimental retrospective study using interrupted time series was conducted in an academic centre in Canada from August 2008 to June 2018. The Antimicrobial Prescription Surveillance System was implemented in August 2010 (intervention 1) and specific rules targeting patients with class III obesity (body mass index ≥ 40 kg/m²) were added in June 2014 (intervention 2). Data were collected from all hospitalised adults receiving antimicrobials which required dose adjustment for severe obesity and were stratified by body mass index. Segmented regression analysis of interrupted time series was used to evaluate the impact of the Antimicrobial Prescription Surveillance System on the proportion of inappropriate days of therapy according to posology and on antimicrobial consumption.

Results

Overall, 65 205 antimicrobial prescriptions (68% non-obese, 25% class I-II obesity, and 7% class III obesity) were analysed. In patients with class III obesity, the intervention was associated with a decrease in the proportion of inappropriate days of therapy (trend after the first intervention, −0.8% per 2-month period [95% CI −1.1 to −0.5], p < 0.001; intercept, 11.3% [95% CI 8.2 to 14.5], p < 0.001), which led to a reduction of 35% over an eight-year period (from pre-intervention level of 19.1%). Intervention 1 resulted in a downward trend in antimicrobial consumption, followed by an increasing trend after intervention 2. In these patients, the most frequent interventions made by pharmacists targeted posology (46%).

Conclusions

Antimicrobial Prescription Surveillance System had a positive impact on dosing optimisation and antimicrobial consumption in patients with class III obesity. Improving antimicrobial prescriptions in these patients is important because suboptimal dosing could be associated with unfavourable outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06682-8.

The impact of a multimodel approach to designing a new orthopedic department

OBJECTIVE

To determine whether a multifaceted approach effectively influenced antibiotic use in an orthopedics department.

DESIGN

Retrospective cohort study comparing the readmission rate and antibiotic use before and after an intervention.

SETTING

A 1,000-bed, tertiary-care, university hospital.

PATIENTS

Adult patients admitted to the orthopedics department between January 2015 and December 2018.

METHODS

During the preintervention period (2015-2016), 1 general orthopedic department was in operation. In the postintervention period (2017-2018), 2 separate departments were created: one designated for elective "clean" surgeries and another that included a "complicated wound" unit. A multifaceted strategy including infection prevention measures and introducing antibiotic stewardship practices was implemented. Admission rates, hand hygiene practice compliance, surgical site infections, and antibiotic treatment before versus after the intervention were analyzed.

RESULTS

The number of admissions and hospitalization days in the 2 periods did not change. Seven-day readmissions per annual quarter decreased significantly from the preintervention period (median, 7 days; interquartile range [IQR], 6-9) to the postintervention period (median, 4 days; IQR, 2-7; P = .038). Hand hygiene compliance increased and surgical site infections decreased in the postintervention period. Although total antibiotic use was not reduced, there was a significant change in the breakdown of the different antibiotic classes used before and after the intervention: increased use of narrow-spectrum β-lactams (P < .001) and decreased use of β-lactamase inhibitors (P < .001), third-generation cephalosporins (P = .044), and clindamycin (P < .001).

CONCLUSIONS

Restructuring the orthopedics department facilitated better infection prevention measures accompanied by antibiotic stewardship implementation, resulting in a decreased use of broad-spectrum antibiotics and a significant reduction in readmission rates.

Collaborative Antimicrobial Stewardship for Surgeons

Antimicrobial stewardship efforts that include surgeons rely on healthy and open communications between surgeons, infectious diseases specialists, and pharmacists. These efforts most frequently are related to surgical prophylaxis, the management of surgical infections, and surgical critical care. Policy should be based on best evidence and timely interactions to develop consensus on how to develop appropriate guidelines and protocols. Flexibility on all sides leads to increasingly strong relationships over time.

2020 Mark Coventry Award: Microorganism-directed oral antibiotics reduce the rate of failure due to further infection after two-stage revision hip or knee arthroplasty for chronic infection: a multicentre randomized controlled trial at a minimum of two years

Aims

The aim of this study was to determine if a three-month course of microorganism-directed oral antibiotics reduces the rate of failure due to further infection following two-stage revision for chronic prosthetic joint infection (PJI) of the hip and knee.

Methods

A total of 185 patients undergoing a two-stage revision in seven different centres were prospectively enrolled. Of these patients, 93 were randomized to receive microorganism-directed oral antibiotics for three months following reimplantation; 88 were randomized to receive no antibiotics, and four were withdrawn before randomization. Of the 181 randomized patients, 28 were lost to follow-up, six died before two years follow-up, and five with culture negative infections were excluded. The remaining 142 patients were followed for a mean of 3.3 years (2.0 to 7.6) with failure due to a further infection as the primary endpoint. Patients who were treated with antibiotics were also assessed for their adherence to the medication regime and for side effects to antibiotics.

Results

Nine of 72 patients (12.5%) who received antibiotics failed due to further infection compared with 20 of 70 patients (28.6%) who did not receive antibiotics (p = 0.012). Five patients (6.9%) in the treatment group experienced adverse effects related to the administered antibiotics severe enough to warrant discontinuation.

Conclusion

This multicentre randomized controlled trial showed that a three-month course of microorganism-directed, oral antibiotics significantly reduced the rate of failure due to further infection following a two-stage revision of total hip or knee arthroplasty for chronic PJI. Cite this article: Bone Joint J 2020;102-B(6 Supple A):3–9.

Is there a Role for Antibiotic Prophylaxis Prior to Dental Procedures in Patients with Total Joint Arthroplasty? A Systematic Review of the Literature

Background: The indication of prophylactic antibiotics prior to dental procedures for non-infected causes in order to reduce the risk of haematogenous periprosthetic joint infection (PJI) remains as controversial. We performed a systematic review of the literature assessing the relationship between PJI and invasive dental procedures and whether there is evidence to support the use of antibiotic prophylaxis. Methods: This review was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews were searched for studies focusing on dental procedures after TJA, reporting on PJI as an outcome. The methodological quality was assessed with the Newcastle-Ottawa quality assessment scale for case-control and cohort studies and by the tool proposed by Murad et al. for observational studies. Results: Our systematic literature review yielded 90 individual studies, of which 9 met the inclusion criteria. The overall infection rate ranged from 0.26% to 2.12%. Of these, cases associated with a dental procedure ranged from 0% to 15.9%. Five of the studies described cases in which antibiotic prophylaxis was administered; however, no clear algorithm regarding type and dosage of antibiotic was mentioned. When assessing the methodological quality of the evidence, all studies had an overall low to moderate quality. Conclusion: The current systematic review, mostly composed of low-quality studies, suggests that there is no direct evidence to indicate prophylactic antibiotics prior to dental procedures in patients with TJA. In line with the current guidelines, no prophylaxis should be used on interventions for non-infected causes, except for occasional unusual situations, which can then be judged individually.

A Prospective Evaluation of Adverse Reactions to Single-Dose Intravenous Antibiotic Prophylaxis During Outpatient Hand Surgery

Background: While it is established that routine prophylactic antibiotics are not needed for all hand surgery, some cases do require it. The purpose of this study was to determine the rate of adverse reactions resulting from prophylactic antibiotic administration on patients undergoing outpatient hand and upper extremity surgical procedures. We hypothesize that the rate of complications resulting from the use of antibiotic prophylaxis is smaller than that reported in the currently referenced literature. Methods: We prospectively evaluated 570 consecutive patients undergoing outpatient upper extremity surgery. Patients were excluded if they were on antibiotics prior to surgery, were discharged on antibiotics, or if they wished to be excluded. Nineteen patients were excluded, resulting in a study cohort of 551 patients. Patients were monitored perioperatively, 2 to 3 days postoperatively, during the first postoperative visit and 1 month postoperatively for adverse reactions. The type and timing of the adverse reaction was recorded. Results: Five hundred fifty-one patients were included for evaluation and 8 patients (1.5%) developed an adverse reaction to antibiotics. Five patients (0.9%) reported a rash and 3 patients (0.5%) reported diarrhea within 3 days of surgery. There were no anaphylactic reactions or complications necessitating hospital transfer or admission in the postoperative period. Conclusion: This study represents a prospective investigation designed to determine the rate of adverse reactions to single-dose antibiotics given during outpatient hand surgery. We conclude that the use of intravenous, single-dose prophylactic antibiotic is safe in the outpatient setting for cases that require it.

Positive "Surprise" Broth Cultures in Nonunion Surgery Do Not Require Antibiotic Treatment

The objective of this study was to review the efficacy of a treatment approach for patients with positive intraoperative cultures during fracture nonunion surgery. The authors performed a retrospective case series at a level I trauma center. In this series, 60 patients without preoperative concern for infection were surgically treated for fracture nonunion. The treatment course of patients after fracture nonunion surgery, including culture results, antibiotic administration, and the presence of clinical infection and radiographic union, was studied. Sixty patients underwent fracture nonunion surgery. Twenty-four patients had a positive intraoperative culture. Fourteen patients had only a positive broth culture, 6 had only a positive routine culture, and 4 had positive mixed (routine and broth) cultures. The most common bacteria was coagulase-negative staphylococci, isolated in 19 of 24 patients, and the only isolated organism in 13 of 24 patients. Patients with a positive broth culture were not treated with antibiotics. Four of 10 patients with either a positive routine or mixed culture grown within 3 days of surgery were treated with antibiotics. All patients achieved clinical healing without signs of infection, and all but 2 patients achieved radiographic union at a mean follow-up of approximately 5 years. In the setting of fracture nonunion surgery, patients with only a positive broth culture and those with only a positive routine or mixed cultures that grew in a delayed fashion (>3 days postoperatively) did not require antibiotic treatment to achieve healing. [Orthopedics. 2019; 42(6):e532-e538.].

Prevalence of methicillin-resistant <em>Staphylococcus aureus</em> and other pathogens in pus samples of orthopedic department at a tertiary care hospital in Pakistan

BACKGROUND Orthopedic infections are difficult to manage. Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most dangerous and harmful bacteria and is difficult to eradicate because of its changing strains as well as sensitivity to different antibiotics. The main aim of this study was to determine the prevalence of pathogens, especially MRSA, associated with orthopedic wounds and their sensitivity to different antibiotics. METHODS A prospective study was conducted from September 2015 to August 2016. Pus samples of 1,350 patients who presented at the out-patient department or admitted with a wound infection after an orthopedic intervention were taken with the help of culture swab and were sent for culture and sensitivity according to hospital protocol. Data analyses were made using the SPSS software, version 17 (IBM). RESULTS Adults aged between 15 and 30 years were most affected, with 444 (32.9%) cases. Of the patients, 268 (19.9%) had negative cultures. Among the patients with positive cultures, the gram-positive cocci and gram-negative rods were 497 (36.8%) and 377 (27.9%), respectively. The most common pathogen was MRSA (240; 17.8%), followed by Escherichia coli and methicillin-sensitive S. aureus. CONCLUSIONS Multiple pathogens are involved in patients having an orthopedic surgical intervention. The high occurrence of MRSA and E. coli has an increasing economic burden on patients because of these pathogens high resistance to antibiotics. Thus, proper preventive measures should be done to decrease the occurrence of such infections as well as their associated morbidity.

Value of antibiotic prophylaxis in routine knee arthroscopy : A retrospective study

OBJECTIVE

Prophylactic antibiotic use prior to routine knee arthroscopy remains controversial. It is important to know whether antibiotics help decrease the surgical site infection (SSI) rate. Our aims were to assess the efficacy of antibiotic prophylaxis in preventing SSI and to identify risk factors for SSI following routine knee arthroscopy without an implant.

METHODS

A retrospective study was conducted using the electronic medical records at the authors' hospital to identify patients that underwent routine knee arthroscopy without an implant between October 2010 and October 2016. Data on demographics, clinical characteristics and antibiotic administration were extracted. Arthroscopic diagnosis, debridement, partial or complete meniscectomy, arthroscopic shaving and microfracture, removal of loose bodies, synovectomy and lateral retinacular release were included. Complex knee arthroscopy with an implant was excluded. Patients were divided into evaluation (with prophylactic antibiotics) and control (no antibiotic treatment) groups. Continuous variables between groups were compared using the Student's t-test. Data were analyzed using the Chi-squared test for percentages between groups. Multivariate logistic regression was used to identify independent risk factors of SSI.

RESULTS

Of 1326 patients, 614 (46.3%) received prophylactic antibiotics, while 712 (53.7%) did not. There were seven (0.53%) SSIs. The SSI rate did not differ significantly between patients receiving antibiotics (0.49%, three) and those not (0.56%, four). Five patients (0.37%) had superficial infections, two (0.33%) were in the prophylactic antibiotic group and three (0.42%) were in the other group. Deep infections occurred in two patients (0.15%), one (0.16%) in the prophylactic antibiotic group and one (0.14%) in the other group. The difference between the two groups was not statistically significant (P = 1.0). Age over 50 years was associated with an increased risk of SSI (relative ratio [RR] = 1.469, 95% confidence interval [CI] 1.09-2.13, P = 0.009).

CONCLUSIONS

Prophylactic antibiotic use in routine knee arthroscopy without an implant may not be necessary. Age over 50 years was associated with an increased risk of SSI.

Control Strategies for Infection Prevention in Total Joint Arthroplasty

Despite the development of newer preventative measures, the rate of infection continues to be approximately 1% for patients undergoing total joint arthroplasty (TJA). The extent of the infection can range from a mild superficial infection to a more serious periprosthetic joint infection (PJI). PJIs not only play a significant role in the clinical well-being of the TJA patient population, but also have substantial economic implications on the health care system. Several approaches are currently being used to mitigate the risk of PJI after TJA. The variety of prophylactic measures to prevent infection after TJA must be thoroughly discussed and evaluated.

Preventing infection in shoulder surgery

Although rare, infection after shoulder surgery can represent a devastating complication. Infection can negatively affect clinical outcomes, and eradication often requires a protracted treatment course. Staphylococcus aureus, Staphylococcus epidermidis, and Cutibacterium acnes are among the most frequently isolated pathogens. Perioperative measures can be implemented to reduce infection risk. Here we review various perioperative practices and their efficacy at reducing infection after shoulder surgery.

Towards a global definition of responsible antibiotic use: results of an international multidisciplinary consensus procedure

Background

Conducted as part of the Driving Reinvestment in Research and Development and Responsible Antibiotic Use (DRIVE-AB) project, this study aimed to identify key elements for a global definition of responsible antibiotic use based on diverse stakeholder input.

Methods

A three-step RAND-modified Delphi method was applied. First, a systematic review of antibiotic stewardship literature and relevant organization web sites identified definitions and synonyms of responsible use. Identified elements of definitions were presented by questionnaire to a multidisciplinary international stakeholder panel for appraisal of their relevance. Finally, questionnaire results were discussed in a consensus meeting.

Results

The systematic review and the web site search identified 17 synonyms (e.g. appropriate, correct) and 22 potential elements to include in a definition of responsible use. Elements were grouped into patient-level (e.g. Indication, Documentation) or societal-level elements (e.g. Education, Future Effectiveness). Forty-eight stakeholders with diverse backgrounds [medical community, public health, patients, antibiotic research and development (R&D), regulators, governments] from 18 countries across all continents participated in the questionnaire. Based on relevance scores, 21 elements were retained, 9 were rephrased and 1 was added. Together, the 22 elements and associated best-practice descriptions comprise an exhaustive list of elements to be considered when defining responsible use.

Conclusions

Combination of concepts from the literature and stakeholder opinion led to an international multidisciplinary consensus on a global definition of responsible antibiotic use. The widely diverging perspectives of stakeholders providing input should ensure the comprehensiveness and relevance of the definition for both individual patients and society. An aspirational goal would be to address all elements.

Perioperative Antibiotics for Clean Hand Surgery: A National Study

PURPOSE

Given that surgical site infections remain a common performance metric in assessing the quality of health care, we hypothesized that prophylactic antibiotics are overutilized in soft tissue hand surgery when antimicrobials are not indicated.

METHODS

We studied insurance claims from the Truven MarketScan Databases to identify patients who underwent 1 of 5 outpatient hand surgery procedures: open or endoscopic carpal tunnel release, trigger finger release, de Quervain release, and wrist ganglion excision between 2009 and 2015 (n = 305,946). Hospital payment claims for preoperative intravenous antibiotics and prescriptions filled for postoperative oral antibiotics were analyzed. We examined the rate and temporal trend of prophylactic antibiotics use and identified risk factors using multivariable logistic regression. We also calculated health care expenditures related to prophylaxis.

RESULTS

Prior to surgery, 13.6% (2009-2015) of patients received prophylactic intravenous antibiotics and trend analysis showed a statistically significant increase from 2009 (10.6%) to 2015 (18.3%), an increase of 72.5%. Preoperative prophylaxis was used most often prior to trigger finger release (17.5%) and least often prior to endoscopic carpal tunnel release (11.2%). Younger age, male sex, lower income, and obese patients had higher odds of receiving antibiotics. The total charge of prophylactic antibiotics medication used in this study equaled $1.6 million.

CONCLUSIONS

In 2015, prophylactic intravenous antibiotics were administered to nearly 1 in 5 patients prior to clean soft tissue hand surgery. Although consensus guidelines indicate prophylaxis is not indicated, their use has increased steadily in the United States from 2009 to 2015.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Implementation and impact of an audit and feedback antimicrobial stewardship intervention in the orthopaedics department of a tertiary-care hospital: a controlled interrupted time series study

A prospective audit and feedback antimicrobial stewardship intervention conducted in the Orthopaedics Department of a university hospital in Portugal was evaluated by comparing an interrupted time series in the intervention group with a non-intervention (control) group. Monthly antibiotic use (except cefazolin) was measured as the World Health Organization's Anatomical Therapeutic Chemical defined daily doses (ATC-DDD) from January 2012 to September 2016, excluding the 6-month phase of intervention implementation starting on 1 January 2015. Compared with the control group, the intervention group had a monthly decrease in the use of fluoroquinolones by 2.3 DDD/1000 patient-days [95% confidence interval (CI) -3.97 to -0.63]. An increase in the use of penicillins by 103.3 DDD/1000 patient-days (95% CI 47.42 to 159.10) was associated with intervention implementation, followed by a decrease during the intervention period (slope = -5.2, 95% CI -8.56 to -1.82). In the challenging scenario of treatment of osteoarticular and prosthetic joint infections, an audit and feedback intervention reduced antibiotic exposure and spectrum.

Treatment Approach for Infection of Healed Fractures After Internal Fixation

OBJECTIVE

To review the efficacy of a treatment approach for patients with infection and colonized implants after open reduction and internal fixation of fractures.

DESIGN

Retrospective case series.

SETTING

Level one trauma center.

PATIENTS

Twenty patients were treated for wound infection with colonized implants after open reduction and internal fixation.

INTERVENTION

Surgical debridement, removal of implants, and a short postoperative oral antibiotic course.

MAIN OUTCOME MEASUREMENT

The course of patients after surgical debridement and removal of implants, including culture results, antibiotic administration, and presence of recurrent clinical infection and radiographic union.

RESULTS

Twenty patients had clinical presentations, including skin breakdown, serous drainage, purulent drainage and/or exposed implants, most commonly of the tibia (15 of 20). Mean time from index procedure to debridement with implant removal was 19.7 months. At the time of debridement and implant removal, 18 of 20 (90%) patients had a positive intraoperative culture (16 routine cultures and 2 broth cultures). The most common bacteria were Enterobacter cloacae (5/17) and methicillin-sensitive Staphylococcus aureus (4/17). All patients had soft tissue healing without signs of recurrent infection after mean follow up of 40 months after implant removal.

CONCLUSIONS

Surgical debridement with implant removal plus a short oral antibiotic course is effective to resolve wound infection with a colonized implant in the setting of healed fracture after internal fixation.

LEVEL OF EVIDENCE

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

An analysis of diagnoses that drive readmission: What can we learn from the hospitals in Southern New England with the highest and lowest readmission performance?

Background: The Hospital Readmission Reduction Program was instituted by the Centers for Medicare & Medicaid Services in 2012 to incentivize hospitals to reduce readmissions.

OBJECTIVE

To examine the most common diagnoses driving readmissions among fee-for-service Medicare beneficiaries in the hospitals with the highest and lowest readmission performance in Southern New England from 2014 to 2016.

METHODS

This is a retrospective observational study using publicly available Hospital Compare data and Medicare Part A claims data. Hospitals were ranked based on risk-adjusted excess readmission ratios. Patient demographic and hospital characteristics were compared for the two cohorts using t-tests. The percentages of readmissions in each cohort attributable to the top three readmission diagnoses were examined.

RESULTS

Highest-performing hospitals readmitted a significantly lower percentage of black patients (p=0.03), were less urban (p<0.01), and had higher Hospital Compare Star ratings (p=0.01). Lowest-performing hospitals readmitted higher percentages of patients for sepsis (9.4% [95%CI: 8.8%-10.0%] vs. 8.1% [95%CI: 7.4%-8.7%]) and complications of device, implant, or graft (3.2% [95%CI: 2.5%-3.9%] vs. 0.2% [95%CI: 0.1%-0.6%]), compared to highest-performing hospitals.

CONCLUSIONS

Ongoing efforts to improve care transitions may be strengthened by targeting early infection surveillance, promoting adherence to surgical treatment guidelines, and improving communication between hospitals and post-acute care facilities. [Full article available at http://rimed.org/rimedicaljournal-2017-08.asp].

[Antibiotic stewardship : A programmatic approach to improved antimicrobial management]

Due to the increasing selection and prevalence of multidrug-resistant gram-negative bacteria and the insufficient development of novel antibiotics, the responsible and prudent use of the available antimicrobial drugs is of major importance. In Germany the rational use of anti-infectives considering the local antimicrobial resistance situation is defined in the infection protection act of 2011. An important tool to follow legal regulations and to improve the treatment of bacterial infections is the antimicrobial stewardship (AMS) concept. Hospitals implementing an AMS program charge a multidisciplinary team of experts to develop and monitor treatment standards and to establish a system of regular consultations and ward rounds. Objectives of this set of measures are the optimization of the individual treatment outcome and on a longer range the improvement of the epidemiological situation. AMS programs include all clinical disciplines that use antimicrobials. Trauma surgery is also affected in a special way as soon as complicated infections and those with multidrug-resistant bacteria are treated.

It Is a Brave New World: Alternative Payment Models and Value Creation in Total Joint Arthroplasty: Creating Value for TJR, Quality and Cost-Effectiveness Programs

BACKGROUND

The increasing cost of our country's healthcare is not sustainable. To address this crisis, the federal government is transiting healthcare reimbursement from the traditional volume-based system to a value-based system. As such, increasing healthcare value has become an essential point of discussion for all healthcare stakeholders.

METHODS

The purpose of this study is to discuss the importance of healthcare value as a means to achieve this goal of value-based medicine and 3 methods to create value in total joint arthroplasty.

RESULTS

These methods are to: (1) improve outcomes greater than the increased costs to achieve this improvement, (2) decrease costs without affecting outcomes, and (3) decrease costs while simultaneously improving outcomes.

CONCLUSION

Following these guidelines will help practitioners thrive in a bundled care environment.

Clostridium difficile Infection: An Orthopaedic Surgeon's Guide to Epidemiology, Management, and Prevention

Clostridium difficile infection is a growing concern in health care and is a worrisome complication in orthopaedics. The incidence and severity of this infection are increasing, although the incidence following orthopaedic surgery is comparatively lower than that seen in patients in most other surgical specialties. The typical geriatric orthopaedic patient may have many risk factors that increase the likelihood of C difficile infection, including advanced age, residence in a long-term care facility, multiple comorbidities, the use of perioperative antibiotics, and a long length of stay. Many antibiotics used for prophylaxis in orthopaedic procedures have been correlated with an increased incidence of C difficile infection. The indications for C difficile testing may vary, and diagnostic methods differ in sensitivity and specificity. The prevention of this infection is multifaceted and consists of practitioner and patient hand hygiene, antibiotic stewardship, contact precautions, and proper environmental cleaning. The main treatment options are metronidazole for mild cases and vancomycin for moderate to severe disease. Up to 40% of cases may have one or more recurrence. Further research is needed to identify novel therapeutic and prevention strategies for C difficile infection.

Efficacy of Prophylactic Antibiotics in Simple Knee Arthroscopy

PURPOSE

To determine the association between the use of preoperative antibiotics and the risk of postoperative infection after simple knee arthroscopy.

METHODS

The electronic medical records of a large integrated health care organization were used to identify patients who underwent simple knee arthroscopy between 2007 and 2012. Patient demographics, potential infection risk factors, and antibiotic administration data were extracted. Simple knee arthroscopy included debridement, meniscectomy, meniscus repair, synovectomy, microfracture, and lateral release. Complex knee arthroscopy, septic knees, and cases involving fractures were excluded. Deep infection was defined as a positive synovial fluid culture or signs and symptoms of infection and gross pus in the knee. Superficial infection was defined as clinical signs of infection localized to a portal site and treatment with an antibiotic.

RESULTS

Of 40,810 simple knee arthroscopies, 32,836 (80.5%) received preoperative antibiotics and 7,974 (19.5%) did not. There were 25 deep infections in the antibiotic group (0.08%) and 11 in the no-antibiotics group (0.14%) (risk ratio = 0.55, 95% confidence interval: 0.27 to 1.12, P = .10). There were 134 superficial infections in the antibiotic group (0.41%) and 32 in the no-antibiotics group (0.40%) (risk ratio = 1.01, 95% confidence interval: 0.29 to 1.49, P = .93).

CONCLUSIONS

In our large sample of patients who underwent simple knee arthroscopy, there was no association between preoperative antibiotic use and postoperative deep or superficial infection rates at the 95% confidence level (P = .05). There was an association between preoperative antibiotic use and a decreased deep infection rate at the P = .10 level.

LEVEL OF EVIDENCE

Level IV, case series.

Biofilm formation increases treatment failure in Staphylococcus epidermidis device-related osteomyelitis of the lower extremity in human patients

The ability to form biofilm on the surface of implanted devices is often considered the most critical virulence factor possessed by Staphylococcus epidermidis in its role as an opportunistic pathogen in orthopaedic device-related infection (ODRI). Despite this recognition, there is a lack of clinical evidence linking outcome with biofilm forming ability for S. epidermidis ODRIs. We prospectively collected S. epidermidis isolates cultured from patients presenting with ODRI. Antibiotic resistance patterns and biofilm-forming ability was assessed. Patient information was collected and treatment outcome measures were determined after a mean follow-up period of 26 months. The primary outcome measure was cure at follow-up. Univariate logistic regression models were used to determine the influence of biofilm formation and antibiotic resistance on treatment outcome. A total of 124 patients were included in the study, a majority of whom (n = 90) involved infections of the lower extremity. A clear trend emerged in the lower extremity cohort whereby cure rates decreased as the biofilm-forming ability of the isolates increased (84% cure rate for infections caused by non-biofilm formers, 76% cure rate for weak biofilm-formers, and 60% cure rate for the most marked biofilm formers, p = 0.076). Antibiotic resistance did not influence treatment cure rate. Chronic immunosuppression was associated with a statistically significant decrease in cure rate (p = 0.044).

CLINICAL SIGNIFICANCE

The trend of increasing biofilm-forming ability resulting in lower cure rates for S. epidermidis ODRI indicates biofilm-forming ability of infecting pathogens does influence treatment outcome of infections of the lower extremity. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1905-1913, 2016.

Staphylococcal orthopaedic device-related infections in older patients

INTRODUCTION

Staphylococci are the most common pathogens causing orthopaedic device-related infections (ODRI). The treatment of these infections often involves multiple surgical procedures combined with systemic antibiotic therapy to treat the infection and restore functionality. Older patients frequently present with a compromised health-status and/or low bone quality, and despite growing importance their outcomes are not well described to date. The primary aim of the current study is to describe outcomes in older patients with ODRIs and to determine if they demonstrate lower cure rates and greater risk for complications in contrast to younger patients.

PATIENTS AND METHODS

Patients treated with an ODRI of the lower extremity at our institution were included in this study. Demographic data, comorbidities and infecting organisms were recorded. Older adult patients were defined as those aged 60 and older. At two-year follow-up post-discharge, we recorded the clinical course, the Lower-Extremity-Functional-Score, the patient reported general health status (SF-12-questionnaire) and the status of infection. The antibiotic resistance pattern of the disease causing pathogens was analysed and compared between the two age groups.

RESULTS

In total, 163 patients (age: 19-94 years) with a staphylococcal ODRI were included. Sixty-four of these infections occurred in older patients, which showed a significantly higher mortality rate (9%). Within follow-up period recurrence of infection occurred significantly more frequently in younger patients (41%) than in older patients (17%). At two-years follow-up cure, which was defined as eradication of infection and terminated therapy, was achieved in 78% of younger and 75% of older patients. However, an ODRI resulted in older patients in a significantly worse functional outcome and impaired physical quality of live, as well as more frequently in an on-going infection, such as a persisting fistula (14% versus 3% in younger patients). Disease causing staphylococci, isolated from older patients showed more frequently a methicillin or multi-drug resistance than those associated with infections in younger patients.

CONCLUSIONS

ODRIs in older patients demonstrated higher morality rates rate, poor functional outcome and higher rates of persistent infections. A compromised health status and a poor bone quality may play a crucial role in this specific patient cohort.

Surgeon preferences regarding antibiotic prophylaxis for ballistic fractures

BACKGROUND

Scant evidence exists to support antibiotic use for low velocity ballistic fractures (LVBF). We therefore sought to define current practice patterns. We hypothesized that most surgeons prescribe antibiotics for LVBF, prescribing is not driven by institutional protocols, and that decisions are based on protocols utilized for blunt trauma.

MATERIALS AND METHODS

A web-based questionnaire was emailed to the membership of the Orthopaedic Trauma Association (OTA). The questionnaire included demographic information and questions about LVBF treatment practices. Two hundred and twenty surgeons responded. One hundred and fifty-four (70 %) respondents worked at a Level-1 trauma center, 176 (80 %) had received fellowship education in orthopaedic trauma and 104 (47 %) treated at least 10 ballistic fractures annually. Responses were analyzed with SAS 9.3 for Windows (SAS Institute Inc, Cary, NC).

RESULTS

One hundred eighty-six respondents (86 %) routinely provide antibiotics for LVBF. Those who did not were more apt to do so for intra-articular fractures (8/16, 50 %) and pelvic fractures with visceral injury (10/16, 63 %). Most surgeons (167, 76 %) do not believe the Gustilo-Anderson classification applies to ballistic fractures, and (20/29, 70 %) do not base their antibiotic choice on the classification system. Few institutions (58, 26 %) have protocols guiding antibiotic use for LVBF.

CONCLUSIONS

Routine antibiotic use for LVBF is common; however, practice is not dictated by institutional protocol. Although antibiotic use generally follows current blunt trauma guidelines, surgeons do not base their treatment decisions the Gustilo-Anderson classification. Given the high rate of antibiotic use for LVBF, further study should focus on providing evidence-based treatment guidelines.

Expanded Gram-Negative Antimicrobial Prophylaxis Reduces Surgical Site Infections in Hip Arthroplasty

BACKGROUND

A first-generation cephalosporin is the recommended antibiotic prophylaxis for implants. However, this standard does not address the increasing prevalence and virulence of gram-negative pathogens infecting patients. We found that gram-negative bacilli caused 30% of our surgical site infections (SSIs) following hip procedures, whereas only 10% of knee SSIs were caused by gram-negative bacilli. To address this, we instituted Expanded Gram-Negative Antimicrobial Prophylaxis (EGNAP) for our hip arthroplasty patients. The purpose of this study is to measure the effect of EGNAP on the SSI rates following primary total hip arthroplasty.

METHODS

The study consisted of 10,084 total patients. Before July 2012, all patients were administered 1 g of cefazolin. After July 2012, our protocol was adjusted by adding the EGNAP with either gentamicin or aztreonam to hip patients (group 1) and not to the knee arthroplasty patients (group 2).

RESULTS

Group 1 consisted of the 5389 primary hip arthroplasty patients. Of these patients, 4122 (before July 2012) did not receive weight-based high-dose gentamicin and 1267 (after July 2012) did. Before the introduction of EGNAP, group 1 SSI rate was 1.19% (49/4122). After July 2012 when EGNAP was added, the overall group 1 SSI rate decreased to 0.55% (7/1267) (P = .05). During the study period, there was not a significant difference in SSI rate of knee arthroplasty (group 2): 1.08% vs 1.02% (P = .999).

CONCLUSIONS

The addition of EGNAP for hip arthroplasty is a safe and effective method to decrease SSIs.

LEVEL OF EVIDENCE

III. Case-control study.

Implementing an intensified antibiotic stewardship programme targeting daptomycin use in orthopaedic surgery: a cost-benefit analysis from the hospital perspective

BACKGROUND

Hospital antibiotic stewardship (ABS) programmes offer several evidence-based tools to control prescription rates of antibiotics in different settings, influence the incidence of nosocomial infections and to contain the development of multi-drug-resistant bacteria. In the context of endoprosthetic surgery, however, knowledge of core antibiotic stewardship strategies, comparisons of costs and benefits of hospital ABS programmes are still lacking.

MATERIALS AND METHODS

We identified a high daptomycin use for the treatment of methicillin-sensitive staphylococcal infections as a potential target for our ABS intervention. In addition, we endorsed periprosthetic tissue cultures for the diagnosis of PJI. Monthly antibiotic use data were obtained from the hospital pharmacy and were expressed as WHO-ATC defined daily doses (DDD) and dose definitions adapted to local guidelines (recommended daily doses, RDD), normalized per 1000 patient days. The pre-intervention period was defined from February 2012 through January 2014 (24 months). The post-intervention period included monthly time points from February 2014 to April 2015 (15 months). For a basic cost-benefit analysis from the hospital perspective, three cost drivers were taken into account: (1) the cost savings due to changes in antimicrobial prescribing; (2) costs associated with the increase in the number of cultured tissue samples, and (3) the appointment of an infectious disease consultant. Interrupted time-series analysis (ITS) was applied.

RESULTS

Descriptive analysis of the usage data showed a decline in overall use of anti-infective substances in the post-intervention period (334.9 vs. 221.4 RDDs/1000 patient days). The drug use density of daptomycin dropped by -75 % (51.7 vs. 12.9 RDD/1000 patient days), whereas the utilization of narrow-spectrum penicillins, in particular flucloxacillin, increased from 13.8 to 33.6 RDDs/1000 patient days. ITS analysis of the consumption dataset showed significant level changes for overall prescriptions, as well as for daptomycin (p < 0.001) and for narrow-spectrum penicillins (p = 0.001). The total costs of antibiotic consumption decreased by an estimated € 4563 per month (p < 0.001), and around 90 % of these savings were linked to a decrease in daptomycin consumption. Overall, the antibiotic stewardship programme was beneficial, as monthly cost savings of € 2575 (p = 0.005) were achieved.

INTERPRETATION

In this example of large endoprosthetic surgery department in a community-based hospital, the applied hospital ABS programme targeting daptomycin use has shown to be feasible, effective and beneficial compared to no intervention.

The Critical Role of the Staff Nurse in Antimicrobial Stewardship--Unrecognized, but Already There

An essential participant in antimicrobial stewardship who has been unrecognized and underutilized is the "staff nurse." Although the role of staff nurses has not formally been recognized in guidelines for implementing and operating antimicrobial stewardship programs (ASPs) or defined in the medical literature, they have always performed numerous functions that are integral to successful antimicrobial stewardship. Nurses are antibiotic first responders, central communicators, coordinators of care, as well as 24-hour monitors of patient status, safety, and response to antibiotic therapy. An operational analysis of inpatient admissions evaluates these nursing stewardship activities and analyzes the potential benefits of nurses' formal education about, and inclusion into, ASPs.