Perioperative Antibiotic Prophylaxis in Total Joint Arthroplasty: A Single Dose Is as Effective as Multiple Doses

The impact of surgical approach in total hip arthroplasty on the organisms profile of periprosthetic joint infections? A systematic review and meta-analysis

PURPOSE

To investigate the impact of the surgical approach in total hip arthroplasty (THA) on the organism profile associated with periprosthetic joint infections (PJI).

METHODS

This systematic review and meta-analysis rigorously followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Four online databases (Medline, Embase, Web of Science, Scopus) were searched from inception till the 2nd of Sep 2023. The focus was all articles reporting the organism profile of hip periprosthetic joint infections in relation to the utilized surgical approach. Exclusion criteria encompassed studies lacking infecting organism specification by surgical approach, technical studies, review articles, case reports, non-English articles and inaccessible full-text articles. Quality assessment was done utilizing the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

A total of 529 microorganism profiles associated with 285 PJIs were analyzed from 11 studies including 44,271 THA patients. The overall rate of PJI in THA noted in the included studies is 0.64%. No significant difference between the direct anterior approach (DAA) and THA other approaches was noted in the incidence of PJI (OR 1.06, 95% CI [0.67, 1.67], p = 0.92). Similarly, no significant difference between the DAA and other THA approaches was noted in the incidence of gram-negative pathogen induced PJI (OR 3.35, 95% CI [0.49, 22.88], p = 0.22).

CONCLUSION

The overall rate of PJI in THA remain low. Utilization of DAA does not increase the risk of PJI compared to other approaches. Further, DAA does not increase the incidence of gram-negative pathogen induced PJI in THA. However, the available evidence on the organism profile based on the surgical approach is limited, and further studies are needed to make robust conclusions.

Cefazolin is Associated with a Lower Periprosthetic Joint Infection Risk than Alternative Antibiotic Regimens Following Total Hip Arthroplasty

INTRODUCTION

There have been conflicting reports on the risk of periprosthetic joint infection (PJI) with the use of alternative antibiotics to cefazolin following arthroplasty. We leveraged recent data from a nationally representative multi-payer dataset to investigate this question.

METHODS

We queried a healthcare dataset from 2016 to 2022 to identify primary total hip arthroplasties (THAs) using Current Procedural Terminology (CPT) and International Classification of Disease-Procedure Coding System (ICD-PCS) codes (27130, 0SR90xx, 0SRB0xx) with a corresponding osteoarthritis diagnosis (International Classification of Disease-Clinical Modification (ICD-CM): M16). Patient demographics, characteristics, and outcomes were extracted from existing dataset variables. The PJIs were defined using ICD-10 diagnosis codes from the Centers for Medicare & Medicaid Services' procedure-specific complication measure within 90 days of surgery. We compared PJI between patients receiving cefazolin antibiotic prophylaxis and patients who received an alternative antibiotic or cefazolin plus another antibiotic. The association between cefazolin use and PJI was evaluated using multinomial logistic regression. This study included 289,369 primary THA patients from 2016 to 2022. There were 25,164 patients (8.7%) who received a non-cefazolin antibiotic, 200,367 (69.2%) received cefazolin only, and 63,838 (22.1%) received cefazolin plus an alternative antibiotic.

RESULTS

In univariate analysis, there was a significant difference in the rate of 90-day PJI between the non-cefazolin group, cefazolin only, and cefazolin plus other antibiotic group (0.9, 0.5, and 0.5%, respectively, P < 0.001). In a logistic regression analysis that adjusted for age, sex, payer, race, ethnicity, and Elixhauser Comorbidity Index, the use of cefazolin only and cefazolin plus other antibiotic, were associated with reduced risk of 90-day PJI [OR (odds ratio) 0.62, 95% CI (confidence interval) (0.53 to 0.72), P < 0.001] and [OR 0.64, 95% CI (0.54 to 0.76), P < 0.001].

CONCLUSIONS

In this nationally representative multi-payer study using recent data, patients who received antibiotic prophylaxis with cefazolin had lower 90-day rates of PJI compared to those receiving alternative antibiotics during primary total hip arthroplasty.

Comparison of Surgical Site Infection After Instrumented Spine Surgery in Patients With High Risk of Infection According to Different Antibiotic Prophylaxis Protocols: A Cohort Study of 132 Patients With a Minimum Follow-Up of 1 year

Study DesignObservational Study.ObjectivesSurgical site infections (SSIs) are one of the major complications in spine surgery. Numerous factors that increase the risk of SSI have been widely described. However, clinical guidelines on antibiotic prophylaxis are usually common for all patients. There are no specific guidelines for patients with a high risk of infection. The aim of this paper is to create a specific protocol for patients at high risk of SSI.MethodsThis is a three-cohort study using a prospective database. Risk patients are those who meet at least two of the following criteria: obesity, diabetes, reoperation and immunosuppression. Between October 2021 and April 2023, 132 patients were recruited.They were divided into three cohorts: cohort A, 46 patients, standard prophylaxis with cefazolin 2 g/8 h for 24 h; cohort B, 46 patients, cefazolin 2 g/8h and amikacin 500 mg/12 h for 24 h; cohort C, 40 patients, cefazolin 2 g/8h and amikacin 500 mg/12 h for 72 h.ResultsThere was a significant decrease in the infection rate depending on the prophylaxis (23.9% in cohort A, 8.7% in cohort B, and 2.5% in cohort C). When logistic regression models were applied and cohorts B and C were compared with A, the following results were obtained: OR of 0.30 (CI: 0.08 - 0.97; P = 0.057) and 0.08 (IC: 0.00 - 0.45; P = 0.019), respectively.ConclusionsProphylaxis with prolonged double antibiotic therapy with cefazolin and amikacin is associated with a statistically significant decrease in the rate of SSI in patients with a high risk of infection.

How many doses and what type of antibiotic should be used as systemic antibiotic prophylaxis in primary hip and knee arthroplasty? A register-based study on 301,204 primary total and hemi- hip and total knee arthroplasties in Norway 2005-2023

BACKGROUND AND PURPOSE

 Guidelines for systemic antibiotic prophylaxis (SAP) in arthroplasty surgery vary worldwide from repeated doses to only 1 preoperatively. We aimed to investigate, primarily whether 4 doses reduced the risk of PJI compared with 1 to 3 doses, and secondarily if there was a difference between types of antibiotics.

METHODS

 Patients reported to the Norwegian Arthroplasty Register and the Norwegian Hip Fracture Register with primary total knee (TKA), total (THA) or hemi- (HA) hip arthroplasty between 2005 and 2023 were included. Cases with 1 to 4 doses of cefalotin (half-life = 45 minutes), cefazolin (90 minutes), cefuroxime (70 minutes), cloxacillin (30 minutes), or clindamycin (180 minutes) were assessed. Primary outcome was 1-year risk of reoperation (adjusted hazard rate ratio; aHRR) for PJI and was estimated by Cox regression analyses. Secondary outcomes were reoperation for PJI and reoperation for any cause with follow-up of up to 19 years. Non-inferiority analyses and propensity score matching with subsequent Kaplan-Meier analyses were performed with a predetermined non-inferiority margin of 15% (aHRR = 1.15).

RESULTS

 301,204 cases were included. Of these, 3,388 (1.1%) were reoperated on for PJI within 1 year. The 1-year incidence of reoperation for PJI was 98/9,760 (1.0%) for 1 dose of SAP, 109/10,956 (0.9%) for 2 doses, 178/18,948 (0.9 %) for 3 doses, and 3,003/261,540 (1.0%) for 4 doses. The 1-year risk (aHRR, 95% confidence interval [CI]) of reoperation for PJI was 1.0 (CI 0.8-1.2), 0.9 (CI 0.8-1.2), and 0.9 (CI 0.9-1.1) for 1, 2, and 3 doses, respectively, compared with 4 doses. The 1-year incidence of reoperation for PJI was 2,162/183,964 (1.2%) for cefalotin, 993/91,159 (1.1%) for cefazolin, 35/4,435 (0.8%) for cefuroxime, 85/9,022 (0.9%) for cloxacillin, and 113/12,624 (0.9%) for clindamycin. Compared with cefazolin, cloxacillin (1.2, CI 1.0-1.6) and cefalotin (1.4, CI 1.2-1.5) had a higher risk of reoperation for PJI, whereas cefuroxime (1.0, CI 0.7-1.4) and clindamycin (1.1, CI 0.9-1.3) had a similar risk.

CONCLUSION

 4 doses of SAP did not reduce the risk of PJI compared with 1 to 3 doses in primary arthroplasty as measured against PJI. Cefazolin, the 1st-generation cephalosporin with the longest half-life, showed the lowest risk of PJI.

Increased rates of periprosthetic joint infection following hip hemiarthroplasty with clindamycin prophylaxis compared to cefazolin

PURPOSE

To compare the efficacy of clindamycin versus cefazolin in preventing periprosthetic joint infection (PJI) in patients undergoing hip hemiarthroplasty (HA) for femoral neck fractures.

METHODS

This retrospective cohort study included 1,139 patients aged ≥ 65 years who underwent HA for femoral neck fractures between January 2017 and October 2023. Patients received either Cefazolin + Gentamicin (n = 1001) or Clindamycin + Gentamicin (n = 138). Propensity score matching was performed at a 6:1 ratio, resulting in 828 patients in the cefazolin group and 138 in the clindamycin group. PJI rates, causative organisms, and mortality were compared. Multivariate logistic regression adjusted for potential confounders.

RESULTS

The PJI rate was significantly higher in the clindamycin group compared to the cefazolin group (7.2% vs. 3.5%, p = 0.042). Multivariate analysis confirmed that clindamycin prophylaxis was independently associated with increased PJI risk (adjusted OR = 2.41, 95% CI: 1.16-4.99, p = 0.018). Other independent risk factors for PJI included age (adjusted OR = 1.03 per year, 95% CI: 1.01-1.05, p = 0.045), diabetes mellitus (adjusted OR = 1.76, 95% CI: 1.10-2.81, p = 0.018), and surgery duration (adjusted OR = 1.07 per minute, 95% CI: 1.01-1.16, p = 0.035). Staphylococcus aureus was the most common pathogen, with no significant differences in bacterial distribution between the groups. No significant differences were found in 30-day or 1-year mortality rates.

CONCLUSION

Clindamycin prophylaxis in hip hemiarthroplasty for femoral neck fractures is associated with a significantly higher risk of PJI compared to cefazolin. These findings support the preferential use of cefazolin in patients without contraindications and demonstrate the critical need for accurate assessment of reported beta-lactam allergies. Results suggest potential benefit from pre-operative allergy evaluation when feasible, as alternative prophylaxis choices may carry increased infection risk. Further research is needed to explore alternative prophylactic strategies for patients with beta-lactam allergies.

Intra-articular injection of vancomycin after arthrotomy closure following gentamicin-impregnated bone cementation in primary total knee arthroplasty provides a high intra-articular concentration while avoiding systemic toxicity: a prospective study

BACKGROUND

This study aimed to elucidate the safety and intra-articular elution profiles of vancomycin and gentamicin bone cement in patients undergoing primary total knee arthroplasty (TKA), with a focus on serum safety thresholds and therapeutic efficacy.

METHODS

Consecutive patients who underwent unilateral primary TKA were prospectively enrolled. The implants were fixed using gentamicin-impregnated bone cement, and after arthrotomy closure, 1000 mg of vancomycin suspended in 25 mL of normal saline was directly injected into the joint. Peripheral venous blood and drain fluid samples were collected 2, 8, and 24 h postoperatively. The serum and intra-articular concentrations of vancomycin and gentamicin were analyzed using liquid chromatography-tandem mass spectrometry within 24 h.

RESULTS

Clinical data reflecting renal and liver function were recorded preoperatively, and at 24 and 72 h postoperatively. A total of 100 patients were included. At 2, 8, and 24 h postoperatively, the serum vancomycin concentration was 7.0 ± 2.0, 5.7 ± 1.8, and 3.6 ± 1.4 µg/mL, respectively, while the intra-articular concentration was 468.5 (interquartile range [IQR] 286.0 to 774.8), 139.5 (IQR 52.0 to 295.3), and 34.4 (IQR 22.2 to 56.8) µg/mL, respectively; 33.2 (IQR 19.5 to 80.5) mg vancomycin was lost in drainage fluid at 24 h postoperatively. For gentamicin, the overall intra-articular concentration was 70.4 (IQR 35.4 to 109.2), 33.8 (IQR 17.8 to 73.9), and 21.1 (IQR 12.2 to 36.0) µg/mL at 2, 8, and 24 h postoperatively, respectively, with an undetectable serum concentration. No cases of acute renal injury, liver injury, ototoxicity, or anaphylaxis were observed.

CONCLUSIONS

Intra-articular injection of 1000 mg vancomycin after arthrotomy closure combined with gentamicin-impregnated bone cement provided a therapeutic intra-articular concentration while avoiding systemic toxicity over the initial 24 h after primary TKA. Therefore, intra-articular vancomycin administration may offer a safer alternative to intravenous antibiotics, reducing systemic toxicity; however, further large-scale studies are necessary.

TRIAL REGISTRATION

ClinicalTrials. Gov (registration number: NCT05338021).

Single-Dose Versus Extended Antibiotic Prophylaxis in Primary Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis

The optimal duration of antibiotic prophylaxis for patients undergoing primary hip or knee arthroplasty remains debated. We conducted a systematic review and meta-analysis to compare the outcomes of single-dose versus extended antibiotic prophylaxis. Studies assessing these strategies for periprosthetic joint infection (PJI), revision surgery, and superficial surgical site infections were selected from systematic searches in PubMed, Embase, and the Cochrane Library. Results were synthesized using random-effects meta-analysis models. Nine studies were included, covering 295,654 patients - 125,489 undergoing total knee arthroplasty and 172,055 undergoing total hip arthroplasty. A significant statistical difference in the incidence of PJI favored single-dose over extended antibiotic prophylaxis (OR 0.78; 95% CI 0.63-0.98; I² = 0%). Our meta-analysis suggests that a single-dose prophylactic antibiotic regimen may be preferable for reducing PJI incidence in primary total hip and knee arthroplasty.

Number of Doses of Systemic Antibiotic Prophylaxis May Be Reduced in Cemented Primary Knee Arthroplasty Irrespective of Use of Antibiotic in the Cement: A Multiregistry-Based Meta-Analysis

Background

The use of systemic antibiotic prophylaxis (SAP) and antibiotic-loaded bone cement (ALBC) is the accepted practice to reduce the risk of periprosthetic joint infection (PJI) in primary total knee arthroplasty (pTKA). However, practice varies internationally. This study's primary aim was to compare the risk of PJI revision after pTKA with ALBC + SAP vs. plain bone cement (PBC) + SAP, and the secondary aim was to assess whether the risk of PJI revision varies with the number of SAP doses.

Methods

Cohort of 289,926 pTKAs for osteoarthritis from arthroplasty registries in Denmark, New Zealand, Norway, Romania, and United States registered from 2010 to 2020. One-year revision for PJI following pTKA with ALBC + SAP vs. PBC + SAP, and single vs. multiple SAP doses was compared. We computed cumulative percent revision (1 minus Kaplan-Meier) using distributed analysis method and adjusted hazard rate ratios (HRRs) using Cox regression analyses within each registry. Advanced distributed meta-analysis was performed to summarize HRRs from all countries.

Results

Among all pTKAs, 64.4% were performed with ALBC + SAP. Each registry reported a 1-year cumulative percent revision for PJI of <1.00% for both pTKAs with ALBC + SAP (0.34%-0.80%) and with PBC + SAP (0.54%-0.69%). The distributed meta-analysis showed HRR = 1.21; (95% confidence interval [CI], 0.79-1.87) for ALBC + SAP compared with PBC + SAP. Similar risk of PJI revision was observed between pTKAs with ALBC + single vs. multiple doses of SAP: 2 doses (0.95; 95% CI, 0.68-1.33), 3 doses (1.09; 95% CI, 0.64-1.87), and 4 doses (1.23; 95% CI, 0.69-2.21). Comparable results were found for the PBC + SAP group except for higher risk of PJI revision with 4 doses of SAP (2.74; 95% CI, 1.11-6.75).

Conclusions

ALBC and PBC entailed similar risk of PJI revision when patients received SAP in pTKA, regardless of number of SAP doses. ALBC or PBC used in combination with SAP in pTKAs, with one single preoperative dose of SAP may be sufficient without compromising the patient safety.

Level of evidence

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

Not so Fast: Extended Oral Antibiotic Prophylaxis Does Not Reduce 90-Day Infection Rate Following Joint Arthroplasty

BACKGROUND

Periprosthetic joint infection (PJI) is a devastating complication following both total hip (THA) and knee (TKA) arthroplasty. Extended oral antibiotic (EOA) prophylaxis has been reported to reduce PJI following TJA in high-risk patients. The purpose of this study was to determine if EOA reduces PJI in all-comers and high-risk THA and TKA populations.

METHODS

This is a retrospective cohort study, including 4,576 patients undergoing primary THA or TKA at a single institution from 2018 to 2022. Beginning in 2020, EOA prophylaxis was administered for 10 days following THA or TKA at our institution. Patients were separated into 2 cohorts (1,769 EOA, 2,807 no EOA) based on whether they received postoperative EOA. The 90-day and 1-year outcomes, with a focus on PJI, were then compared between groups. A subgroup analysis of high-risk patients was also performed.

RESULTS

There was no difference in 90-day PJI rates between cohorts (EOA 1 versus no EOA 0.8%; P = .6). The difference in the rate of PJI remained insignificant at 1 year (EOA 1 versus no EOA 1%; P = .9). Similarly, our subgroup analysis of high-risk patients demonstrated no difference in postoperative PJI between EOA (n = 254) and no EOA (n = 396) (0.8 versus 2.3%, respectively; P = .2). Reassuringly, we also found no differences in the incidence of Clostridium difficile infection (EOA 0.1 versus no EOA 0.1%; P > .9) or in antibiotic resistance among those who developed PJI within 90 days (EOA 59 versus no EOA 83%; P = .2).

CONCLUSIONS

With the numbers available for analysis, EOA prophylaxis was not associated with PJI risk reduction following primary TJA when universally deployed. Furthermore, among high-risk patients, there was no statistically significant difference. While we did not identify increased antibiotic resistance or Clostridium difficile infection, we cannot recommend wide-spread adoption of EOA prophylaxis, and clarification regarding the role of EOA, even in high-risk patients, is needed.

Patterns of antibiotic prescription in implant dentistry and antibiotic resistance awareness among European dentists: A questionnaire-based study

OBJECTIVES

Antimicrobial resistance is an alarming global public health concern, threatening the effective treatment of common infections. This phenomenon is driven by the improper prescription of antibiotics. This study aimed to elucidate the patterns of antibiotic prescription in implant dentistry among European dentists and their awareness of antibiotic resistance.

MATERIALS AND METHODS

An anonymous online validated questionnaire was distributed via e-mail to 6431 recipients through the European Association for Osseointegration. It comprised of 17 structured questions investigating demographic variables, working environment, clinical experience, attitude towards antibiotic prescription in particular in relation to implant dentistry and COVID-19 pandemic, and awareness of antibiotic resistance. Data were collected from April to May 2023.

RESULTS

281 dentists from 33 European countries completed the survey. Almost 80% affirmed to routinely prescribe antibiotics as prophylaxis as well as after dental implant placement, especially in medically compromised patients or in cases of bone grafting. Amoxicillin, alone (61%) or in combination with clavulanic acid (56%), was the most common antibiotic of choice. Awareness of penicillin resistance among respondents was high. For peri-implantitis treatment, more than half reported the use of systemic antibiotics. The large majority (95%) did not prescribe more antibiotics since the beginning of COVID-19 pandemic. Less than 40% declared to follow national guidelines for antibiotic prescription.

CONCLUSION

This survey revealed a high prescription rate of antibiotics in implant dentistry, despite the awareness about antibiotic resistance among the respondents. The development and adherence to European guidelines has been identified as a potential strategy for improving antimicrobial stewardship.

Additional doses of prophylactic antibiotics post-arthroplasty: Are there any benefits?

Guidelines for prophylactic antibiotic administration in total joint replacement vary considerably in terms of drug, dosage, route of administration and duration of cover. Despite the range of treatment options available, infection remains the most common reason for arthroplasty failure in the decades following a procedure, simultaneously increasing health care costs and lowering patient satisfaction considerably. This work aims to evaluate whether there are benefits to administering further doses of antibiotic post-arthroplasty, in addition to the recommendations of current protocols. We present a review of evidence surrounding infection rates in a variety of prophylactic regimens, and weigh this against further considerations such as cost to the patient and risks of nephrotoxicity. In summary, the available evidence does not suggest a benefit to administering additional doses post-arthroplasty in most cases. However, further doses may benefit those deemed at high risk of infection, or those in areas of high methicillin-resistant Staphylococcus aureus prevalence.

Perioperative Differences Between Outpatient and Inpatient Pathways Following Hip and Knee Arthroplasty

Background

Optimization of clinical pathways and logistics led to the introduction of outpatient joint arthroplasty of the hip and knee. Nevertheless, little is known about what these current protocols look like and how they differ from "standard" inpatient protocols. This study aimed to find preoperative, intraoperative, and postoperative differences between outpatient and inpatient pathways.

Methods

A questionnaire (ranging between 23 and 37 items) was developed and administered by email to orthopedic surgeons who were a member of the Dutch Hip Society and Dutch Knee Society. Survey response rate was 38% (N = 117).

Results

No significant differences were found in preoperative pathway characteristics. The administration regime for tranexamic acid significantly differed between outpatient and inpatient pathways (P < .001 and P = .002 for hip and knee arthroplasty, respectively), with outpatient pathways using a combined (eg, oral and intravenous) administration regime more frequently. The perioperative antibiotic prophylaxis regime also significantly differed between outpatient and inpatient pathways (P < .001 and P = .014, respectively), with outpatient pathways more frequently incorporating fewer antibiotic doses. Same-day postoperative mobilization significantly less often occurred if surgery took place later that day in inpatient hip arthroplasty pathways (24%; P = .034). Postoperative hemoglobin-check occurred significantly more often on indication in outpatient than in inpatient hip and knee arthroplasty pathways (∼75% vs ∼25%; P = .001).

Conclusions

Few intraoperative and postoperative differences in outpatient and inpatient pathways were found and probably mainly relied on logistical grounds. Nonetheless, findings suggested that outpatient pathways tended to be more up-to-date and innovative than inpatient pathways.

Supportive Care of Hematopoietic Stem Cell Donors

Supportive care needs for hematopoietic stem cell recipients have been studied. Less is known about the care needs of stem cell donors. Care challenges arise at donor selection, preparation for the donation, the donation procedure and the immediate and long-term after-care. Care needs were analyzed for 1,831 consecutive bone marrow and peripheral stem cell donors at MedStar Georgetown University Hospital between January 2018 and August 2023 in support of a review of the current literature. During the selection, related donors may experience psychological pressures affecting their motivation, while donation centers may be willing to accept co-morbidities in these donors which might preclude donation in unrelated peers. For bone marrow donations, it is important to select donors not only according to optimal genetic matching criteria but also according to suitable donor/recipient weight ratios, to facilitate sufficient stem cell yields. During the donation preparation phase, side effects and complications related to stem cell stimulation must be anticipated and managed for peripheral cell donors, while the pros and cons of autologous blood donation should be evaluated carefully for bone marrow donors. The stem cell donation procedure itself carries potential side effects and complications as well. Peripheral cell donors may require a central line and may encounter hypocalcemia, thrombocytopenia, and anemia. Bone marrow donors face risks associated with anesthesia, blood loss and pain. Post-procedure care focusses on pain management, blood cell recovery and the psychological support necessary to regain a high quality-of-life existence. Hematopoietic stem donors are giving part of themselves to save another's life. They deserve comprehensive supportive care to accompany them throughout the donation process.

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.

Using antibiotics wisely

PURPOSE OF REVIEW

This review will describe role of shorter antibiotic therapies, early switch from intravenous to oral therapy, and artificial intelligence in infectious diseases.

RECENT FINDINGS

There is evidence that shorter courses of antibiotics are noninferior to standard durations of therapy. This has been demonstrated with Enterobacterales bacteremia that can be treated with 7 days of therapy, community acquired pneumonia with 3 days and ventilator associated pneumonia with just 7 days of antibiotic therapy. The conversion from intravenous to oral therapy in treating bacteremia, endocarditis and bone and joint infections is safe and effective and reduces line complications and costs. Also, for clean surgical procedures only one dose of antibiotic is needed, but it should be the most effective antibiotic which is cefazolin. This means avoiding clindamycin, removing penicillin allergies where possible for improved outcomes. Finally, the role of artificial intelligence to incorporate into using antibiotics wisely is rapidly emerging but is still in early stages.

SUMMARY

In using antibiotics wisely, targeting such as durations of therapy and conversion from intravenous antibiotic therapy to oral are low hanging fruit. The future of artificial intelligence could automate a lot of this work and is exciting but needs to be proven.

VIDEO ABSTRACT

http://links.lww.com/COID/A50.

Variation of Practice in Prophylactic Protocol to Reduce Prosthetic Joint Infection in Primary Hip and Knee Arthroplasty: A National Survey in the United Kingdom

Purpose

Prosthetic joint infection (PJI) has an enormous physiological and psychological burden on patients. Surgeons rightly wish to minimise this risk. It has been shown that a standardised, evidence-based approach to perioperative care leads to better patient outcomes. A review of current practice was conducted using a cross-sectional survey among surgeons at multiple centers nationwide.

Materials and Methods

An 11-question electronic survey was circulated to hip and knee arthroplasty consultants nationally via the BOA (British Orthopaedic Association) e-newsletter.

Results

The respondents included 56 consultants working across 19 different trusts. Thirty-four (60.7%) screen patients for asymptomatic bacteriuria (ASB) preoperatively, with 19 (55.9%) would treating with antibiotics. Fifty-six (100%) screen for methicillin-resistant Staphylococcus aureus and treat if positive. Only 15 (26.8%) screen for methicillin-sensitive S. aureus (MSSA) or empirically eradicate. Zero (0%) routinely catheterise patients perioperatively. Forty-one (73.2%) would give intramuscular or intravenous gentamicin for a perioperative catheterisation. All surgeons use laminar flow theatres. Twenty-six (46.4%) use only an impervious gown, 6 (10.7%) exhaust pipes, and 24 (42.3%) surgical helmet system. Five different antimicrobial prophylaxis regimens are used 9 (16.1%) cefuroxime, 2 (3.6%) flucloxacillin, 19 (33.9%) flucloxacillin and gentamicin, 10 (17.9%) teicoplanin, 16 (28.6%) teicoplanin and gentamicin. Twenty-two (39.3%) routinely give further doses.

Conclusion

ASB screening, treatment and intramuscular gentamicin for perioperative catheterisation is routinely practiced despite no supporting evidence base. MSSA screening and treatment is underutilised. Multiple antibiotic regimens exist despite little variation in organisms in PJI. Practice varies between surgeons and centers, we should all be practicing evidence-based medicine.

Effect of single versus multiple prophylactic antibiotic doses on prosthetic joint infections following primary total hip arthroplasty in patients with osteoarthritis at public and private hospitals in Denmark: protocol for a nationwide cross-over, cluster randomised, non-inferiority trial [The Pro-Hip-Quality Trial]

INTRODUCTION

A feared complication after total hip arthroplasty (THA) is prosthetic joint infection (PJI), associated with high morbidity and mortality. Prophylactic antibiotics can reduce the risk of PJI. However, there is no consensus on the dosages and current recommendations are based on a low evidence level. The objective is to compare the effect of a single versus multiple doses of prophylactic antibiotics administered within 24 hours on PJI.

METHODS AND ANALYSIS

The study is designed as a cross-over, cluster randomised, non-inferiority trial. All clinical centres use both antibiotic practices (1 year of each intervention). All Danish orthopaedic surgery departments will be involved: Based on quality databases, 2-year cohorts of approximately 20 000 primary THAs conducted at 39 public and private hospitals, will be included.

INCLUSION CRITERIA

age ≥18 years, all indications for THA except patients operated due to acute or sequelae from proximal femoral or pelvic fractures or bone tumour or metastasis. The primary outcome is PJI within 90 days after primary THA. Secondary outcomes include (1) serious adverse events, (2) potential PJI, (3) length of hospitalisation stay, (4) cardiovascular events, (5) hospital-treated infections, (6) community-based antibiotic use, (7) opioid use and (8) use of acetaminophen and non-steroidal anti-inflammatory drugs. All outcome measures will be extracted from national databases. Analyses will be based on the intention-to-treat population. Non-inferiority will be shown if the upper limit of the two-sided 95% CI for the OR is less than 1.32 for the single dose as compared with multiple doses. The results will establish best practice on antibiotic prophylaxis dosages in the future.

ETHICS AND DISSEMINATION

This study has been approved by Committees on Health Research Ethics for The Capital Region of Denmark (21069108) and The Danish Medicines Agency (2021091723). All results will be presented in peer-reviewed medical journals and international conferences.

TRIAL REGISTRATION NUMBER

NCT05530551.

Antibiotic prophylaxis in clean and clean-contaminated plastic surgery: A critical review

Antibiotic prophylaxis is frequently used in plastic surgery procedures, despite the generally low rates of infection and few guidelines on the practice. The increasing prevalence of bacterial resistance to antibiotics calls for a reduction in unnecessary antibiotic use. The aim of this review was to create an updated summary of the available data on the effectiveness of antibiotic prophylaxis in reducing the postoperative infection in clean and clean-contaminated plastic surgery. A systematic literature search was performed on the databases Medline, Web of Science, and Scopus, limited to articles published January 2000 onward. Randomized controlled trials (RCTs) were included in the primary review, whereas older RCTs and other studies were sought if 2 or fewer relevant RCTs were identified. Overall, 28 relevant RCTs, 2 nonrandomized trials, and 15 cohort studies were identified. Although the number of studies for each type of surgery is limited, the data suggest that prophylactic systemic antibiotic may be unnecessary in noncontaminated facial plastic surgery, reduction mammaplasty, and breast augmentation. In addition, no benefit is apparent from extending the antibiotic prophylaxis over 24 h in rhinoplasty, aerodigestive tract reconstruction, and breast reconstruction. No studies assessing the necessity of antibiotic prophylaxis in abdominoplasty, lipotransfer, soft tissue tumor surgery, or gender affirmation surgery were identified. In conclusion, limited data are available on the effectiveness of antibiotic prophylaxis in clean and clean-contaminated plastic surgery. More studies on this topic are needed before strong recommendations can be made on the use of antibiotics in this setting.

Dose optimization in surgical prophylaxis: sub-inhibitory dosing of vancomycin increases rates of biofilm formation and the rates of surgical site infection

Antibiotic stewardship is viewed as having great public health benefit with limited direct benefit to the patient at the time of administration. The objective of our study was to determine if inappropriate administration of antibiotics could create conditions that would increase the rates of surgical infection. We hypothesized that sub-MIC levels of vancomycin would increase Staphylococcus aureus growth, biofilm formation, and rates of infection. S. aureus MRSA and MSSA strains were used for all experiments. Bacteria were grown planktonically and monitored using spectrophotometry. Quantitative agar culture was used to measure planktonic and biofilm bacterial burden. A mouse abscess model was used to confirm phenotypes in vivo. In the planktonic growth assay, increases in bacterial burden at ¼ MIC vancomycin were observed in USA300 JE2 by 72 h. Similar findings were observed with ½ MIC in Newman and SH1000. For biofilm formation, USA300 JE2 at ¼ and ½ MIC vancomycin increased biofilm formation by approximately 1.3- and 2.3-fold respectively at 72 h as compared to untreated controls. Similar findings were observed with Newman and SH1000 with a 2.4-fold increase in biofilm formation at ½ MIC vancomycin. In a mouse abscess model, there was a 1.2-fold increase with sub-MIC vancomycin at 3 days post infection. Our study showed that Sub-optimal vancomycin dosing promoted S. aureus planktonic growth and biofilm formation, phenotypic measures of bacterial virulence. This phenotype induced by sub-MIC levels of vancomycin was also observed to increase rates of infection and pathogenesis in our mouse model. Risks of exposure to sub-MIC concentrations with vancomycin in surgical procedures are greater as there is decreased bioavailability in tissue in comparison to other antibiotics. This highlights the importance of proper antibiotic selection, stewardship, and dosing for both surgical prophylaxis and treatment of infection.

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.

Prevention Techniques Have Had Minimal Impact on the Population Rate of Prosthetic Joint Infection for Primary Total Hip and Knee Arthroplasty: A National Database Study

BACKGROUND

Several studies over the years have offered modalities that may greatly decrease the rate of periprosthetic joint infection when implemented. As a result, one would expect a drastic decrease in infection rate among the implementing population with its widespread use. The purpose of this study was to assess whether there exists a decrease in infection rate over time, after accounting for available confounding variables, within a large national database.

METHODS

A large national database from 2005 to 2019 was queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). In total, 221,416 THAs and 354,049 TKAs were performed over the study period. Differences in 30-day infection rate were assessed with time and available preoperative risk factors using multinominal logistic regressions.

RESULTS

Rate of infection overall trended downward for both THA and TKA. After accounting for confounding variables, odds of THA infection marginally decreased over time (odds ratio 0.968 [0.952-0.985], P < .0001), while the odds of a TKA infection marginally increased with time (odds ratio 1.037 [1.020-1.054], P < .0001).

CONCLUSION

Individual peer-reviewed publications have presented infection control modalities demonstrating dramatic decreases in infection rate while analysis at a population level shows almost no changes in infection rate over a 15-year time period. This study supports continued investigation for influential modalities in preventing periprosthetic joint infection and care in patient selection for primary hip and knee arthroplasty.

Postoperative fever: differences between elective vs. traumatic hip, knee and shoulder arthroplasty

BACKGROUND

It is unclear whether there is a difference in the incidence of postoperative fever (POF) between hip, knee and shoulder arthroplasty. The influence of a trauma setting has not been investigated.

METHODS

A retrospective review was performed on 675 joint replacement surgeries (hip, knee, shoulder arthroplasty) in an elective or trauma setting over a 2 year period (2016-2018). Patient demographics and perioperative/postoperative parameters were investigated. The fever curve was characterized. The results and costs of any fever-related diagnostic workup were reviewed.

RESULTS

A total of 89 patients (13.2%) experienced a POF ≥ 38.0 °C, only 21 patients (3.1%) a POF ≥ 38.5 °C (of the latter: 4.6% of hip arthroplasties, 0.6% of knee arthroplasties, 0% of shoulder arthroplasties). There was a significantly greater risk (OR 3.88) for POF ≥ 38.5 °C in trauma total hip arthroplasty (THA) compared to elective THA (10.6 vs. 3.0%; p < 0.01). Differences in POF rate between the various joint areas were statistically insignificant when comparing only elective and trauma cases with each other, even though there was a trend for higher rates in hip surgery. Patients experiencing POF ≥ 38.5 °C were more often males (p < 0.01) and had an increased intraoperative blood loss (p = 0.03) and longer hospital stay (p < 0.01). There was only 1/89 POF patients developing an early periprosthetic joint infection. The cost of a positive fever workup (3/27 patients, 11.1%) leading to a new diagnosis and treatment was 2045 US$.

CONCLUSION

POF ≥ 38.5 °C was more frequent in traumatic THA compared to elective THA. A trend of difference between POF rates between the different joint areas was statistically insignificant after separating elective and traumatic cases. The risk of developing an early periprosthetic joint infection was not increased in POF. A fever-related diagnostic workup was rarely helpful in the absence of clinical symptoms.

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.

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.

Cefadroxil-Induced Clostridium difficile Infection Following Total Knee Arthroplasty

Perioperative infection prophylaxis is a fundamental element of total knee arthroplasty (TKA). There has been a recent trend toward the use of extended postoperative oral antibiotics in high-risk patients. We describe a case report of a patient who underwent a primary TKA and subsequently developed Clostridium difficile colitis after an extended course of postoperative prophylactic oral cefadroxil. Following the C. difficile infection, the patient eventually developed bacteremia and a multidrug-resistant Escherichia coli prosthetic joint infection which required multiple debridements. Extended use of postoperative prophylactic oral cefadroxil may increase the risk of C. difficile-associated diarrhea. Additionally, our case suggests that C. difficile infection may subsequently increase the risk of bacteremia which could lead to prosthetic joint infection. More evidence is required to further define this risk.

The Cost-Effectiveness of Extended Oral Antibiotic Prophylaxis for Infection Prevention After Total Joint Arthroplasty in High-Risk Patients

BACKGROUND

Extended oral antibiotic prophylaxis may decrease rates of prosthetic joint infection (PJI) after total joint arthroplasty (TJA) in patients at high risk for infection. However, the cost-effectiveness of this practice is not clear. In this study, we used a break-even economic model to determine the cost-effectiveness of routine extended oral antibiotic prophylaxis for PJI prevention in high-risk TJA patients.

METHODS

Baseline PJI rates in high-risk patients, the cost of revision arthroplasty for PJI, and the costs of extended oral antibiotic prophylaxis regimens were obtained from the literature and institutional purchasing records. These variables were incorporated in a break-even economic model to calculate the absolute risk reduction (ARR) in infection rate necessary for extended oral antibiotic prophylaxis to be cost-effective. ARR was used to determine the number needed to treat (NNT).

RESULTS

Extended oral antibiotic prophylaxis with Cefadroxil in patients at high risk for PJI was cost-effective at an ARR in baseline infection rate of 0.187% (NNT = 535) and 0.151% (NNT = 662) for TKA and THA, respectively. Cost-effectiveness was preserved with varying costs of antibiotic regimens, PJI treatment costs, and infection rates.

CONCLUSION

The use of extended oral antibiotic prophylaxis may reduce PJI rates in patients at high risk for infection following TJA and appears to be cost-effective. However, the current evidence supporting this practice is limited in quality. The use of extended oral antibiotic prophylaxis should be weighed against the possible development of future antimicrobial resistance, which may change the value proposition.

Preoperative Prophylactic Antibiotics in Total Hip and Knee Arthroplasty: What, When, and How

Although there are numerous nonpatient-related factors that may help reduce infection risk, the proper use of prophylactic antibiotics is most responsible for reducing infection. The role of prophylactic antibiotics is to reduce early periprosthetic joint replacement, which is accomplished by having adequate antibiotic tissue levels at the time of skin incision. The goal of this section of the symposium is to review current antibiotic recommendations, how to manage patients with a self-reported penicillin allergy, review the use of dual antibiotics, discuss the use of antibiotics in the outpatient total joint setting, as well as very briefly discuss the administration of intraosseous antibiotics in knee arthroplasty.

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.

Best Practices for Postoperative Management of Posterior Sacroiliac Joint Fusion

Sacroiliac joint (SIJ) pain is a common cause of low back pain. Traditionally, treatment for SIJ joint pain and dysfunction has consisted of physical therapy, medication management, SIJ injections, and SIJ ablations. Improved recognition of the SIJ as an etiology for back pain has led to advances in treatment options. Radiofrequency of the lateral sacral branches has been shown to be effective, though evidence is fraught with inconsistent patient selection, study design and procedural technique. It also does not directly address the mechanical dysfunction of the SIJ. In order to create a more enduring approach SIJ fusion has become an attractive option to reduce pain and to improve function. This method of SI joint treatment requires guidance in the perioperative phase of care from both the physicians and advanced practice providers (APP). In order to improve care and outcomes of those undergoing posterior SI joint fusion the American Society of Pain and Neuroscience appointed an expert panel of physicians and advanced practice providers to create a best practice for the post operative care of this approach. As with any best practice, the panel considered current peer reviewed literature and clinical expertise to create guidance today. This is intended to be a living document with modifications as additional evidence comes to light in data publication. The goals of this paper are to focus on (1) wound care, (2) medication use, (3) physical activity and (4) therapeutic exercises.

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

Timing and duration of antibiotic prophylaxis is associated with the risk of infection after hip and knee arthroplasty

AIMS

Antibiotic prophylaxis involving timely administration of appropriately dosed antibiotic is considered effective to reduce the risk of surgical site infection (SSI) after total hip and total knee arthroplasty (THA/TKA). Cephalosporins provide effective prophylaxis, although evidence regarding the optimal timing and dosage of prophylactic antibiotics is inconclusive. The aim of this study is to examine the association between cephalosporin prophylaxis dose, timing, and duration, and the risk of SSI after THA/TKA.

METHODS

A prospective multicentre cohort study was undertaken in consenting adults with osteoarthritis undergoing elective primary TKA/THA at one of 19 high-volume Australian public/private hospitals. Data were collected prior to and for one-year post surgery. Logistic regression was undertaken to explore associations between dose, timing, and duration of cephalosporin prophylaxis and SSI. Data were analyzed for 1,838 participants. There were 264 SSI comprising 63 deep SSI (defined as requiring intravenous antibiotics, readmission, or reoperation) and 161 superficial SSI (defined as requiring oral antibiotics) experienced by 249 (13.6%) participants within 365 days of surgery.

RESULTS

In adjusted modelling, factors associated with a significant reduction in any SSI and deep SSI included: correct weight-adjusted dose (any SSI; adjusted odds ratio (aOR) 0.68 (95% confidence interval (CI) 0.47 to 0.99); p = 0.045); commencing preoperative cephalosporin within 60 minutes (any SSI, aOR 0.56 (95% CI 0.36 to 0.89); p = 0.012; deep SSI, aOR 0.29 (95% CI 0.15 to 0.59); p < 0.001) or 60 minutes or longer prior to skin incision (aOR 0.35 (95% CI 0.17 to 0.70); p = 0.004; deep SSI, AOR 0.27 (95% CI 0.09 to 0.83); p = 0.022), compared to at or after skin incision. Other factors significantly associated with an increased risk of any SSI, but not deep SSI alone, were receiving a non-cephalosporin antibiotic preoperatively (aOR 1.35 (95% CI 1.01 to 1.81); p = 0.044) and changing cephalosporin dose (aOR 1.76 (95% CI 1.22 to 2.57); p = 0.002). There was no difference in risk of any or deep SSI between the duration of prophylaxis less than or in excess of 24 hours.

CONCLUSION

Ensuring adequate, weight-adjusted dosing and early, preoperative delivery of prophylactic antibiotics may reduce the risk of SSI in THA/TKA, whereas the duration of prophylaxis beyond 24 hours is unnecessary. Cite this article: Bone Jt Open 2022;3(3):252-260.

Enhanced recovery after surgery for major orthopedic surgery: a narrative review

Background

With increasing interest in enhanced recovery after surgery (ERAS), the literature on ERAS in orthopedic surgery is also rapidly accumulating. This review article aims to (1) summarize the components of the ERAS protocol applied to orthopedic surgery, (2) evaluate the outcomes of ERAS in orthopedic surgery, and (3) suggest practical strategies to implement the ERAS protocol successfully.

Main body

Overall, 17 components constituting the highly recommended ERAS protocol in orthopedic surgery were identified. In the preadmission period, preadmission counseling and the optimization of medical conditions were identified. In the preoperative period, avoidance of prolonged fasting, multimodal analgesia, and prevention of postoperative nausea and vomiting were identified. During the intraoperative period, anesthetic protocols, prevention of hypothermia, and fluid management, urinary catheterization, antimicrobial prophylaxis, blood conservation, local infiltration analgesia and local nerve block, and surgical factors were identified. In the postoperative period, early oral nutrition, thromboembolism prophylaxis, early mobilization, and discharge planning were identified. ERAS in orthopedic surgery reduced postoperative complications, hospital stay, and cost, and improved the patient outcomes and satisfaction with accelerated recovery. For successful implementation of the ERAS protocol, various strategies including the standardization of care system, multidisciplinary communication and collaboration, ERAS education, and continuous audit system are necessary.

Conclusion

The ERAS pathway enhanced patient recovery with a shortened length of stay, reduced postoperative complications, and improved patient outcomes and satisfaction. However, despite the significant progress in ERAS implementation in recent years, it has mainly focused on major surgeries such as arthroplasty. Therefore, further efforts to apply, audit, and optimize ERAS in various orthopedic surgeries are necessary.

Are Patient-Reported Drug Allergies Associated With Prosthetic Joint Infections and Functional Outcomes Following Total Hip and Knee Arthroplasty?

BACKGROUND

The purpose of this study is to determine if the number and types of patient-reported drug allergies are associated with prosthetic joint infection (PJI) and functional outcomes following total joint arthroplasty (TJA).

METHODS

This is a retrospective review of all patients who underwent a primary, elective total hip (THA) or knee arthroplasty (TKA) over a 10-year period at a single academic institution. Demographic, clinical information, and number and type of patient-reported drug allergy was collected. Univariate and multivariate logistic regressions were performed to identify risk factors for PJI and risk of PJI based on number of allergies. Univariate analysis was also performed to identify if the number of patient-reported allergies affected functional outcome scores.

RESULTS

Of 31,109 patients analyzed, there were 941 (3%) revisions for infection (491 knees and 450 hips). At least one allergy was reported by 16,435 (52.8%) patients, with a mean of 1.2 ± 1.9. Those who underwent revision for infection had a significantly higher number of reported allergies (1.68 ± 1.9 vs 1.23 ± 1.9, P < .0005, 95% confidence interval -0.58 to 0.33). On univariate regression the number of allergies independently predicted revision TJA for infection (P < .0001) as did age, gender, body mass index, and smoking status. On multivariate regression for each additional patient-reported allergy, risk of PJI increased by 1.11 times (95% confidence interval 1.07-1.14, P < .0001). Number of patient-reported allergies did not predict 3-month or 1-year functional outcome scores.

CONCLUSION

Patients with a higher number of reported allergies may be at increased risk of PJI following TJA.

LEVEL OF EVIDENCE

Prognostic Level II.

Arthroscopic rotator cuff repair without antibiotic prophylaxis does not increase the infection rate

PURPOSE

Rotator cuff repair is a commonly performed shoulder procedure. In the past 20 years, there has been a shift from mini-open towards arthroscopic repair, and many units exclusively use arthroscopic techniques for rotator cuff surgery. The aim of this study was to find out whether withholding antibiotics had any effect on the infection rate in patients undergoing arthroscopic rotator cuff repair.

METHODS

A retrospective analysis of 336 consecutive patients with an arthroscopic rotator cuff repair (RCR) and a minimum 2-year follow-up was performed. The control group received prophylactic antibiotics (controls) and the cases of interest did not receive perioperative antibiotics. A power analysis was performed according to literature regarding infection proportions. The primary outcome was an infection (superficial or deep) in the operated shoulder.

RESULTS

There were 336 patients who underwent a RCR. Two-hundred-and-twelve in the control group and 124 in the non-antibiotic group. Average ages were 57.3 ± 12.5 and 56.8 ± 13.2 years in each group, respectively. The follow-up times ranged from 24 to 76 months. Equipment used and surgical techniques were identical, only operating times were statistically different between the groups (control 77.2 ± 41.3 min versus no antibiotic cases 52.9 ± 16.7 min) (p = 0.000009). There was no recorded infection in either group.

CONCLUSION

Infection following arthroscopic surgery is uncommon. Small incisions, constant lavage with saline, minimal hardware insertion and short operating times all combine to minimise the risks. Current results point towards no detriment in withholding prophylactic antibiotics in low-risk patients undergoing routine rotator cuff repair surgery. Therefore, judicious use of prophylactic antibiotics in patients undergoing this procedure is advocated to prevent potential harm to those it is administered to.

LEVEL OF EVIDENCE

Level III.

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 antibiotic prophylaxis courses on postoperative complications following total joint arthroplasty: Finding from Chinese population

WHAT IS KNOWN AND OBJECTIVE

Prolonged antibiotic prophylaxis after total joint arthroplasty (TJA) may not assist in minimizing postoperative complications, however, data based on the Chinese population have been limited. The purpose of this study is to investigate the effect of antibiotic prophylaxis on postoperative complications after TJA in Chinese patients.

METHODS

We retrospectively reviewed 990 patients undergoing elective primary TJA surgery from January 2016 to June 2019. Patients who received a short course (≤3 days) of antibiotic prophylaxis were compared with those who received a longer course (>3 days). Logistic regression analysis and subgroup analysis were performed to control for potential confounders. Beyond that, survival analysis was used to determine the cumulative incidence of postoperative complications.

RESULTS AND DISCUSSION

Follow-up to 12 months after surgery, the prevalence of system complications in the longer course group and the short course group were 5.1% and 3.9%, respectively (p = 0.451). Similarly, no statistical differences in incisional complications (1.5% vs. 1.8%, p > 0.999) and periprosthetic joint infection (PJI) (1.0% vs. 1.0%, p > 0.999) were observed between the two groups. After performing logistic regression analysis and survival analysis, no potential association was found between the course of antibiotic prophylaxis and postoperative complications. In addition, prolonged antibiotic prophylaxis conferred no benefit for high-risk obese patients.

WHAT IS NEW AND CONCLUSION

Extended antibiotic prophylaxis did not result in a statistically significant and clinically meaningful reduction in postoperative complications. Therefore, we recommended that the duration of antibiotic prophylaxis in TJA should be shortened to 3 days or less in the Chinese population.

Perioperative Antibiotic Prophylaxis: Single and 24-Hour Antibiotic Dosages are Equally Effective at Preventing Periprosthetic Joint Infection in Total Joint Arthroplasty

BACKGROUND

Perioperative antibiotic prophylaxis is used to prevent surgical site infection and periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). Secondary to a national shortage of cefazolin, patients at our institution began receiving a single preoperative prophylactic antibiotic dose for primary TJA and no 24-hour postoperative antibiotic prophylaxis. The purpose of the study was to compare the efficacy of single-dose antibiotic use versus 24-hour dosing of prophylactic antibiotics in the prevention of acute PJI and short-term complications after primary TJA.

METHODS

A retrospective review of 3317 patients undergoing primary TJA performed from January 2015 to December 2019 identified 554 patients who received a single dose of preoperative antibiotic prophylaxis during the antibiotic shortage and 2763 patients who received post-TJA 24-hour antibiotic prophylaxis before the shortage. Patient records were evaluated for acute PJI, superficial infection, 90-day reoperation, and 90-day complications.

RESULTS

There were no significant differences in patient characteristics between single-dose and 24-hour antibiotic groups. Similarly, there were no significant differences in rates of acute PJI (0.7% vs 0.2%; P = .301), superficial infection (2.4% vs 1.4%; P = .221), 90-day reoperation (2.1% vs 1.1%; P = .155), and 90-day complications (9.9% vs 7.9%; P = .169) between single and 24-hour antibiotic dose. Post hoc power analysis demonstrated adequate sample size, beta = 93%.

CONCLUSION

Single-dose prophylactic antibiotics did not lead to an increased risk of acute PJI or short-term complications after TJA. Our study suggests that administration of a single antibiotic dose may be safely considered in patients undergoing routine primary TJA.

The AAHKS Clinical Research Award: Extended Oral Antibiotics Prevent Periprosthetic Joint Infection in High-Risk Cases: 3855 Patients With 1-Year Follow-Up

BACKGROUND

Surgical and host factors predispose patients to periprosthetic joint infection (PJI) after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). While surgical factors are modifiable, host factors can be challenging, and there are limited data demonstrating that preoperative patient optimization decreases risk of PJI. The goal of this study was to evaluate whether extended oral antibiotic prophylaxis reduces the one-year infection rate in high-risk patients.

METHODS

A total of 3855 consecutive primary THAs and TKAs performed between 2011 and 2019 at a suburban academic hospital with modern perioperative and infection-prevention protocols were retrospectively reviewed. Beginning in January 2015, a 7-day oral antibiotic prophylaxis protocol was implemented after discharge for patients at high risk for PJI. The percentage of high-risk patients diagnosed with PJI within 1 year was compared between groups that did and did not receive extended antibiotic prophylaxis. Univariate and logistic regression analyses were performed, with P ≤ .05 denoting statistical significance.

RESULTS

Overall 1-year infection rates were 2.26% and 0.85% after THA and TKA, respectively. High-risk patients with extended antibiotic prophylaxis had a significantly lower rate of PJI than high-risk patients without extended antibiotic prophylaxis (0.89% vs 2.64%, respectively; P < .001). There was no difference in the infection rate between high-risk patients who received antibiotics and low-risk patients (0.89% vs 1.29%, respectively; P = .348) with numbers available.

CONCLUSION

Extended postoperative oral antibiotic prophylaxis for 7 days led to a statistically significant and clinically meaningful reduction in 1-year infection rates of patients at high risk for infection. In fact, the PJI rate in high-risk patients who received antibiotics was less than the rate seen in low-risk patients. Thus, extended oral antibiotic prophylaxis may be a simple measure to effectively counteract poor host factors. Moreover, the findings of this study may mitigate the incentive to select healthier patients in outcome-based reimbursement models. Further study with a multicenter randomized control trial is needed to further validate this protocol.

LEVEL OF EVIDENCE

Therapeutic level III.

Prolonged antibiotic prophylaxis use in elective orthopaedic surgery - a cross-sectional analysis

Purpose

Surgical antibiotic prophylaxis (SAP) prevents surgical site infections (SSI). In orthopaedic surgery, the use of prolonged SAP (PSAP) has been reported in daily routine, despite guidelines advising against it. Therefore, we asked: What is the proportion of PSAP use, defined as administration of SAP ≥24 h after elective orthopaedic surgery? Are there patient- and surgery-related predictors of PSAP use?

Methods

This cross-sectional analysis investigated 1292 patients who underwent elective orthopaedic surgery including total joint arthroplasties at one Swiss centre between 2015 and 2017. Patient comorbidities, surgical characteristics and occurrence of SSI at 90 days in PSAP group were compared to the SAP group (< 24 h post-operative).

Results

PSAP use was 12% (155 of 1292). Patient-related factors associated with PSAP compared to the SAP group included older age (63 vs. 58y; p < 0.001), higher BMI (29 vs. 27 kg/m²; p < 0.001), ASA classification ≥3 (31% vs. 17%; p < 0.001) and lung disease (17% vs. 9%; p = 0.002). Surgery-related factors associated with PSAP were use of prosthetics (62% vs. 45%; p < 0.001), surgery of the knee (65% vs. 25%; p < 0.001), longer surgery duration (87 vs. 68 min; p < 0.001) and presence of drains (90% vs. 65%; p < 0.001). All four SSI occurred in the SAP group (0 vs. 4; p = 1.0). Surgeons administered PSAP with varying frequencies; proportions ranged from 0 to 33%.

Conclusion

PSAP use and SSI proportions were lower than reported in the literature. Several patient- and surgery-related factors associated with PSAP use were identified and some were potentially modifiable. Also, experienced surgeons seemed to implement differing approaches regarding the duration of SAP administration.

Postoperative Prophylactic Antibiotics in Spine Surgery: A Propensity-Matched Analysis

BACKGROUND

Surgical site infections are common and costly complications after spine surgery. Prophylactic antibiotics are the standard of care; however, the appropriate duration of antibiotics has yet to be adequately addressed. We sought to determine whether the duration of antibiotic administration (preoperatively only versus preoperatively and for 24 hours postoperatively) impacts postoperative infection rates.

METHODS

All patients undergoing inpatient spinal procedures at a single institution from 2011 to 2018 were evaluated for inclusion. A minimum of 1 year of follow-up was used to adequately capture postoperative infections. The 1:1 nearest-neighbor propensity score matching technique was used between patients who did and did not receive postoperative antibiotics, and multivariable logistic regression analysis was conducted to control for confounding.

RESULTS

A total of 4,454 patients were evaluated and, of those, 2,672 (60%) received 24 hours of postoperative antibiotics and 1,782 (40%) received no postoperative antibiotics. After propensity-matched analysis, there was no difference between patients who received postoperative antibiotics and those who did not in terms of the infection rate (1.8% compared with 1.5%). No significant decrease in the odds of postoperative infection was noted in association with the use of postoperative antibiotics (odds ratio = 1.17; 95% confidence interval, 0.620 to 2.23; p = 0.628). Additionally, there was no observed increase in the risk of Clostridium difficile infection or in the short-term rate of infection with multidrug-resistant organisms.

CONCLUSIONS

There was no difference in the rate of surgical site infections between patients who received 24 hours of postoperative antibiotics and those who did not. Additionally, we found no observable risks, such as more antibiotic-resistant infections and C. difficile infections, with prolonged antibiotic use.

LEVEL OF EVIDENCE

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

Think Twice before Prescribing Antibiotics for That Swollen Knee: The Influence of Antibiotics on the Diagnosis of Periprosthetic Joint Infection

Periprosthetic joint infection (PJI) is a rare but devastating complication after total joint arthroplasty. An estimated 7-12% of patients have negative cultures despite clear clinical evidence of infection. One oft-cited reason for this occurrence is the administration of antibiotics in the weeks prior to obtaining cultures. This article reviews the influence of antibiotics on the diagnosis of PJI. Specifically, we examine the effect of prophylactic and therapeutic antibiotic administration on the diagnostic accuracy of microbiological cultures as well as serum and synovial biomarkers. We also explore the potential of molecular techniques in overcoming these limitations in patients who have received antibiotics before specimen collection and propose areas for future research.

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.

Similar risk of complete revision for infection with single-dose versus multiple-dose antibiotic prophylaxis in primary arthroplasty of the hip and knee: results of an observational cohort study in the Dutch Arthroplasty Register in 242,179 patients

Background and purpose - The optimal type and duration of antibiotic prophylaxis for primary arthroplasty of the hip and knee are subject to debate. We compared the risk of complete revision (obtained by a 1- or 2-stage procedure) for periprosthetic joint infection (PJI) after primary total hip or knee arthroplasty between patients receiving a single dose of prophylactic antibiotics and patients receiving multiple doses of antibiotics for prevention of PJI. Patients and methods - A cohort of 130,712 primary total hip and 111,467 knee arthroplasties performed between 2011 and 2015 in the Netherlands was analyzed. We linked data from the Dutch arthroplasty register to a survey collected across all Dutch institutions on hospital-level antibiotic prophylaxis policy. We used restricted cubic spline Poisson models adjusted for hospital clustering to compare the risk of revision for infection according to type and duration of antibiotic prophylaxis received. Results - For total hip arthroplasties, the rates of revision for infection were 31/10,000 person-years (95% CI 28-35), 39 (25-59), and 23 (15-34) in the groups that received multiple doses of cefazolin, multiple doses of cefuroxime, and a single dose of cefazolin, respectively. The rates for knee arthroplasties were 27/10,000 person-years (95% CI 24-31), 40 (24-62), and 24 (16-36). Similar risk of complete revision for infection among antibiotic prophylaxis regimens was found when adjusting for confounders. Interpretation - In a large observational cohort we found no apparent association between the type or duration of antibiotic prophylaxis and the risk of complete revision for infection. This does question whether there is any advantage to the use of prolonged antibiotic prophylaxis beyond a single dose.

Antibiotic Stewardship for Total Joint Arthroplasty in 2020

Projections indicate an increase in primary and revision total joint arthroplasties (TJAs). Periprosthetic joint infections (PJIs) are one of the most common and devastating causes of failure after TJA. Perioperative administration of systemic and/or local antibiotics is used for both prophylaxis and treatment of PJI. Antibiotic stewardship is a term that has been met with clinical acceptance and success in other specialties of medicine. Identifying antibiotic best practice use in the fight against PJI is limited by studies that are extremely heterogeneous in their design. Variations in studies include antibiotic selection and duration, surgical débridement steps, type of antibiotic delivery (intra-articular, local, intravenous, and prolonged oral), mix of primary and revision surgery cohorts, both hip and knee cohorts, infecting organisms, and definitions of treatment success/failure. This review highlights the current challenges of antibiotic stewardship in TJA.

Identifying targets for improvement using a nationally standardized survey: Surgical antimicrobial prophylaxis in orthopedic surgery

BACKGROUND

Surgical antimicrobial prophylaxis (SAP) is commonly administered in orthopedic procedures. Research regarding SAP appropriateness for specific orthopedic procedures is limited and is required to facilitate targeted orthopedic prescriber behavior change.

OBJECTIVES

To describe SAP prescribing and appropriateness for orthopedic procedures in Australian hospitals.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, national, quality improvement study with retrospective analysis of data collected from Australian hospitals via Surgical National Antimicrobial Prescribing Survey (Surgical NAPS) audits from January 1, 2016, to April 15, 2019, were analyzed.

METHODS

Logistic regression identified hospital, patient and surgical factors associated with appropriateness. Adjusted appropriateness was calculated from the multivariable model. Additional subanalyses were conducted on smaller subsets to calculate the adjusted appropriateness for specific orthopedic procedures.

RESULTS

In total, 140 facilities contributed to orthopedic audits in the Surgical NAPS, including 4,032 orthopedic surgical episodes and 6,709 prescribed doses. Overall appropriateness was low, 58.0% (n = 3,894). This differed for prescribed procedural (n = 3,978, 64.7%) and postprocedural doses (n = 2,731, 48.3%). The most common reasons for inappropriateness, when prophylaxis was required, was timing for procedural doses (50.9%) and duration for postprocedural prescriptions (49.8%). The adjusted appropriateness of each orthopedic procedure group was low for procedural SAP (knee surgery, 54.1% to total knee joint replacement, 74.1%). The adjusted appropriateness for postprocedural prescription was also low (from hand surgery, 40.7%, to closed reduction fractures, 68.7%).

CONCLUSIONS

Orthopedic surgical specialties demonstrated differences across procedural and postprocedural appropriateness. The metric of appropriateness identifies targets for quality improvement and is meaningful for clinicians. Targeted quality improvement projects for orthopedic specialties need to be developed to support optimization of antimicrobial use.

Infection Risk-Adjusted Antibiotic Prophylaxis Strategies in Arthroplasty: Short Review of Evidence and Experiences of a Tertiary Center in Spain

There is growing body of evidence that important patient-, procedure- and pathogen-related factors are linked to higher risks for prosthetic joint infections (PJI) following arthroplasty surgeries. The prior identification and optimization of such risk factors is considered paramount to minimize the incidence of these infections. Without any doubt, antibiotic prophylaxis remains one of the cornerstones among all preventive measures. However, the ideal antibiotic prophylaxis is still in debate and discussions have emerged, whether certain situations deserve adjustments or variations of the standard protocol taking into account antibiotic resistance surveillance data and patient risk factors for infections. This review aims to provide the reader with an overview of possible antibiotic prophylaxis strategies in response to these risks and discusses the clinical experiences so far obtained. We further present preliminary evidence that the use of a reinforced local antibiotic prophylaxis regimen with high-dose dual antibiotic-loaded bone cement may be an effective and easy-to-apply option in patients at high infection risks.

Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining

A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting.