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

Abstract

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.

The use of triple antibiotic prophylaxis during total knee replacement surgeries in Awka, Nigeria

“…Despite the fact that some studies have found that subsequent use of post-operative antibiotics after the initial preoperative dose may not give additional benefit. [1,10,11,14,15,19] However, some other studies have noted that post-operative doses after the initial pre-operative dose have an advantage over preoperative-only doses. [ 3,35,38] So, if we ignore confounding factors like the expertise of the operating surgeon, the operating time, and patient comorbidities, what made the difference between the prevalence of 0.77% of SSIs in our centre and that of other similar centres operating under almost the same conditions?…”

“…Vancomycin, characterized by its comparatively slower tissue permeation, necessitates early administration to ensure adequate concentrations are attained at the surgical site. [3,11] The correlation between Staphylococcus aureus (S aureus) colonization and the risk of periprosthetic joint infection (PJI) is gaining prominence in the orthopaedic literature. Research indicates that patients preparing for orthopaedic surgery exhibit S aureus colonization rates akin to those observed in the broader population.…”

National variation in prophylactic antibiotic use for elective primary total joint replacement

“…A single dose of cefuroxime 1.5 g was recommended by nine trusts (8.3%), while other regimens varied very widely across trusts and were distinct for most of the remaining 67 centres (61.5%). This variation is notable, given recent research by Badge et al 26 showing that adequate weight-based dosage and early administration of the prophylactic antibiotics may reduce the risk of SSI in total hip and total knee arthroplasty.…”

International Survey of Practice for Prophylactic Systemic Antibiotic Therapy in Hip and Knee Arthroplasty

“…Prolonged antibiotic prophylaxis beyond 24 h has been shown to be ineffective at reducing SSIs and may increase antimicrobial resistance [ 40 , 41 ]. A multi-centre prospective study of 19 Australian hospitals found prolonged administration of antibiotics beyond 24 h showed no difference in rates of SSIs for primary TKA and THA [ 42 ]. Prospective surveillance of 2641 coronary artery bypass graft procedures found prolonged antibiotic exposure was a risk factor for antibiotic resistant organism infections [ 40 ].…”