Characteristics of Antibiotic Prophylaxis and Risk of Surgical Site Infections in Primary Total Hip and Knee Arthroplasty

Temporal Patterns and Treatment Associations in Complications Following Hip Arthroplasty

Background and Objectives: Hip arthroplasty is commonly performed to enhance mobility and quality of life in patients with severe joint degeneration. However, post-surgery complications such as infections, dislocations, and mechanical failures remain prevalent and vary over time. This study examines the relationship between time intervals post-surgery and the occurrence of complications and explores the associations between specific treatment modalities and complications. It also investigates temporal patterns of infectious and mechanical complications to inform more effective post-surgery care. Materials and Methods: A retrospective cohort study was conducted on hip arthroplasty patients to analyze the occurrence and distribution of complications across medium-term (1-5 years) and long-term (≥6 years) intervals. Treatment modalities, including joint debridement, lavage, antibiotics, and mechanical interventions, were analyzed for their association with complications. Chi-Square tests were used, with significance set at p < 0.05. Results: A significant association was found between time intervals and complications (χ2 = 58.149, df = 19, p < 0.001). Infections were more prevalent in the medium-term, while mechanical complications such as dislocation, implant loosening, and periprosthetic fractures were more common in the long-term. Antibiotics were strongly linked to infectious complications (χ2 = 279.000, p < 0.001), and mechanical treatments were associated with fractures and dislocations. Conclusions: The study confirms that the timing of complications post-surgery plays a critical role in their occurrence. Specific complications become more prevalent at different intervals, emphasizing the need for tailored treatment strategies. Antibiotics for infections and mechanical interventions for fractures and dislocations should be adjusted based on timing. These findings highlight the importance of time-specific post-surgery care and suggest areas for further research on long-term strategies and risk factors.

Cefazolin vs. alternative beta-lactams for prophylaxis in lower extremity fracture surgery: A target trial emulation

BACKGROUND

Cefazolin is the primary antibiotic for surgical prophylaxis in orthopedic procedures. The cessation of cefazolin supply in approximately 60 % of Japanese hospitals from 2019 to 2020 provided an opportunity to evaluate the effectiveness of alternative beta-lactams for preventing surgical site infection (SSI). Given the global potential for antibiotics shortages, confirming the effectiveness of alternative beta-lactams is critical.

PURPOSE

This study aims to evaluate the differences in risk of reoperation for SSI between cefazolin and alternative beta-lactams in patients undergoing lower extremity fracture surgeries.

METHODS

We emulated a target trial to compare the effectiveness of cefazolin with alternative beta-lactams-specifically broad-spectrum penicillins and cephalosporins-in preventing SSI using a Japanese hospital administrative database provided by JMDC Inc. We included patients undergoing initial open reduction and internal fixation for closed lower extremity fractures between March 1, 2019, and February 29, 2020. The outcome was reoperation for SSI within 30 days after surgery. Risks were estimated using pooled logistic regression with adjustment for confounders via inverse probability weighting. Sensitivity analyses extended the follow-up period to 90 and 365 days.

RESULTS

Of the 16,602 patients analyzed, 35 patients (0.30 %) in the cefazolin group (11,538 patients) and 16 patients (0.32 %) in the alternative beta-lactam group (5,064 patients) underwent reoperation for SSI within 30 days. The estimated 30-day risk was 0.31 % in the cefazolin group and 0.37 % in the alternative beta-lactam group, resulting in a risk difference of -0.06 % (95 % confidence interval [CI], -0.33 to 0.14) and a risk ratio of 0.82 (95 % CI, 0.50 to 1.52). In sensitivity analyses, the estimated 90-day risk was 0.67 % in the cefazolin group and 0.57 % in the alternative beta-lactam group, with a risk difference of 0.10 % (95 % CI, -0.15 to 0.32) and a risk ratio of 1.19 (95 % CI, 0.80 to 1.62). The 365-day risk was 1.02 % and 0.90 %, respectively, with a risk difference of 0.12 % (95 % CI, -0.29 to 0.39) and a risk ratio of 1.13 (95 % CI, 0.78 to 1.51).

CONCLUSIONS

In surgeries for lower extremity fractures, substituting cefazolin with alternative beta-lactams did not result in substantial differences in the risk of reoperation for SSI.

A nurse-driven penicillin allergy risk score in the preoperative setting was associated with increased cefazolin use perioperatively

STUDY OBJECTIVE

To characterize and assess the effects of a preoperative, nurse-driven penicillin allergy risk stratification tool on rates of perioperative cefazolin and second-line antibiotic use.

DESIGN

Quasi-experimental quality improvement study of penicillin-allergic surgical patients undergoing procedures for which cefazolin is indicated.

SETTING

Outpatient Perioperative Care Clinic (PCC) for preoperative surgical patients at a tertiary care center.

PATIENTS

670 and 1371 adult penicillin-allergic PCC attendants and non-attendants, respectively.

INTERVENTION

A paper penicillin allergy risk stratification questionnaire was administered during the PCC visit. Nurses were educated on its use.

MEASUREMENTS

Antibiotic (cefazolin, clindamycin, vancomycin) use rates in the 24 months before and 17 months after intervention implementation in November 2020 (November 2018 - April 2022) were assessed in penicillin-allergic PCC attendants with statistical process control charts. Multivariable logistic regression assessed antibiotic use rates pre- and post-intervention adjusting for age, sex, surgical specialty and penicillin allergy history severity. Similar analyses were done in penicillin-allergic PCC non-attendants.

MAIN RESULTS

Of 670 penicillin-allergic PCC attendants, 451 (median [IQR] age, 66 (Sousa-Pinto et al., 2021 [14])) were analyzed pre-intervention and 219 (median [IQR] age, 66 (Mine et al., 1970 [13])) post-intervention. One month after implementation, process measures demonstrated an upward shift in cefazolin use for PCC attendants versus no shift or other special cause variation for PCC non-attendants. There were increased odds of cefazolin use (aOR 1.67, 95% CI [1.09-2.57], P = 0.019), decreased odds of clindamycin use (aOR 0.61, 95% CI [0.42-0.89], P = 0.010) and decreased odds of vancomycin use (aOR 0.56, 95% CI [0.35-0.88], P = 0.013) in PCC attendants post-intervention. This effect did not occur in PCC non-attendants. There was no increase in perioperative anaphylaxis post-intervention.

CONCLUSIONS

A simple penicillin allergy risk stratification tool implemented in the preoperative setting was associated with increased use of cefazolin and decreased rates of second-line agents post implementation.

The effect of different preventive strategies during total joint arthroplasty on periprosthetic joint infection: a network meta-analysis

BACKGROUND

Periprosthetic joint infection after total joint arthroplasty has a large incidence, and it may often require two or more stages of revision, placing an additional burden on clinicians and patients. The purpose of this network meta-analysis is to evaluate the effect of four different preventive strategies during total joint arthroplasty on the prevention of periprosthetic joint infection.

METHODS

The study protocol was registered at PROSPERO (CRD: 42,023,448,868), and the literature search databases included Web of Science, PubMed, OVID Cochrane Central Register of Controlled Trials, OVID EMBASE, and OVID MEDLINE (R) ALL that met the requirements. The network meta-analysis included randomized controlled trials, retrospective cohort studies and prospective cohort studies with the outcome of periprosthetic joint infection. The gemtc R package was applied to perform the network meta-analysis to evaluate the relative results of different preventive strategies.

RESULTS

This network meta-analysis study included a total of 38 articles with 4 preventive strategies and negative controls. No improvement was observed in antibiotic-loaded bone cement compared with negative controls. Chlorhexidine showed the highest probability of delivering the best preventive effect, and povidone iodine had the second highest probability. Although vancomycin ranked after chlorhexidine and povidone iodine, it still showed a significant difference compared with negative controls. In addition, the incidence after applying chlorhexidine was significantly lower than that after applying negative controls and vancomycin. In the heterogeneity test between direct and indirect evidence, there was no apparent heterogeneity between them.

CONCLUSION

The study indicated that chlorhexidine, povidone iodine and vancomycin showed significant efficacy in preventing periprosthetic joint infection after total joint arthroplasty, while antibiotic-loaded bone cement did not. Therefore, more high-quality randomized controlled trials are needed to verify the results above.

The safety and efficacy of unicompartmental knee arthroplasty in outpatient surgical centers: A systematic review and meta-analysis

BACKGROUND

Unicompartmental knee arthroplasty (UKA) is an effective treatment method for knee osteoarthritis. With the development and implementation of enhanced recovery after surgery, UKA is now increasingly performed in outpatient surgical centers. However, there is ongoing debate regarding the safety and effectiveness of performing UKA in outpatient settings.

METHODS

The search was performed to retrieve randomized controlled trials and cohort studies on outpatient UKA from PubMed, Cochrane Library, EMbase, CNKI, and WanFangData databases. The search was conducted from the inception of the databases until August 31, 2023. After independent screening, data extraction, and risk of bias evaluation by two researchers, meta-analysis was performed using RevMan 5.4 software.

RESULTS

A total of eight studies involving 18,411 patients were included. The results showed that the postoperative transfusion rate in the outpatient group was lower than that in the inpatient group [OR = 0.36, 95%CI (0.24, 0.54), p < 0.00001], and the difference was statistically significant. However, there was no significant difference between the two groups in terms of readmission rate, reoperation rate, surgical site infection, and periprosthetic fracture. The differences were not statistically significant.

CONCLUSION

Compared to the traditional inpatient route, the blood transfusion rate for single-condyle replacement in the outpatient operation center is lower, and there is no significant difference in readmission rate, reoperation rate, surgical site infection, and periprosthesis fracture. The outpatient approach to UKA is safe, feasible, and highly satisfactory for patients. However, the results have certain limitations, and a rigorous preoperative complication risk assessment can minimize the risk of UKA in outpatient surgery centers.

TRIAL REGISTRATION

PROSPERO number CRD42023405373.

A novel method for quantification of cefazolin local tissue concentration in blood, fat, synovium, and bone marrow using liquid chromatography - mass spectrometry

To be effective, the concentration of antibiotic used must exceed the minimum inhibitory concentration (MIC) against infecting organisms at and in the surgical site. Few studies follow antibiotic levels for tissues that are manipulated during surgery. The aim of this work was to develop and validate a novel LC-MS method as well as an efficient extraction technique for the quantification of cefazolin in local tissues and whole blood. This method uses the same efficient extraction method across multiple tissue types affected by orthopedic surgery: blood, fat, synovium, and bone marrow. The ability to quantify cefazolin in these tissues will help identify surgical techniques and antibiotic dosing protocols that better protect patients from infection. The internal standard, 13C2,15N-cefazolin, co-elutes with cefazolin, and was used in calibration curves and tissue extracts as well as for cefazolin recovery and matrix effects. The protocol was rigorously tested, including measurements of reproducibility and calibration curve quality. The recovery of the extraction method ranges from 94% to 113% across all sample types. There is little to no matrix effect on cefazolin signal (98-120%). The developed method was used to determine cefazolin concentrations in tissues of 10 patients undergoing a total knee replacement. Cefazolin blood concentrations were approximately 500 times higher than in adipose, synovium, and bone marrow tissues. This clinical data shows that although the minimum inhibitory concentration is largely surpassed in blood, the concentration of cefazolin in fat, synovium, and bone marrow could be insufficient during a knee replacement. This method of cefazolin quantification will help surgeons optimize antibiotic concentrations in the local tissues during knee replacement surgery and potentially reduce serious post-surgical infections.

Incidence of Surgical Site Infection Despite Preoperative Cefazolin Administration in Total Knee Arthroplasty Patients: A Tertiary Hospital Experience

INTRODUCTION

Surgical site infection (SSI) is an infection that occurs after surgery on the incision site. Cefazolin is an old-generation antibiotic that decreases the risk of SSI. This study aimed to determine the relationship between the incidence of SSI, cefazolin administration, and the factors contributing to the relationship between them.

METHODS

This is a retrospective study that used a data collection sheet to collect variables from the medical records of patients who underwent total knee arthroplasty (TKA) between 2016 and 2020. We looked mainly for the type of antibiotics given preoperatively, the number of doses given, discontinuation of antibiotics postoperatively, length of hospital stay, intensive care unit (ICU) admission, and SSI occurrence.  Results: A total of 195 patients were included. The majority (87.8%) were given two grams of cefazolin. Patients who have taken one gram of cefazolin had a slightly higher hospital stay than those who took two grams. However, all the patients did not develop an SSI.

CONCLUSION

There was no incidence of SSI despite preoperative cefazolin administration in TKA patients. Patients who received higher doses of cefazolin had a shorter length of hospital stay.

Post-operative prophylactic antibiotics in aseptic revision hip and knee arthroplasty: a propensity score matching analysis

The use of extended antibiotic (EA) prophylaxis (> 24 h) remains controversial in aseptic revision arthroplasty. We sought to determine whether EA prophylaxis reduces the risk of periprosthetic joint infection (PJI) in aseptic revision hip and knee arthroplasty. A total of 2800 patients undergoing aseptic revision hip and knee arthroplasty at five institutional databases from 2008 to 2017 were evaluated. One to two nearest-neighbor propensity score matching analysis was conducted between patients who did and did not receive extended antibiotic prophylaxis. The matching elements included age, sex, body mass index, Charlson comorbidity index, hospital distribution, year of surgery, joint (hip or knee), surgical time, CRP, preoperative hemoglobin, albumin, and length of stay. The primary outcome was the development of PJI, which was assessed at 30 days, 90 days, and 1 year following revision and analyzed separately. A total of 2467 (88%) patients received EA prophylaxis, and 333 (12%) patients received standard antibiotic (SA) prophylaxis (≤ 24 h). In the propensity-matched analysis, there was no difference between patients who received EA prophylaxis and those who did not in terms of 30-day PJI (0.3% vs. 0.3%, p = 1.00), 90-day PJI (1.7% vs. 2.1%, p = 0.62) and 1- year PJI (3.8% vs. 6.0%, p = 0.109). For revision hip, the incidence of PJI was 0.2% vs 0% at 30 days (p = 0.482), 1.6% vs 1.4% at 90 days (p = 0.837), and 3.4% vs 5.1% at 1 year (p = 0.305) in the EA and SA group. For revision knee, the incidence of PJI was 0.4% vs 0.9% at 30 days (p = 0.63), 1.8% vs 3.4% at 90 days (p = 0.331), and 4.4% vs 7.8% at 1 year (p = 0.203) in the EA and SA group. A post hoc power analysis revealed an adequate sample size with a beta value of 83%. In addition, the risks of Clostridium difficile and resistant organism infection were not increased. This multi-institutional study demonstrated no difference in the rate of PJIs between patients who received extended antibiotic prophylaxis and those who did not in aseptic revision arthroplasty. The risk of C. difficile and resistant organism infection was not increased with prolonged antibiotic use.

Risk factors associated with surgical site infections following joint replacement surgery: a narrative review

Background

Surgical site infection following joint replacement surgery is still a significant complication, resulting in repeated surgery, prolonged antibiotic therapy, extended postoperative hospital stay, periprosthetic joint infection, and increased morbidity and mortality. This review discusses the risk factors associated with surgical site infection.

Related risk factors

The patient-related factors include sex, age, body mass index (BMI), obesity, nutritional status, comorbidities, primary diagnosis, living habits, and scores of the American Society of Anesthesiologists physical status classification system, etc. Surgery-related factors involve preoperative skin preparation, prolonged duration of surgery, one-stage bilateral joint replacement surgery, blood loss, glove changes, anti-microbial prophylaxis, topical anti-bacterial preparations, wound management, postoperative hematoma, etc. Those risk factors are detailed in the review.

Conclusion

Preventive measures must be taken from multiple perspectives to reduce the incidence of surgical site infection after joint replacement surgery.

A validated LC-MS/MS method for the quantitation of cefazolin in human adipose tissue: Application of EMR-Lipid sorbent as an efficient sample clean-up before mass spectrometric analyses

A novel, simple, rapid, and sensitive high-performance liquid chromatography-tandem mass spectrometry method was developed to determine cefazolin concentrations in human adipose tissue. Sample preparation was performed by protein precipitation followed by using Captiva EMR-Lipid plates. The mobile phase consisted of 5 mM ammonium formate and 0.1% formic acid in water and 0.1% formic acid in ACN, and was pumped through a Synergi Fusion-RP column with a gradient elution program at a flow rate of 0.3 mL/min. The mass spectrometer was operated in a positive ion mode. Cloxacillin was used as an internal standard due to the observed cross-signal contribution between cefazolin and ¹³C₂,¹⁵N-cefazolin. The method was validated according to the FDA and EMA guidelines and passed all the acceptance criteria. The calibration range was 0.05-50 µg/mL in adipose tissue homogenate (0.15-150 µg/g in adipose tissue), precision CV < 4.5%, accuracy within 93.1-100.4%. The carry-over was negligible, recovery of the method was high, and no significant matrix effect was present. Rat subcutaneous adipose tissue was demonstrated to be a suitable surrogate matrix for human adipose tissue. The validated method was successfully applied in a pilot pharmacokinetic study and will further be used in a large cohort of non-obese and obese patients dosed prophylactically with cefazolin before surgeries.

Use of prophylactic antibiotics on surgical site infections in arthroplasty patients (Scoping Review)

Background

Increased demand for arthroplasty also increases the number of complications of arthroplasty, especially surgical site infection (SSI). One of the effective strategies in preventing surgical site infection is the use of appropriate prophylactic antibiotics.

Objective

To identify and analyse information from clinical studies regarding factors affecting the effectiveness of prophylactic antibiotics in arthroplasty patients.

Methods

A scoping review was conducted through the PubMed, Scopus, and Google Scholar databases within a publication range from January 2004 to August 2020. Study data are extracted and analysed by a minimum of two reviewers.

Results

The search results found 2.419 articles, with 39 articles were included for further analysis. Cefazolin monotherapy was the most frequently studied antibiotic (15 articles) followed by vancomycin monotherapy (8 articles). Most widely used antibiotics in arthroplasty were cefazolin mono-therapy (997.599 procedures with SSI incidence range: 0,20–16,05%) followed by vancomycin mono-therapy (125.170 procedures with SSI incidence range: 0.27–3,88%) The correct antibiotic dose has a lower percentage of the SSI than the wrong antibiotic dose. Meanwhile, administration of antibiotics within single dose or <24 h had a lower SSI percentage than administration of antibiotics >24 h. Administration antibiotics before incision also have a lower SSI percentage than after incision. There were no studies that discussed re-dosing of antibiotics in this scoping review.

Conclusions

There is still a need for further research related to the duration and specific timing of first dose of prophylactic antibiotics, especially regarding single dose or multiple dose antibiotics to obtain maximum effectiveness of antibiotic prophylaxis

Antimicrobial Resistance, the COVID-19 Pandemic, and Lessons for the Orthopaedic Community

Antimicrobial resistance (AMR) is widely regarded as one of the most important global public health challenges of the twenty-first century. The overuse and the improper use of antibiotics in human medicine, food production, and the environment as a whole have unfortunately contributed to this issue. Many major international scientific, political, and social organizations have warned that the increase in AMR could cost the lives of millions of people if it is not addressed on a global scale. Although AMR is already a challenge in clinical practice today, it has taken on a new importance in the face of the coronavirus disease 2019 (COVID-19) pandemic. While improved handwashing techniques, social distancing, and other interventional measures may positively influence AMR, the widespread use of antibiotics to treat or prevent bacterial coinfections, especially in unconfirmed cases of COVID-19, may have unintended negative implications with respect to AMR. Although the exact number of bacterial coinfections and the rate at which patients with COVID-19 receive antibiotic therapy remain to be accurately determined, the pandemic has revived the discussion on antibiotic overuse and AMR. This article describes why the COVID-19 pandemic has increased our awareness of AMR and presents the immense global impact of AMR on society as a whole. Furthermore, an attempt is made to stress the importance of tackling AMR in the future and the role of the orthopaedic community in this worldwide effort.