Extended Oral Antibiotic Prophylaxis After Aseptic Total Hip or Knee Arthroplasty Revisions: A Preliminary Report

Extended oral antibiotics in primary and revision total joint arthroplasty: An update

Periprosthetic joint infections (PJI) are a significant healthcare and economic burden after joint replacement surgery. Extended oral antibiotic prophylaxis (EOAP) has been highlighted as a safe, efficacious, and cost-effective measure to mitigate the risk of infection against the increasing demands for total joint arthroplasty (TJA). Several studies have demonstrated substantial reductions in PJI rates, particularly among high-risk populations receiving a 7-day course of antibiotics, mainly with use of cefadroxil. Conversely, other studies have found no significant differences or even increased infection rates, highlighting concerns over antimicrobial resistance, Clostridium difficile infections (CDI), and other antibiotic-related adverse events. Additionally, recent trends show a substantial rise in EOAP utilization across the United States, demonstrating need for clear and evidence-based guidelines. There is a need for high quality randomized controlled trials to help identify optimal patient selection criteria, antibiotic type, and duration to effectively balance the benefits of EOAP against potential risks. Although there is limited evidence of significant antibiotic associated complications with the use of EOAP, care should be utilized prior to widespread adoption with antibiotic stewardship in mind.

Extended oral antibiotic prophylaxis and PJI-free survivorship after primary total knee arthroplasty

INTRODUCTION

Recent evidence has emerged supporting the use of extended oral antibiotic (EOA) prophylaxis after primary total knee replacement (TKA) to reduce periprosthetic joint infection (PJI) in high-risk patients. However, much of the evidence stems from single-institution series with limited sample sizes. This study aimed to explore the impact of EOA on complications and infection-free survivorship in a large cohort of patients after primary TKA.

METHODS

A large national database was used to identify patients undergoing primary TKA from 2015 to 2022. Patients receiving 7-14 days of EOA were identified. Propensity-score matching, based on patient comorbidities, was used to match patients who received EOA and to control patients who did not. Three cohorts were created: any-risk, high-risk, and standard-risk. Complications at 90-days were assessed with univariate analysis and survivorship free of PJI to 2 years was analyzed with the Kaplan-Meier method and cox regression.

RESULTS

We identified 5,701 patients who received EOA: 3,628 (64%) with high-risk comorbidities and 2,073 (36%) standard risk. There were no significant reduction in hazard of PJI at 90-days (any-risk: HR: 1.65, 95% CI: 0.90-3.04, P = 0.11; high-risk: HR: 1.37, 95% CI: 0.69-2.70, P = 0.4; standard-risk: HR: 1.51, 95% CI: 0.53-4.26, P = 0.4), 1 year (P > 0.07), or 2 years (any-risk: HR: 1.42, 95% CI: 0.98-2.05, P = 0.065; high-risk: HR: 1.14, 95% CI: 0.76-1.73, P = 0.5; standard-risk: HR: 1.51, 95% CI: 0.76-2.98, P = 0.2) with EOA administration.

DISCUSSION

EOA prophylaxis was not associated with improved PJI-free survivorship at any measured time point following primary TKA in either high-risk or standard-risk risk patients. Given the observed widespread use of EOA, our study highlights the need for further investigation to delineate what specific populations may benefit from EOA prophylaxis.

Increasing Utilization of Extended Oral Antibiotic Prophylaxis Following Total Knee Arthroplasty From 2010 to 2022

BACKGROUND

Extended oral antibiotic (EOA) prophylaxis has been shown to reduce rates of periprosthetic joint infection in high-risk patients following total knee arthroplasty (TKA). Although national societies' recommendations against their use and clinical efficacy remain controversial, the increase in the literature surrounding EOA prophylaxis suggests a potential change in practice patterns that may warrant the creation of national guidelines. The purpose of this study was to investigate the trends in the utilization of EOA prophylaxis following TKA from 2010 to 2022.

METHODS

Patients who underwent primary or aseptic revision TKA between 2010 and 2022 were identified in a national administrative claims database. Temporal trends in EOA usage following primary or revision TKA were calculated, and secondary analysis examined rates of utilization across demographics, including patients considered at high risk for infection. In total, 1,258,759 primary and 91,530 aseptic revision TKA patients were included in this study.

RESULTS

From 2010 to 2022, EOA prescriptions increased by 321 and 368% following primary and revision TKA, respectively. Rates of utilization among high-risk individuals were similar to those of the general population.

CONCLUSIONS

The use of EOA prophylaxis after TKA has increased significantly since 2010. Given their increasing usage and variation in prescription patterns among patients at high risk of infection, guidelines surrounding their use are necessary to promote antibiotic stewardship while preventing rates of infection.

Rates of Extended Oral Antibiotic Prophylaxis After Primary Total Knee Arthroplasty Among High-Risk and Standard-Risk Patients: 2009 to 2022

BACKGROUND

Recent evidence suggests extended courses of oral antibiotics (EOA) after total hip arthroplasty and total knee arthroplasty (TKA) may reduce the risk of periprosthetic joint infection in high-risk patients. EOA rates after total hip arthroplasty have risen significantly. However, there is a lack of epidemiologic data on EOA prophylaxis following TKA. Therefore, we investigated national trends in EOA prophylaxis for primary TKA and whether these rates were reflective of changes in patient risk or prescribing practices.

METHODS

Adult patients undergoing TKA between 2009 and 2022 were identified in a national insurance claims database. An EOA was defined as a 7 to 14-day course of a first-generation cephalosporin, cefdinir, clindamycin, doxycycline, or trimethoprim-sulfamethoxazole filled between 5 days preoperatively and 3 days postoperatively. Annual EOA rates were calculated and stratified by preoperative periprosthetic joint infection risk. Multivariable logistic regression was used to explore whether rates reflected changing patient characteristics. Future rates were predicted with time-series forecasting.

RESULTS

We identified 712,212 eligible TKA cases. EOA rates rose from 0.91% in 2009 to 7.95% in 2022. Rates increased by 686% among standard-risk patients and 786% among high-risk patients. Logistic regression models using patient comorbidities could not account for changes in EOA rates. EOA rates were projected to rise to 18.3% by 2030.

CONCLUSIONS

Rates of EOA prophylaxis after TKA rose significantly from 2009 to 2022. This trend could not be explained by changing patient characteristics, suggesting widespread changes in antibiotic prescribing practices, which may be reflective of recent studies favoring EOA use. There is a need for further high-quality research examining the safety, efficacy, and role of EOA prophylaxis in the primary TKA patient population.

Impact of Extended Prophylactic Antibiotics on Risk of Prosthetic Joint Infection in Primary Total Hip Arthroplasty: A Matched Cohort Analysis

BACKGROUND

Extended oral prophylactic antibiotics have been increasingly used in arthroplasty with the goal of reducing the risk of prosthetic joint infection (PJI). While a reduction in the rate of PJI has been noted with extended oral antibiotic regimens in high-risk patients, no large database study has assessed infection risk after primary total hip arthroplasty among well-balanced cohorts receiving and not receiving postoperative extended oral antibiotics.

METHODS

A retrospective cohort study was conducted using a national database, TriNetX, to identify patients who underwent primary total hip arthroplasty. This cohort was stratified by oral antibiotic prescription within one day of procedure. A one-to-one propensity score matching based on age, sex, class of obesity, and medical comorbidities was conducted. Outcomes explored in this study were 90-day risk of PJI, superficial skin infection, deep skin infection, and all-cause revision.

RESULTS

90-day postoperative infection complications of PJI were higher in the group receiving antibiotics (hazard ratio: 1.83, P -value = 0.012). Other complications such as superficial skin infection, deep skin infection, and all-cause revision showed no statistically significant differences.

CONCLUSION

This database analysis of 5,476 patients demonstrated no decrease in complications of PJI, superficial or deep skin infection, or revision at 90 days. Future randomized controlled trials are needed to evaluate the efficacy of extended oral antibiotics.

LEVEL OF EVIDENCE

III.

Benefits and Adverse Events Associated With Extended Antibiotic Use for One Year Following Periprosthetic Joint Infection in Total Knee Arthroplasty: A Prospective Cohort Analysis

BACKGROUND

Periprosthetic joint infections (PJIs) are common and serious complications following knee and hip arthroplasty. Our previous retrospective study suggested extended antibiotics following debridement, antibiotics, and implant retention (DAIR) decreased failure rates and were not associated with increased adverse events (AEs) as compared to a standard 6 weeks of antibiotic therapy. Further, extended antibiotics beyond one year did not provide additional benefits. These observations were tested in this prospective cohort study.

METHODS

A prospective cohort of patients who underwent DAIR for total knee arthroplasty PJI and received primary antibiotics were compared to patients who received primary antibiotics combined with extended antibiotics for one year. Participants had a minimum of 2-year follow-up after the final dose of antibiotics.

RESULTS

A prospective cohort of 79 patients was followed, where 39 participants (52.7%) received primary antibiotics and 35 participants (47.3%) received both primary and extended antibiotics following DAIR. Multivariable time-to-event analyses revealed that extended antibiotic use was an independent predictor of treatment success. Infection-free survival differed significantly between the two treatment regimens, as the hazard of PJI failure was significantly lower for extended antibiotics as compared to primary antibiotics alone (adjusted hazard ratio [HR] = 0.46 [0.24 to 0.87], P = 0.017). The AE rates did not significantly differ between patients treated with primary antibiotics only versus primary combined with extended antibiotics.

CONCLUSIONS

This prospective cohort study supports our previous observations that extended antibiotics for one year were associated with lower failure rates as compared to primary antibiotics alone. Extended antibiotics after primary antibiotics were not found to be associated with increased AEs as compared to only primary antibiotics.

Duration of cefazolin prophylaxis did not impact infection risk in a murine model of joint arthroplasty

To minimize periprosthetic joint infection (PJI) risk, some clinicians prescribe extended antibiotic prophylaxis (EAP) following total joint arthroplasty (TJA). Given the limited evidence supporting EAP, we sought to evaluate impact of prophylactic antibiotic duration on PJI risk in a murine TJA model. A titanium prosthesis was implanted into the proximal tibia of 89 mice and inoculated with 102 colony forming units (cfu) of Staphylococcus aureus Xen36. Control mice (n = 20) did not receive antibiotics. Treated mice received either 24 h (n = 35) or 4 days (n = 34) of cefazolin prophylaxis. Cultures were obtained from the prostheses, tibia, femur, and knee tissues 3 weeks after surgery. All mice in the control group developed PJI. Both prophylaxis regimens reduced the rate of PJI relative to the control, with only 2/35 mice in the 24-h cohort (p < 0.0001) and 1/34 in 4-day cohort developing PJI (p < 0.0001). CFU counts from the prostheses, bone and knee tissues were reduced for the 24-h and 4-day prophylaxis cohorts relative to the control (p < 0.0001 for both). There was no difference in rates of PJI or CFU counts between the two prophylaxis cohorts (p = 0.58). Prophylactic cefazolin profoundly reduced rates of PJI in a murine model of TJA in which all control animals developed PJI. Extending cefazolin prophylaxis duration from 24 h to 4 days did not result in improved PJI rates or decreased bacterial loads in infected cases. While these results strongly support use of antibiotic prophylaxis for TJA, EAP did not appear to add benefit in the described mouse model.

Extended Prophylactic Antibiotics for Primary and Aseptic Revision Total Joint Arthroplasty: A Meta-Analysis

BACKGROUND

There is growing interest in extended antibiotic prophylaxis (EAP) following total joint arthroplasty (TJA); however, the benefit of EAP remains controversial. For this investigation, both oral and intravenous antibiotic protocols were included in the EAP group.

METHODS

The Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, PubMed, MEDLINE, Web of Science, Ovid Embase, Elton B. Stephens CO, and Cumulative Index to Nursing and Allied Health Literature were queried for literature comparing outcomes of primary and aseptic revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients who were treated with either ≤24 hours of postoperative antibiotic prophylaxis (standard of care [SoC]) or >24 hours of EAP. The primary outcome was periprosthetic joint infection (PJI). A pooled relative-risk random-effects Mantel-Haenszel model was implemented to compare cohorts.

RESULTS

There were 18 studies with a total of 19,153 patients included. There was considerable variation in antibiotic prophylaxis protocols with first-generation cephalosporins being the most commonly implemented antibiotic for both groups. Patients treated with EAP were 35% less likely to develop PJI relative to the SoC (P = .0004). When examining primary TJA, patients treated with EAP were 39% and 40% less likely to develop a PJI for TJA (P = .0008) and THA (P = .02), respectively. There was no significant difference for primary TKA (P = .17). When examining aseptic revision TJA, EAP led to a 36% and 47% reduction in the probability of a PJI for aseptic revision TJA (P = .007) and aseptic revision TKA (P = .008), respectively; there was no observed benefit for aseptic revision THA (P = .36).

CONCLUSIONS

This meta-analysis demonstrated that patients treated with EAP were less likely to develop a PJI relative to those treated with the SoC for all TJA, primary TJA, primary THA, aseptic revision TJA, and aseptic revision TKA. There was no significant difference observed between EAP and SoC for primary TKA or aseptic revision THA.

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.

Trends in Extended Oral Antibiotic Prophylaxis Utilization Following Primary and Revision Total Hip Arthroplasty From 2010 to 2022

BACKGROUND

In patients considered high-risk for infection, extended oral antibiotic (EOA) prophylaxis has been demonstrated to reduce rates of prosthetic joint infection following total hip arthroplasty (THA). Although national guidelines regarding their use have not yet been created, the increase in literature surrounding EOA prophylaxis suggests a potential change in practice patterns. The purpose of this study was to investigate the trends in utilization of EOA prophylaxis following THA from 2010 to 2022 and identify prescription patterns.

METHODS

A total of 646,059 primary THA and 51,879 aseptic revision THA patients were included in this study. Patients who underwent primary or aseptic revision THA between 2010 and 2022 were identified in a national administrative claims database. Rates and duration of EOA prescriptions were calculated. A secondary analysis examined rates of utilization across demographics, including patients considered high risk for infection.

RESULTS

From 2010 to 2022, utilization of EOA increased by 366% and 298% following primary and revision THA, respectively. Of patients prescribed postoperative antibiotics, 30% and 59% were prescribed antibiotics for more than 7 days following primary and revision THA, respectively. Rates of utilization were similar between high-risk individuals and the general population.

CONCLUSIONS

Rates of utilization of EOA prophylaxis after THA have increased significantly since 2010. As current trends demonstrate a wide variation in prescription patterns, including in length of antibiotic duration and in patient population prescribed, guidelines surrounding the use of EOA prophylaxis after THA are necessary to promote antibiotic stewardship while preventing rates of periprosthetic joint infection.

How are Oral Antibiotics Being Used in Total Joint Arthroplasty? A Review of the Literature

While the role and benefit of perioperative intravenous (IV) antibiotics in patients undergoing total joint arthroplasty (TJA) is well-established, oral antibiotic use in TJA remains a controversial topic with wide variations in practice patterns. With this review, we aimed to better educate the orthopedic surgeon on when and how oral antibiotics may be used most effectively in TJA patients, and to identify gaps in the literature that could be clarified with targeted research. Extended oral antibiotic prophylaxis (EOAP) use in high-risk primary, aseptic revision, and exchange TJA for infection may be useful in decreasing periprosthetic joint infection (PJI) rates. When prescribing oral antibiotics either as EOAP or for draining wounds, patient factors, type of surgery, and type of infectious organisms should be considered in order to optimally prevent and treat PJI. It is important to maintain antibiotic stewardship by administering the proper duration, dose, and type of antibiotics and by consulting infectious disease when necessary.

The Use of Oral Antibiotics After Total Joint Arthroplasty: A Critical Analysis Review

» There is conflicting and insufficient evidence that extended oral antibiotic (EOA) therapy prevents infection in high-risk patients undergoing primary total joint arthroplasty (TJA), limiting recommendation for or against the practice.» In the case of aseptic revision TJA, the evidence is also conflicting and limited by underlying confounders, preventing recommendation for use of EOA.» There is fair evidence that use of EOA after debridement antibiotic therapy and implant retention of the prosthesis prolongs infection-free survival, but randomized controlled trials are needed. On the other hand, there is strong evidence that patients undergoing 2-stage revision should receive a period of suppressive oral antibiotics after the second stage.» The optimal duration of EOA in primary TJA, aseptic revision, and debridement antibiotic therapy and implant retention of the prosthesis is unknown. However, there is strong evidence that 3 months of EOA suppression may be appropriate after reimplantation as part of 2-stage exchange arthroplasty.» Complications secondary to EOA are reported to be between 0% and 13.7%, yet are inconsistently reported and poorly defined. The risks associated with antibiotic use, including development of antimicrobial resistance, must be weighed against a possible decrease in infection rate.

Antibiotic Prophylaxis in One-Stage Revision of Septic Total Knee Arthroplasty: A Scoping Review

BACKGROUND

Total knee replacement (TKA) is becoming a routine procedure in orthopedic surgery. One of the possible complications of this surgery is periprosthetic joint infection (PJI). The purpose of this study is to identify, through a literature review, which antibiotic is used as prophylaxis for septic one-stage revision TKA and what is the rationale for its use.

METHODS

We searched: MEDLINE, Embase, PsycINFO on Ovid, the Cochrane Library, and the Google Scholar Database. The searches were limited by date (January 2005 to September 2022) and to the English language. All types of original research were considered, including prospective or retrospective longitudinal studies, cross-sectional studies, and randomized trials. The specific search terms were ((antibiotic [MeSH]) AND (prophylaxis)) and (TKA OR TKR OR "Arthroplasty, Replacement, Knee" [MeSH] OR ((knee) adj2 (replace* OR arthroplasty* OR prosthe*))).

RESULTS

Despite our research efforts, we found no article capable of answering the question of which antibiotic to use as surgical prophylaxis for a septic revision one-stage TKA.

CONCLUSIONS

Although the research results are inconclusive, we would recommend using the same antibiotic prophylaxis as for primary joint replacement, i.e., cefazolin, as it was recommended for its low side effect rate and relative effectiveness.

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.