Intraoperative Bacterial Contamination and Activity of Different Antimicrobial Prophylaxis Regimens in Primary Knee and Hip Replacement

Enhanced recovery after surgery (ERAS) protocols for total joint replacement surgery

The enhanced recovery after surgery (ERAS) protocols are a comprehensive therapeutic approach that prioritizes the well-being of patients. It encompasses several aspects such as providing sufficient nutritional support, effectively managing pain, ensuring appropriate fluid management and hydration, and promoting early mobilization after surgery. The advent of ERAS theory has led to a shift in focus within modern ERAS protocols. At present, ERAS protocols emphasize perioperative therapeutic strategies employed by surgeons and anesthesiologists, as well as place increased importance on preoperative patient education, interdisciplinary collaboration, and the enhancement of patient satisfaction and clinical outcomes. This editorial highlights the application of ERAS protocols in the current context of total joint replacement surgery.

Most hospital patients at risk for bacterial infection undergo an anesthetic: implications for infection control practices related to the anesthesia workspace

PURPOSE

Even with nearly 100% compliance with prophylactic antibiotic protocols, many surgical patients (> 5%) develop surgical site infections, some caused by pathogens transmitted from the anesthesia workspace (e.g., anesthesia machine), including multidrug-resistant Staphylococcus aureus. Reducing contamination of the anesthesia workspace substantively reduces the risk of surgical site infections. We estimated the percentage of hospital patients at risk for health care-associated infections who may benefit from the application of basic preventive measures under the control of anesthesia practitioners (e.g., their hand hygiene).

METHODS

We conducted a retrospective cohort study which included every patient admitted to the University of Miami Health System from April 2021 through March 2022 for hospitalization, surgery, emergency department visits, or outpatient visits. Lists were created for the start date and times of every parenteral antibiotic administered and every anesthetic.

RESULTS

Among 28,213 patient encounters including parenteral antibiotic(s), more than half (64.3%) also included an anesthetic (99% confidence interval, 62.2 to 66.6). The hypothesis that most antibiotics were administered during encounters when a patient underwent an anesthetic was accepted (P < 0.001). This observation may seem counterintuitive because parenteral antibiotics were administered for fewer than half of the 53,235 anesthetics (34.2%). The result was a consequence of most anesthetics (63.5%) at the health system being conducted in nonoperating room locations, and only 7.2% of such patients received a parenteral antibiotic.

CONCLUSIONS

Because approximately two-thirds of patients who receive an intravenous antibiotic also undergo an anesthetic, greater use of effective infection control measures in the anesthesia operating room workspace has the potential to substantively reduce overall rates of hospital infections.

Local tissue concentrations of cefazolin during total joint arthroplasty: a systematic review

BACKGROUND

Periprosthetic joint infections (PJI) following joint arthroplasty are now the leading cause of reoperation and are associated with serious morbidity to the patient, often requiring several staged operations and a prolonged course of parenteral antibiotics. Prophylactic administration of intravenous antibiotics before skin incision is arguably the most important measure to prevent PJI; however, the dose effectiveness of cefazolin in target tissue is not well known. We aimed to identify parameters affecting local tissue concentration (LTC) of cefazolin.

METHODS

We performed a literature search using the following keywords: "orthopaedics," "orthopedic," "arthroplasty" and "cefazolin." We included studies that measured LTC of cefazolin from samples obtained during either a total knee or total hip arthroplasty.

RESULTS

Of the 332 records screened, we included 10 studies that described LTC of cefazolin. The included studies evaluated dosing (n = 7), procedure type (n = 3), body mass index (n = 1) and tourniquet utilization (n = 1).

CONCLUSION

Few studies have measured LTC levels of antibiotics (or levels of cefazolin) to validate current recommendations for antibiotic prophylaxis in orthopedic surgery. With infection as the leading reason for early reoperation or revision surgery, the parameters affecting LTC during orthopedic procedures need to be further assessed.

Transmission of Staphylococcus aureus in the anaesthesia work area has greater risk of association with development of surgical site infection when resistant to the prophylactic antibiotic administered for surgery

BACKGROUND

The extent to which the transmission of prophylactic-antibiotic-resistant bacteria from the anaesthesia work area increases the risk of surgical site infection (SSI) is unknown. It was hypothesized that the risk of SSI would increase progressively from no transmission to transmission of prophylactic-antibiotic-resistant isolates.

METHODS

This was a retrospective analysis of archival samples collected in two previously published studies with similar inclusion criteria and sample collection methodology (observational study 2009-2010 and randomized trial 2018-2019). Archival isolates were linked by barcode to all patient demographic and procedural information, including the prophylactic antibiotic administered, transmission and development of SSI. For this study, all archival isolates underwent prophylactic antibiotic susceptibility testing, and the ordered association of transmission of Staphylococcus aureus (no transmission, transmission of prophylactic-antibiotic-susceptible isolates and transmission of prophylactic-antibiotic-resistant isolates) with SSI was assessed.

RESULTS

The risk of development of SSI was 2% (8/406) without S. aureus transmission, 11% (9/84) with transmission of S. aureus isolates that were susceptible to the prophylactic antibiotic used, and 18% (4/22) with transmission of prophylactic-antibiotic-resistant S. aureus isolates. The Cochrane-Armitage two-sided test for ordered association was P<0.0001. Treating these three groups as 0, 1 and 2, by exact logistic regression, the odds of SSI increased by 3.59 with each unit increase (95% confidence interval 1.92-6.64; P<0.0001).

CONCLUSIONS

Transmission of S. aureus in the anaesthesia work area reliably increases the risk of SSI, especially when the isolates are resistant to the prophylactic antibiotic administered.

Key Elements of Enhanced Recovery after Total Joint Arthroplasty: A Reanalysis of the Enhanced Recovery after Surgery Guidelines

Recent guidelines have produced a consensus statement for perioperative care in hip and knee replacement. However, there is still a need for reanalysis of the evidence and recommendations. Therefore, we retrieved and reanalyzed the evidence of each recommended components of enhanced recovery after surgery (ERAS) based on the guidelines of total joint arthroplasty. For each one, we included for the highest levels of evidence and those systematic reviews and meta-analyses were preferred. The full texts were analyzed and the evidence of all components were summarized. We found that most of the recommended components of ERAS are supported by evidence, however, the implementation details of each recommended components need to be further optimized. Therefore, implementation of a full ERAS program may maximize the benefits of our clinical practice but this combined effect still needs to be further determined.

Does addition of gentamicin for antibiotic prophylaxis in total knee arthroplasty reduce the rate of periprosthetic joint infection?

BACKGROUND

First-generation cephalosporins are used as antibiotic prophylaxis in total joint arthroplasty patients. However, this regimen does not address Gram-negative bacteria causing periprosthetic joint infection (PJI). Previous studies have suggested that the addition of an aminoglycoside as antibiotic prophylaxis in THA reduces surgical site infection (SSI), and less is known on its effect in TKA. This study aimed to investigate if the addition of a single-dose gentamicin, administered pre-operatively, is associated with lower rates of infection in TKA patients.

PATIENTS AND METHODS

This is a retrospective study of patients who underwent primary TKA as treatment for osteoarthritis between January 2011 and April 2021, with a minimum 1-year follow-up. The mean age was 69.9 (± 9.8), the mean BMI was 29.7 (± 5.5), and most patients had American Society of Anaesthesiology (ASA) score of 2-3 (92.9%). Patients were stratified based on the peri-operative antibiotic prophylaxis they received: cefazolin with addition of gentamicin (case group) or cefazolin (control group). Our primary study endpoints were rates of PJI and SSI, which were compared between groups using the chi-square test. Statistical significance was set as p < 0.05.

RESULTS

The final study population consisted of 1590 patients, 1008 (63.4%) in the control group and 582 (36.6%) patients in the case group. The total infection rate for patients that received gentamicin dropped by 34%; however, this finding did not reach statistical significance (1.3% (control) vs. 0.86% (case), p = 0.43). The same drop was seen after subdivision of infections to PJI (0.5% vs. 0.34%, 32% drop, p = 0.66) and SSI (0.8% vs. 0.52%, 35% drop, p = 0.52).

CONCLUSIONS

A single dose of gentamicin administered pre-operatively to a standard antibiotic prophylaxis was not associated with a statistically significant lower rate of PJI. Although the difference in infection rate did not reach statistical significance, the current study noted a drop in the rate of infection by 1/3 in the gentamicin cohort. Further investigation to evaluate the potential benefit of adding gentamicin to a peri-operative antibiotic regimen is warranted.

The Impact of Patient-Reported Penicillin or Cephalosporin Allergy on the Occurrence of the Periprosthetic Joint Infection in Primary Knee and Hip Arthroplasty

Reducing the risk of periprosthetic joint infections (PJI) requires a multi-pronged strategy including usage of a prophylactic antibiotic. A history of penicillin or cephalosporin allergy often leads to a change in prophylactic antibiotic regimen to avoid serious side effects. The purpose of the present retrospective study was to determine incidence of PJI based on perioperative antibiotic regimen in total hip arthroplasty (THA), total knee arthroplasty (TKA) or unicompartmental knee arthroplasty (UKA). A review of all primary THAs, primary TKAs and primary UKAs, undertaken between 2011 and 2020 in a tertiary referral hospital, was performed. The standard perioperative antibiotic for joint arthroplasty (JA) in the analyzed tertiary hospital is cefuroxime. There were no differences in prophylactic antibiotic regimen over time. In 7.9% (211 of 2666) of knee arthroplasties and in 6.0% (206 of 3419) of total hip arthroplasties, a second-line prophylactic antibiotic was used. There was no statistically significant higher occurrence of PJI between the first-line and second-line prophylactic antibiotic in knee arthroplasties (p = 0.403) as well as in total hip arthroplasties (p = 0.309). No relevant differences in age, American Society of Anesthesiologists (ASA) score and body mass index (BMI) between the groups were observed.