Changing antibiotic prophylaxis for primary joint arthroplasty affects postoperative complication rates and bacterial spectrum

Antibiotics and healthcare facility-associated Clostridioides difficile infection: systematic review and meta-analysis 2020 update

BACKGROUND

Antibiotic use is the most important modifiable risk factor for healthcare facility-associated Clostridioides difficile infection (HCFA-CDI). Previous systematic reviews cover studies published until 31 December 2012.

OBJECTIVES

To update the evidence for associations between antibiotic classes and HCFA-CDI to 31 December 2020.

METHODS

PubMed, Scopus, Web of Science Core Collection, WorldCat and Proquest Dissertations & Theses were searched for studies published since 1 January 2013. Eligible studies were those conducted among adult hospital inpatients, measured exposure to individual antibiotics or antibiotic classes, included a comparison group and measured the occurrence of HCFA-CDI as an outcome. The Newcastle-Ottawa Scale was used to appraise study quality. To assess the association between each antibiotic class and HCFA-CDI, a pooled random-effects meta-analysis was undertaken. Meta-regression and subgroup analysis was used to investigate study characteristics identified a priori as potential sources of heterogeneity.

RESULTS

Carbapenems and third- and fourth-generation cephalosporin antibiotics remain the most strongly associated with HCFA-CDI, with cases more than twice as likely to have recent exposure to these antibiotics prior to developing HCFA-CDI. Modest associations were observed for fluoroquinolones, clindamycin and β-lactamase inhibitor combination penicillin antibiotics. Individual study effect sizes were variable and heterogeneity was observed for most antibiotic classes.

CONCLUSIONS

This review provides the most up-to-date synthesis of evidence in relation to the risk of HCFA-CDI associated with exposure to specific antibiotic classes. Studies were predominantly conducted in North America or Europe and more studies outside of these settings are needed.

Risk Factors for Kidney Dysfunction With the Use of Gentamicin in Open Fracture Antibiotic Treatment

OBJECTIVES

To evaluate all patients who received gentamicin for open fracture treatment and determine the incidence of, and risk factors for, kidney injury in this population.

DESIGN

Retrospective, case control.

SETTING

Single institution; Level 1 trauma center.

PATIENTS/PARTICIPANTS

A retrospective chart review identified patients who received gentamicin for open fracture antibiotic treatment from January 2008 to December 2012. Overall, 371 patients met the inclusion criteria and were categorized into 2 groups using risk, injury, failure, loss of kidney function, and end-stage kidney disease criteria: normal kidney function (74.9%) versus abnormal kidney function (25.1%).

INTERVENTION

Use of gentamicin in open fracture antibiotic treatment.

MAIN OUTCOME MEASUREMENTS

Kidney function; injury and treatment characteristics (eg, mechanism of injury; Gustilo-Anderson classification; number of surgical debridements, timing of definitive wound coverage, and type of wound coverage); and patient information (eg, age, height, weight, and body mass index, tobacco use, diabetes mellitus, human immunodeficiency virus, hepatitis, and current chemotherapy treatment).

RESULTS

Those with abnormal kidney function had lower baseline creatinine (P < 0.001) and higher injury severity scores (16.5 vs. 11.8, P < 0.001) and were more likely to require intensive care unit admission (P < 0.001) than the normal group. Female sex (P = 0.015), and higher weight (P = 0.004), ICU admission (P < 0.001), and use of CT contrasted imaging (P < 0.001) were independently associated with abnormal kidney function. Abnormal kidney function incidence also sharply increased with age.

CONCLUSIONS

Females and heavier individuals are at-risk of kidney injury while receiving gentamicin. ICU admission and concurent CT contrasted imaging are strongly associated with kidney injury in patients receiving gentamicin for open fracture treatment, and gentamicin should be avoided in those >60 years of age.

LEVEL OF EVIDENCE

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Adverse effects of a single dose of gentamicin in adults: a systematic review

AIMS

To systematically review the frequency and type of adverse events associated with a single dose of intravenous or intramuscular gentamicin in adults, for any indication, in studies where a comparator was available.

METHODS

A review protocol was developed and registered (PROSPERO: CRD42013003229). Studies were eligible for review if they: recruited participants aged ≥16 years; used gentamicin intramuscularly or intravenously as a single one-off dose; compared gentamicin to another medication or placebo; and monitored adverse events. MEDLINE, EMBASE, Cochrane Library, trial registries, conference proceedings and other relevant databases were searched up to November 2016. Risk of bias was assessed on all included studies.

RESULTS

In total, 15 522 records were identified. After removal of duplicates, screening of title/abstracts for relevance and independent selection of full texts by two reviewers, 36 studies were included. Across all the included studies, 24 107 participants received a single one-off dose of gentamicin (doses ranged from 1 mg kg^-1 to 480 mg per dose). Acute kidney injury was described in 2520 participants receiving gentamicin. The large majority of cases were reversible. There were no cases of ototoxicity reported in patients receiving gentamicin. A meta-analysis was not performed due to study heterogeneity.

CONCLUSIONS

A significant number of patients saw a transient rise in creatinine after a single dose of gentamicin at doses up to 480 mg. Persistent renal impairment and other adverse events were relatively rare.

The use of high-dose dual-impregnated antibiotic-laden cement with hemiarthroplasty for the treatment of a fracture of the hip: The Fractured Hip Infection trial

Aims

A fracture of the hip is the most common serious orthopaedic injury, and surgical site infection (SSI) is one of the most significant complications, resulting in increased mortality, prolonged hospital stay and often the need for further surgery. Our aim was to determine whether high dose dual antibiotic impregnated bone cement decreases the rate of infection.

Patients and Methods

A quasi-randomised study of 848 patients with an intracapsular fracture of the hip was conducted in one large teaching hospital on two sites. All were treated with a hemiarthroplasty. A total of 448 patients received low dose single-antibiotic impregnated cement (control group) and 400 patients received high dose dual-antibiotic impregnated cement (intervention group). The primary outcome measure was deep SSI at one year after surgery.

Results

The rate of deep SSI was 3.5% in the control group and 1.1% in the intervention group (p = 0.041; logistic regression adjusting for age and gender). The overall rate of non-infective surgical complications did not differ between the two groups (unadjusted chi-squared test; p > 0.999).

Conclusion

The use of high dose dual-antibiotic impregnated cement in these patients significantly reduces the rate of SSI compared with standard low dose single antibiotic loaded bone cement.

Cite this article: Bone Joint J 2016;98-B:1534–1541.

What is the role of catheter antibiotic prophylaxis for patients undergoing joint arthroplasty?

BACKGROUND

Antimicrobial prophylaxis at the time of urinary catheter insertion and removal is commonly administered in patients undergoing joint arthroplasty, despite the lack of evidence to support this practice. The rationale is the theoretical risk of prosthetic joint infection arising from bacterial seeding from the urinary tract at the time of catheterization. In an era of antimicrobial stewardship, further assessment is warranted.

METHODS

This study aimed to investigate the incidence of catheter-associated (CA) bacteriuria and bacteraemia in patients undergoing total joint arthroplasty and to assess the antimicrobial susceptibility of any isolated microorganisms. This prospective observational study undertaken over a 6-month period (May to October 2014) included 99 patients undergoing elective primary hip and knee arthroplasty at St Vincent's Hospital, Melbourne. Urine specimens were collected at insertion and removal of urinary catheters along with blood cultures upon urinary catheter removal.

RESULTS

Overall 98% of the cohort received catheter antimicrobial prophylaxis for urinary catheter insertion and removal; the majority of patients received gentamicin (94%). Bacteriuria on catheter insertion had an incidence of 4.4%. The incidence of CA bacteriuria was 1.3%. All cultured organisms were sensitive to commonly used antibiotics including cephazolin. There were no cases of bacteraemia with urinary catheter removal. Increasing age, American Society of Anesthesiologists status and female gender were associated with the development of bacteriuria.

CONCLUSION

The incidence of CA bacteriuria and bacteraemia with antimicrobial prophylaxis is low. This study provokes discussion about the requirement of catheter prophylaxis in this surgical context and the utility of preoperative urine screening.

Clostridium difficile-associated diarrhoea in primary joint arthroplasty in Aneurin Bevan University Health Board South

INTRODUCTION

The choice of perioperative antibiotics to reduce the prevalence of infection after joint arthroplasty should be considered carefully to minimise the risk of nosocomial infections. Dramatic increases in the incidence and severity of healthcare-associated Clostridium difficile infection with Clostridium difficile-associated diarrhoea (CDAD) have occurred since 2000.

METHODS

A retrospective audit of patients who underwent total hip and total knee replacement between 1 January 2005 and 31 December 2007 was undertaken in Aneurin Bevan University Health Board South (ABHBS). Stool samples from patients who had diarrhoea <12 months of surgery were recorded. Positive samples for CDAD <1 month of surgery were identified. After the change in practice in June 2010, a re-audit linked joint-replacement patients between 1 July 2010 and 26 June 2013 with infection control-records for CDAD-positive cases.

RESULTS

In the first audit cycle, 1900 joint procedures were carried out in 1845 patients. There were 4 cases of CDAD <1 month of surgery (0.22%). In the re-audit period, 2591 joint procedures were undertaken in 2400 patients: no cases of CDAD <1 month of surgery were recorded. Fisher's exact test gave a two-tailed p=0.036.

CONCLUSIONS

The significant reduction in CDAD cases after the change in perioperative antibiotic regimen for primary joint arthroplasty mirrored a 66% reduction in overall CDAD cases in the ABUHBS between 2008 and 2012. This reduction was accompanied by financial savings in antibiotics and nursing hours.

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

Objectives

We wanted to investigate regional variations in the organisms reported to be causing peri-prosthetic infections and to report on prophylaxis regimens currently in use across England.

Methods

Analysis of data routinely collected by Public Health England’s (PHE) national surgical site infection database on elective primary hip and knee arthroplasty procedures between April 2010 and March 2013 to investigate regional variations in causative organisms. A separate national survey of 145 hospital Trusts (groups of hospitals under local management) in England routinely performing primary hip and/or knee arthroplasty was carried out by standard email questionnaire.

Results

Analysis of 189 858 elective primary hip and knee arthroplasty procedures and 1116 surgical site infections found statistically significant variations for some causative organism between regions. There was a 100% response rate to the prophylaxis questionnaire that showed substantial variation between individual trust guidelines. A number of regimens currently in use are inconsistent with the best available evidence.

Conclusions

The approach towards antibiotic prophylaxis in elective arthroplasty nationwide reveals substantial variation without clear justification. Only seven causative organisms are responsible for 89% of infections affecting primary hip and knee arthroplasty, which cannot justify such widespread variation between prophylactic antibiotic policies.

Cite this article: Bone Joint Res 2015;4:181–189.

The effect of triclosan coated sutures on rate of surgical site infection after hip and knee replacement: a protocol for a double-blind randomised controlled trial

Background

187,000 hip and knee joint replacements are performed every year in the National Health Service (NHS). One of the commonest complications is surgical site infection (SSI), and this represents a significant burden in terms of patient morbidity, mortality and cost to health services around the world. The aim of this randomised controlled trial (RCT) is to determine if the addition of triclosan coated sutures to a standard regimen can reduce the rate of SSI after total knee replacement (TKR) and total hip replacement (THR).

Methods

2400 patients due to undergo a total hip or knee replacement are being recruited into this two-centre RCT. Participants are recruited before surgery and randomised to either standard care or intervention group. Participants, outcome assessors and statistician are blind to treatment allocation throughout the study. The intervention consists of triclosan coated sutures vs. standard non-coated sutures. The primary outcome is the Health protection Agency (HPA) defined superficial surgical site infection at 30 days. Secondary outcomes include HPA defined deep surgical site infection at 12 months, length of hospital stay, critical care stay, and payer costs.

Discussion

To date there are no orthopaedic randomised controlled trials on this scale assessing the effectiveness of a surgical intervention, particularly those that can be translated across the surgical specialities. The results from this trial will inform evidence-based recommendations for suture selection in the management of patients undergoing total hip or knee replacement. If triclosan coated sutures are found to be an effective intervention, implementation into clinical practice could improve long-term outcomes for patients undergoing hip and knee replacement.

Trial registration

Current Controlled Trials ISRCTN 17807356.

Reduced short-term complications and mortality following Enhanced Recovery primary hip and knee arthroplasty: results from 6,000 consecutive procedures

BACKGROUND AND PURPOSE

Enhanced Recovery (ER) is a well-established multidisciplinary strategy in lower limb arthroplasty and was introduced in our department in May 2008. This retrospective study reviews short-term outcomes in a consecutive unselected series of 3,000 procedures (the "ER" group), and compares them to a numerically comparable cohort that had been operated on previously using a traditional protocol (the "Trad" group).

METHODS

Prospectively collected data on surgical endpoints (length of stay (LOS), return to theater (RTT), re-admission, and 30- and 90-day mortality) and medical complications (stroke, gastrointestinal bleeding, myocardial infarction, and pneumonia within 30 days; deep vein thrombosis and pulmonary embolism within 60 days) were compared. Results ER included 1,256 THR patients and 1,744 TKR patients (1,369 THRs and 1,631 TKRs in Trad). The median LOS in the ER group was reduced (3 days vs. 6 days; p = 0.01). Blood transfusion rate was also reduced (7.6% vs. 23%; p < 0.001), as was RTT rate (p = 0.05). The 30-day incidence of myocardial infarction declined (0.4% vs. 0.9%; p = 0.03) while that of stroke, gastrointestinal bleeding, pneumonia, deep vein thrombosis, and pulmonary embolism was not statistically significantly different. Mortality at 30 days and at 90 days was 0.1% and 0.5%, respectively, as compared to 0.5% and 0.8% using the traditional protocol (p = 0.03 and p = 0.1, respectively).

INTERPRETATION

This is the largest study of ER arthroplasty, and provides safety data on a consecutive unselected series. The program has achieved a statistically significant reduction in LOS and in cardiac ischemic events for our patients, with a near-significant decrease in return to theater and in mortality rates.

The effect of high dose antibiotic impregnated cement on rate of surgical site infection after hip hemiarthroplasty for fractured neck of femur: a protocol for a double-blind quasi randomised controlled trial

Background

Mortality following hip hemiarthroplasty is in the range of 10-40% in the first year, with much attributed to post-operative complications. One such complication is surgical site infection (SSI), which at the start of this trial affected 4.68% of patients in the UK having this operation. Compared to SSI rates of elective hip surgery, at less than 1%, this figure is elevated. The aim of this quasi randomised controlled trial (RCT) is to determine if high dose antibiotic impregnated cement can reduce the SSI in patients at 12-months after hemiarthroplasty for intracapsular fractured neck of femur.

Methods

848 patients with an intracapsular fractured neck of femur requiring a hip hemiarthroplasty are been recruited into this two-centre double-blind quasi RCT. Participants were recruited before surgery and quasi randomised to standard care or intervention group. Participants, statistician and outcome assessors were blind to treatment allocation throughout the study. The intervention consisted of high dose antibiotic impregnated cement consisting of 1 gram Clindamycin and 1 gram of Gentamicin. The primary outcome is Health Protection Agency (HPA) defined deep surgical site infection at 12 months. Secondary outcomes include HPA defined superficial surgical site infection at 30 days, 30 and 90-day mortality, length of hospital stay, critical care stay, and complications.

Discussion

Large randomised controlled trials assessing the effectiveness of a surgical intervention are uncommon, particularly in the speciality of orthopaedics. The results from this trial will inform evidence-based recommendations for antibiotic impregnated cement in the management of patients with a fractured neck of femur undergoing a hip hemiarthroplasty. If high dose antibiotic impregnated cement is found to be an effective intervention, implementation into clinical practice could improve long-term outcomes for patients undergoing hip hemiarthroplasty.

Trial registration

Current Controlled Trials: ISRCTN25633145

Oral versus intravenous tranexamic acid in enhanced-recovery primary total hip and knee replacement

In our department we use an enhanced recovery protocol for joint replacement of the lower limb. This incorporates the use of intravenous tranexamic acid (IVTA; 15 mg/kg) at the induction of anaesthesia. Recently there was a national shortage of IVTA for 18 weeks; during this period all patients received an oral preparation of tranexamic acid (OTA; 25 mg/kg). This retrospective study compares the safety (surgical and medical complications) and efficacy (reduction of transfusion requirements) of OTA and IVTA. During the study period a total of 2698 patients received IVTA and 302 received OTA. After adjusting for a range of patient and surgical factors, the odds ratio (OR) of receiving a blood transfusion was significantly higher with IVTA than with OTA (OR 0.48 (95% confidence interval 0.26 to 0.89), p = 0.019), whereas the safety profile was similar, based on length of stay, rate of readmission, return to theatre, deep infection, stroke, gastrointestinal bleeding, myocardial infarction, pneumonia, deep-vein thrombosis and pulmonary embolism. The financial benefit of OTA is £2.04 for a 70 kg patient; this is amplified when the cost saving associated with significantly fewer blood transfusions is considered.

Although the number of patients in the study is modest, this work supports the use of OTA, and we recommend that a randomised trial be undertaken to compare the different methods of administering tranexamic acid.

Cite this article: Bone Joint J 2013;95-B:1556–61.