Do we know everything about perioperative antibiotic prophylaxis in joint replacement surgery?
30.08.2016
Do we know everything about perioperative antibiotic prophylaxis in joint replacement surgery?
Progress in surgical approaches for the treatment of degenerative diseases of large joints, primarily osteoarthritis and osteoarthritis, has allowed joint replacement to be considered the main intervention used for cases where conservative treatment is either ineffective or futile.
At the current stage of technological development, knee and hip joint replacement surgery is an economically justified way to significantly improve the quality of life for patients. Moreover, the frequency of complications and failures after such procedures continues to decrease with the improvement of surgical techniques and the introduction of new prosthetic designs.
However, regardless of how advanced the implants and surgical preparation are, there remain significant risks both from the patient side (especially comorbidities such as rheumatoid arthritis [1]) and those related to the surgery itself, which may lead to postoperative infectious complications. Today, the Charlson comorbidity index is used to assess the risks of postoperative infection at the surgical site (SSI), with a value of 3 or higher being an independent risk factor for purulent complications — including both wound infections and deep (periprosthetic) infections [2]. For such patients, the perioperative prophylaxis protocol should be implemented with particular care!
An effective method that has been proven to significantly reduce the frequency of postoperative purulent-septic complications is perioperative antibiotic prophylaxis (PAP) [3]. According to J. Chandrananth et al. [4], the frequency of postoperative SSIs in patients undergoing knee joint replacement who received PAP in strict accordance with established guidelines (either national or local) was 2.7%, compared to 5% in the group where surgeons ignored the established perioperative antibiotic protocol. Among patients undergoing hip joint replacement, the frequency of SSIs with PAP was less than 1%! According to S. Ravi et al. (2016), the introduction of modern technologies in orthopedics, along with PAP, has led to a reduction in SSIs to 0.87% (0.7% after hip joint replacement and 1.0% after knee joint replacement).
Despite the fact that PAP has served surgeons well for almost 50 years and is widely used in routine practice, some key points have yet to be fully clarified. So, what should be the main considerations for PAP to work effectively?
First — the choice of antimicrobial agent.
To determine which antibiotic to use, it is essential to have an understanding of the main pathogens responsible for postoperative infections. These are primarily gram-positive cocci, namely coagulase-negative staphylococci and S. aureus.
The antimicrobial agent with proven activity against gram-positive cocci is CEFALOZIN.
It is evident that cefazolin is currently the cornerstone of PAP in hip and knee joint replacement surgeries [6].
Another antibiotic with proven efficacy through multiple clinical studies is the second-generation cephalosporin CEFUROXIME.
Both CEFALOZIN and CEFUROXIME are recommended by leading specialists for routine PAP in patients without risk factors for SSIs caused by resistant microorganisms, particularly MRSA [6].
Vancomycin deserves special mention.
In one study analyzing the pathogens causing SSIs in patients who received full PAP, it was found that coagulase-negative staphylococci were responsible for 35% of the complications, of which 92% were resistant to cefazolin — the primary antimicrobial agent used for PAP. In 25% of cases, Staphylococcus aureus was cultured, with 9.1% being MRSA. Overall, 53% of all pathogens isolated were resistant to cefazolin, but nearly all were sensitive to vancomycin [5].
Notably, over the last decade, there has been a significant increase in the detection of Staphylococcus epidermidis from SSI foci, especially strains resistant to methicillin: from 0% in 2001-2003 to 74% in 2010-2012 [7].
Does this suggest the routine use of vancomycin for PAP? There are currently no clear prerequisites for this. According to S. Ravi et al. (2016), vancomycin should be prescribed in cases of a proven high risk of SSIs caused by methicillin-resistant gram-positive cocci. However, no data has yet shown greater effectiveness for vancomycin-based PAP protocols compared to standard regimens. The cost and risk of side effects, however, significantly increase!
Therefore, vancomycin is a reserve drug for PAP:
In patients with beta-lactam allergies.
In patients at high risk for SSIs caused by methicillin-resistant gram-positive cocci.
Unfortunately, "high risk" is not a precise criterion, and given the heterogeneity of the patient population requiring joint replacement, vancomycin should always be "on hand" and used when necessary for PAP.
It is known that nasal carriage of S. aureus is a significant risk factor for periprosthetic infection. Therefore, screening tests for this pathogen should be conducted in high-risk patients, with decolonization protocols implemented when necessary [6].
Second — the choice of dosage.
For CEFALOZIN, the optimal dose is 1 g (according to a multicenter study, 1 g of cefazolin was administered in the vast majority of cases — over 70%) [6, 9]. A dose of 2 g was administered mainly to patients with excessive body weight.
The preoperative dose of CEFUROXIME is 1.5 g.
For VANCOMYCIN, a dose of 1 g is sufficient.
Third — the timing of the first dose.
PAP should begin BEFORE the surgery (before the incision). This is a universal rule for PAP in surgery: antibiotic concentrations in the serum and tissues of the surgical site must be bactericidal (above the MIC) for the likely pathogens of SSIs at the time of incision. The optimal time for administration is 30-60 minutes before the actual incision [6].
Postoperative use of antibiotics is not advisable. According to a meta-analysis by P. Thornley et al. (2015), in the group of patients receiving "prophylactic" antibiotics after joint replacement surgery, the frequency of SSIs was 3.1%, compared to 2.3% in the placebo group.
Fourth — the route of administration.
Without a doubt, CEFALOZIN, CEFUROXIME, or VANCOMYCIN should be administered intravenously.
Fifth — how long should antibiotic administration for PAP continue?
Unfortunately, there are still no strict recommendations. However, most surgeons adhere to the practice of continuing antibiotic administration for 24 hours after joint replacement surgery, as follows:
CEFALOZIN — 1 g IV every 8 hours.
CEFUROXIME — 0.75 g IV every 8 hours.
VANCOMYCIN — 1 g IV drop every 12 hours.
Thus, PAP is an effective method to reduce the frequency of SSIs in joint replacement surgeries, backed by extensive evidence. However, it is important to remember that antibiotics are a reliable and proven tool in the fight against complications, but only when used properly.
References:
1. Saitoh M, Matsushita K. Prevention of surgical site infection for orthopaedic surgery in rheumatoid arthritis. Nihon Rinsho. 2016 Jun;74(6):993-9.
2. Wu CT, Chen IL, Wang JW, Ko JY, Wang CJ, Lee CH. Surgical Site Infection After Total Knee Arthroplasty: Risk Factors in Patients With Timely Administration of Systemic Prophylactic Antibiotics. J Arthroplasty. 2016 Jul;31(7):1568-73.
3. Solarino G, Abate A, Vicenti G, Spinarelli A, Piazzolla A, Moretti B. Reducing periprosthetic joint infection: what really counts? Joints. 2016 Jan 31;3(4):208-14.
4. Chandrananth J, Rabinovich A, Karahalios A, Guy S, Tran P. Impact of adherence to local antibiotic prophylaxis guidelines on infection outcome after total hip or knee arthroplasty. J Hosp Infect. 2016 Aug;93(4):423-7.
5. Ravi S, Zhu M, Luey C, Young SW. Antibiotic resistance in early periprosthetic joint infection. ANZ J Surg. 2016 Aug 25. [Epub ahead of print]
6. Bosco J, Bookman J, Slover J, Edusei E, Levine B. Principles of Antibiotic Prophylaxis in Total Joint Arthroplasty: Current Concepts. Instr Course Lect. 2016;65:467-75.
7. Zajonz D, Wuthe L, Rodloff AC, Prietzel T, von Salis-Soglio GF, Roth A, Heyde CE, Josten C, Ghanem M. Infections of hip and knee endoprostheses. Spectrum of pathogens and the role of multiresistant bacteria.Chirurg. 2016 Apr;87(4):332-9.
8. Thornley P, Evaniew N, Riediger M, Winemaker M, Bhandari M, Ghert M. Postoperative antibiotic prophylaxis in total hip and knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. CMAJ Open. 2015 Jul 17;3(3):E338-43.
9. Marculesu CE, Osmon DR. Antibiotic prophylaxis in orthopedic prosthetic surgery. Infect Dis Clin N Am. 2005;19:931–46.
At the current stage of technological development, knee and hip joint replacement surgery is an economically justified way to significantly improve the quality of life for patients. Moreover, the frequency of complications and failures after such procedures continues to decrease with the improvement of surgical techniques and the introduction of new prosthetic designs.
However, regardless of how advanced the implants and surgical preparation are, there remain significant risks both from the patient side (especially comorbidities such as rheumatoid arthritis [1]) and those related to the surgery itself, which may lead to postoperative infectious complications. Today, the Charlson comorbidity index is used to assess the risks of postoperative infection at the surgical site (SSI), with a value of 3 or higher being an independent risk factor for purulent complications — including both wound infections and deep (periprosthetic) infections [2]. For such patients, the perioperative prophylaxis protocol should be implemented with particular care!
An effective method that has been proven to significantly reduce the frequency of postoperative purulent-septic complications is perioperative antibiotic prophylaxis (PAP) [3]. According to J. Chandrananth et al. [4], the frequency of postoperative SSIs in patients undergoing knee joint replacement who received PAP in strict accordance with established guidelines (either national or local) was 2.7%, compared to 5% in the group where surgeons ignored the established perioperative antibiotic protocol. Among patients undergoing hip joint replacement, the frequency of SSIs with PAP was less than 1%! According to S. Ravi et al. (2016), the introduction of modern technologies in orthopedics, along with PAP, has led to a reduction in SSIs to 0.87% (0.7% after hip joint replacement and 1.0% after knee joint replacement).
Despite the fact that PAP has served surgeons well for almost 50 years and is widely used in routine practice, some key points have yet to be fully clarified. So, what should be the main considerations for PAP to work effectively?
First — the choice of antimicrobial agent.
To determine which antibiotic to use, it is essential to have an understanding of the main pathogens responsible for postoperative infections. These are primarily gram-positive cocci, namely coagulase-negative staphylococci and S. aureus.
The antimicrobial agent with proven activity against gram-positive cocci is CEFALOZIN.
It is evident that cefazolin is currently the cornerstone of PAP in hip and knee joint replacement surgeries [6].
Another antibiotic with proven efficacy through multiple clinical studies is the second-generation cephalosporin CEFUROXIME.
Both CEFALOZIN and CEFUROXIME are recommended by leading specialists for routine PAP in patients without risk factors for SSIs caused by resistant microorganisms, particularly MRSA [6].
Vancomycin deserves special mention.
In one study analyzing the pathogens causing SSIs in patients who received full PAP, it was found that coagulase-negative staphylococci were responsible for 35% of the complications, of which 92% were resistant to cefazolin — the primary antimicrobial agent used for PAP. In 25% of cases, Staphylococcus aureus was cultured, with 9.1% being MRSA. Overall, 53% of all pathogens isolated were resistant to cefazolin, but nearly all were sensitive to vancomycin [5].
Notably, over the last decade, there has been a significant increase in the detection of Staphylococcus epidermidis from SSI foci, especially strains resistant to methicillin: from 0% in 2001-2003 to 74% in 2010-2012 [7].
Does this suggest the routine use of vancomycin for PAP? There are currently no clear prerequisites for this. According to S. Ravi et al. (2016), vancomycin should be prescribed in cases of a proven high risk of SSIs caused by methicillin-resistant gram-positive cocci. However, no data has yet shown greater effectiveness for vancomycin-based PAP protocols compared to standard regimens. The cost and risk of side effects, however, significantly increase!
Therefore, vancomycin is a reserve drug for PAP:
In patients with beta-lactam allergies.
In patients at high risk for SSIs caused by methicillin-resistant gram-positive cocci.
Unfortunately, "high risk" is not a precise criterion, and given the heterogeneity of the patient population requiring joint replacement, vancomycin should always be "on hand" and used when necessary for PAP.
It is known that nasal carriage of S. aureus is a significant risk factor for periprosthetic infection. Therefore, screening tests for this pathogen should be conducted in high-risk patients, with decolonization protocols implemented when necessary [6].
Second — the choice of dosage.
For CEFALOZIN, the optimal dose is 1 g (according to a multicenter study, 1 g of cefazolin was administered in the vast majority of cases — over 70%) [6, 9]. A dose of 2 g was administered mainly to patients with excessive body weight.
The preoperative dose of CEFUROXIME is 1.5 g.
For VANCOMYCIN, a dose of 1 g is sufficient.
Third — the timing of the first dose.
PAP should begin BEFORE the surgery (before the incision). This is a universal rule for PAP in surgery: antibiotic concentrations in the serum and tissues of the surgical site must be bactericidal (above the MIC) for the likely pathogens of SSIs at the time of incision. The optimal time for administration is 30-60 minutes before the actual incision [6].
Postoperative use of antibiotics is not advisable. According to a meta-analysis by P. Thornley et al. (2015), in the group of patients receiving "prophylactic" antibiotics after joint replacement surgery, the frequency of SSIs was 3.1%, compared to 2.3% in the placebo group.
Fourth — the route of administration.
Without a doubt, CEFALOZIN, CEFUROXIME, or VANCOMYCIN should be administered intravenously.
Fifth — how long should antibiotic administration for PAP continue?
Unfortunately, there are still no strict recommendations. However, most surgeons adhere to the practice of continuing antibiotic administration for 24 hours after joint replacement surgery, as follows:
CEFALOZIN — 1 g IV every 8 hours.
CEFUROXIME — 0.75 g IV every 8 hours.
VANCOMYCIN — 1 g IV drop every 12 hours.
Thus, PAP is an effective method to reduce the frequency of SSIs in joint replacement surgeries, backed by extensive evidence. However, it is important to remember that antibiotics are a reliable and proven tool in the fight against complications, but only when used properly.
References:
1. Saitoh M, Matsushita K. Prevention of surgical site infection for orthopaedic surgery in rheumatoid arthritis. Nihon Rinsho. 2016 Jun;74(6):993-9.
2. Wu CT, Chen IL, Wang JW, Ko JY, Wang CJ, Lee CH. Surgical Site Infection After Total Knee Arthroplasty: Risk Factors in Patients With Timely Administration of Systemic Prophylactic Antibiotics. J Arthroplasty. 2016 Jul;31(7):1568-73.
3. Solarino G, Abate A, Vicenti G, Spinarelli A, Piazzolla A, Moretti B. Reducing periprosthetic joint infection: what really counts? Joints. 2016 Jan 31;3(4):208-14.
4. Chandrananth J, Rabinovich A, Karahalios A, Guy S, Tran P. Impact of adherence to local antibiotic prophylaxis guidelines on infection outcome after total hip or knee arthroplasty. J Hosp Infect. 2016 Aug;93(4):423-7.
5. Ravi S, Zhu M, Luey C, Young SW. Antibiotic resistance in early periprosthetic joint infection. ANZ J Surg. 2016 Aug 25. [Epub ahead of print]
6. Bosco J, Bookman J, Slover J, Edusei E, Levine B. Principles of Antibiotic Prophylaxis in Total Joint Arthroplasty: Current Concepts. Instr Course Lect. 2016;65:467-75.
7. Zajonz D, Wuthe L, Rodloff AC, Prietzel T, von Salis-Soglio GF, Roth A, Heyde CE, Josten C, Ghanem M. Infections of hip and knee endoprostheses. Spectrum of pathogens and the role of multiresistant bacteria.Chirurg. 2016 Apr;87(4):332-9.
8. Thornley P, Evaniew N, Riediger M, Winemaker M, Bhandari M, Ghert M. Postoperative antibiotic prophylaxis in total hip and knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. CMAJ Open. 2015 Jul 17;3(3):E338-43.
9. Marculesu CE, Osmon DR. Antibiotic prophylaxis in orthopedic prosthetic surgery. Infect Dis Clin N Am. 2005;19:931–46.
