Prophylaxis with Teicoplanin and Cefuroxime Reduces the Rate of Prosthetic Joint Infection after Primary Arthroplasty

Abstract

The aim of this study was to compare the prosthetic joint infection (PJI) rate after total joint arthroplasty in two consecutive periods of treatment with different antibiotic prophylaxes: cefuroxime versus cefuroxime plus teicoplanin. We retrospectively reviewed 1,896 patients who underwent total hip arthroplasty or total knee arthroplasty between March 2010 and February 2013. From March 2010 to August 2011, patients received 1.5 g of cefuroxime during induction of anesthesia and another 1.5 g 2 h later (the C group). From September 2011, 800 mg of teicoplanin was added to cefuroxime (the CT group). Throughout the period studied, there were no variations in pre-or postoperative protocols. Univariate and multivariate analyses were performed to evaluate independent predictors of PJI. There were 995 (55.7%) patients in the C group and 791 (44.3%) in the CT group. Patients in the CT group had a significantly lower PJI rate than patients in the C group (1.26% versus 3.51%, P ‫؍‬ 0.002). There were no infections due to Staphylococcus aureus in the CT group (0% versus 1.6% in the C group, P < 0.001). A stepwise forward Cox regression model identified male sex (hazard ratio [HR], 3.85; 95% confidence interval [CI], 2.09 to 7.18), a body mass index of >35 kg/m 2 (HR, 2.93; 95% CI, 1.37 to 6.27), the presence of lung disease (HR, 2.46; 95% CI, 1.17 to 5.15), and red blood cell transfusion (HR, 3.70; 95% CI, 1.89 to 7.23) to be independent variables associated with a higher risk of PJI. The addition of teicoplanin was associated with a lower risk of infection (HR, 0.35; 95% CI, 0.17 to 0.74). In conclusion, the addition of teicoplanin to cefuroxime during primary arthroplasty was associated with a significant reduction in the global PJI rate due to a reduction of infections caused by Gram-positive bacteria.

Multicentre randomised double-blind placebo controlled trial of combination vancomycin and cefazolin surgical antibiotic prophylaxis: the Australian surgical antibiotic prophylaxis (ASAP) trial

“…Resistant Gram-positive organisms are the most common cause of SSIs following joint replacement surgery in Australia and are associated with poorer outcomes 14 22–24. These resistant Gram-positive organisms, including methicillin-resistant Staphylococcus aureus (MRSA), other methicillin-resistant Staphylococcus species and Enterococcus species, cause over 50% of all culture-positive infections in Australia, which is similar to international reports 22 25–33…”

“…In particular, large cohort studies by Sewick et al and Liu et al reported a reduction in the incidence of SSIs isolating resistant Gram-positive organisms following adoption of combination prophylaxis with vancomycin and cefazolin 48 50. Similarly, Tornero et al reported a 64% reduction in the overall rate of prosthetic joint infection following the adoption combination prophylaxis with teicoplanin and cefuroxime (1.26% vs 3.51%; p=0.002); of note, there was a significant reduction in all Staphylococcus aureus SSIs (methicillin resistant and sensitive) in the combination prophylaxis cohort (0 vs 21 SSIs; p=0.0001) 30. This suggests a potential synergy between glycopeptides and beta-lactams, which is corroborated by other laboratory and clinical studies 51 52.…”

“…There is emerging evidence from cohort studies demonstrating a reduction in the incidence of SSIs after introduction of combination prophylaxis 30 44 47–49. In particular, large cohort studies by Sewick et al and Liu et al reported a reduction in the incidence of SSIs isolating resistant Gram-positive organisms following adoption of combination prophylaxis with vancomycin and cefazolin 48 50.…”

Vancomycin prophylaxis in prosthetic joint surgery?

“…For example, a study with before-and-after design compared 995 patients who received only cefuroxime with 791 who received cefuroxime and teicoplanin (another antibiotic from glycopeptide group) as surgery prophylaxis. They showed that the PJI rate in the group with teicoplanin addition was lower than in the cefuroxime only group (1.3% versus 3.5%) [11]. This study did not mention delayed PJI specifically due to coagulase-negative staphylococci.…”

2018 International Consensus Meeting on Musculoskeletal Infection: Research Priorities from the General Assembly Questions

“…Decisions on using single versus dual‐agent prophylaxis should depend on local epidemiology, and resistant rates addressing particular needs . Similarly, glycopeptide prophylaxis has led to a significant relative risk reduction for SSI from MRSA . However, combining antibiotics such as vancomycin and cefazolin comes with higher risks of acute kidney injury.…”