Should All Patients Receive Extended Oral Antibiotic Prophylaxis? Defining Its Role in Patients Undergoing Primary and Aseptic Revision Total Joint Arthroplasty

BACKGROUND

Prior studies have demonstrated reduced periprosthetic joint infection (PJI) rates following extended oral antibiotics (EOAs) for high-risk patients undergoing primary total joint arthroplasty (TJA). This study compared 3-month PJI rates in all patients undergoing primary or aseptic revision TJA with or without EOA prophylaxis.

METHODS

In total, 2,982 consecutive primary (n = 2,677) and aseptic revision (n = 305) TJAs were performed by a single, fellowship-trained arthroplasty surgeon from 2016 to 2022 were retrospectively reviewed. Beginning January 2020, all patients received 7 days of 300 mg oral cefdinir twice daily immediately postoperatively. Rates of PJI at 3 months were compared between patients who received or did not receive EOA.

RESULTS

Rates of PJI at 3 months in patients undergoing primary and aseptic revision TJA were significantly lower in those receiving EOA prophylaxis compared to those who did not (0.41 versus 1.13%, respectively; P = .02). After primary TJA, lower PJI rates were observed with EOA prophylaxis utilization (0.23 versus 0.74%, P = .04; odds ratio [OR] 3.85). Following aseptic revision TJA, PJI rates trended toward a significant decrease with the EOA compared to without (1.88 versus 4.83%, respectively; P = .16; OR 2.71).

CONCLUSIONS

All patients undergoing primary or aseptic revision TJA who received EOA prophylaxis were 3.85 and 2.71 times less likely, respectively, to develop PJI at 3 months compared to those without EOA. Future studies are needed to determine if these results are maintained at postoperative time periods beyond 3 months following primary TJA.

LEVEL OF EVIDENCE

III, Retrospective review.

Is There a Role for Extended Postoperative Oral Antibiotics in Primary Total Joint Arthroplasty High-Risk Individuals After Surgery for Periprosthetic Joint Infection?

With moderate level of evidence, 76% of delegates (super majority/strong consensus) of the most recent (2018) International Consensus Meeting on orthopedic infections agreed that extended oral antibiotics directed toward initial organisms after reimplantation for 3 months probably reduce the risk of failure due to periprosthetic joint infection. Nevertheless, the use of oral antibiotics becomes increasingly problematic with extended or long-term utilization. The development of antibiotic resistance and side effects are of particular concern, the most common being Clostridium difficile-associated diarrhea. Antibiotic stewardship is important when preventing and treating periprosthetic joint infection to hopefully prevent increase of bacterial antibiotic resistance. Two recent studies showed a significant difference in the incidence of surgical site infections after arthroplasty procedures in high-risk patients during short- and long-term follow-up without significant increase of adverse effects. However, another study showed no significant benefit of this practice. This summary discussed the details of those studies suggesting that the use of extended oral antibiotic prophylaxis in high-risk primary and revision hip and knee arthroplasty may reduce infection rates; nonetheless, additional higher level of evidence (level 1) is still needed to validate this practice as its potential adverse effects are not clear.

Extended Oral Antibiotic Prophylaxis After Aseptic Revision TKA: Does It Decrease Infection Risk?

BACKGROUND

Extended oral antibiotic prophylaxis (EOA) has been shown to potentially reduce infection rates after high-risk primary total knee arthroplasties (TKAs) and reimplantations. However, data is limited regarding EOA after aseptic revision TKAs. This study evaluated the impact of EOA on infection-related outcomes after aseptic revision TKAs.

METHODS

904 aseptic revision TKAs from 2014-2019 were retrospectively identified. Patients who received EOA >24 hours perioperatively (n = 267) were compared to those who did not (n = 637) using an inverse probability of treatment weighting model. Mean age was 66 years, mean BMI was 33 kg/m², and 54% were female. Outcomes included cumulative probabilities of any infection, periprosthetic joint infection (PJI), superficial infection, and re-revision or reoperation for infection.

RESULTS

The cumulative probability of any infection after aseptic revision TKA was 1.9% at 90 days, 3.5% at 1 year, and 8.1% at 5 years. Patients without EOA had a higher risk of any infection at 90 days (HR = 7.1; P = .01), but not other time points. The cumulative probability of PJI after aseptic revision TKA was 0.8% at 90 days, 2.3% at 1 year, and 6.5% at 5 years. Patients without EOA did not have an increased risk of PJI. There were no differences in re-revision or reoperation for infection at any time point between groups.

CONCLUSION

Extended oral antibiotics after aseptic revision TKA were associated with a 7-fold decreased risk of any infection at 90 days. The results suggest a potential role for EOA after aseptic revision TKA and warrant additional prospective studies.

LEVEL OF EVIDENCE

Level III.