Antibiotic prophylaxis for wound infections in total joint arthroplasty: a systematic review

We reviewed systematically the published evidence on the effectiveness of antibiotic prophylaxis for the reduction of wound infection in patients undergoing total hip and total knee replacement. Publications were identified using the Cochrane Library, MEDLINE, EMBASE and CINAHL databases. We also contacted authors to identify unpublished trials. We included randomised controlled trials which compared any prophylaxis with none, the administration of systemic antibiotics with that of those in cement, cephalosporins with glycopeptides, cephalosporins with penicillin-derivatives, and second-generation with first-generation cephalosporins. A total of 26 studies (11 343 participants) met the inclusion criteria. Methodological quality was variable. In a meta-analysis of seven studies (3065 participants) antibiotic prophylaxis reduced the absolute risk of wound infection by 8% and the relative risk by 81% compared with no prophylaxis (p < 0.00001). No other comparison showed a significant difference in clinical effect. Antibiotic prophylaxis should be routine in joint replacement but the choice of agent should be made on the basis of cost and local availability.     

Antimicrobial prophylaxis in elective colon surgery. Experience of 1,035 operations in a community hospital

An 11 year study of 1,035 elective colon resections reaffirmed the value of oral antibiotic prophylaxis. Five antibiotic regimens were used in 88 percent of the patients. The most effective and most frequently used regimen was the combination of parenteral cephalosporin with oral erythromycin and an aminoglycoside. The overall infection rate with this regimen was 11 percent and the wound sepsis rate was 2.5 percent. The use of parenteral cephalosporins alone was not effective. Furthermore, resistant bacteria were cultured from the wound infections of parenteral cephalosporin patients. A nondirective annual review of these data and each surgeon's infection rate resulted in a change in the antibiotic ordering practices and decreased infection rates. It is no longer acceptable surgical practice to omit antibiotic prophylaxis in colon operations.     

Reducing the cost of surgical prophylaxis

A four-part program was implemented in order to control the rising cost of prophylactic antibiotics: limiting the number of cephalosporins on formulary; prohibiting the use of third- and most second-generation cephalosporins for prophylaxis; using a special order form to designate use as empiric, therapeutic, or prophylactic; and mandatory discontinuance of prophylactic antibiotics after 24 hours. The total cost for administration of prophylactic antibiotics was reduced from an average of $37.35 per case for the six months preceding the start of these restrictive policies to an average of $21.99 per case during the next twelve months. Class I and class II wound-infection rates were 2.0 per cent and 4.9 per cent, respectively, prior to the adoption of the new antibiotic practices. Comparable infection rates were 1.8 per cent and 2.1 per cent, respectively, after this program was initiated. The rising cost of antibiotic prophylaxis can be reduced without adversely affecting wound-infection rates.     

CLINICAL TRIAL OF PROPHYLAXIS OF WOUND SEPSIS IN ELECTIVE COLORECTAL SURGERY COMPARING TICARCILLIN WITH TINIDAZOLE

A prospective randomized single blind controlled clinical trial was undertaken to compare prophylactic therapy using a systemic antibiotic active against both aerobic and anaerobic bacteria with an oral antibiotic agent active only against anaerobic bacteria in elective colorectal surgery. One hundred and thirty-one patients received ticarcillin and 130 received tinidazole. The wound infection rate was 8% in those patients receiving ticarcillin prophylaxis and 20% in those receiving tinidazole (P < 0.05). Multivariate analysis of the factors affecting wound infection rate showed that there were three independent factors that reached statistical significance: the prophylactic antibiotic used; the type of hospital (public or private) in which the operation was performed, and the presence of a stoma at operation. The wound infection rate in those patients receiving tinidazole prophylaxis was more than twice that reported previously by the authors. The mortality in patients receiving ticarcillin prophylaxis was 1.5% compared to 9.2% in those receiving tinidazole prophylaxis (P < 0.05). The clinical anastomotic leakage rate was similar in each antibiotic prophylactic group, 8.6% in those receiving ticarcillin and 7.3% in those receiving tinidazole.     

预防性抗生素在肝癌经肝动脉治疗中应用价值的Meta分析

目的评价预防性应用抗生素对肝细胞肝癌（HCC）患者行经肝动脉化疗栓塞术（TACE）后感染发病率的影响。 方法收集已公开发表有关比较HCC患者TACE术预防性应用抗生素和不应用抗生素患者感染发病率的临床研究,按Meta分析要求对检索到的原始研究的质量进行评估,对符合条件的所有研究结果进行Mete分析,计算研究组相对对照组感染发病率的危险度（RR）,评价预防性应用抗生素对患者感染发病率的影响。 结果符合纳入标准共4篇文献,总样本量1 358例。预防性应用抗生素病例960例,术后感染83例;未应用抗生素病例398例,术后感染43例;合并RR=0.88,95%CI=0.62~1.24。 结论HCC患者行TACE术无须常规使用抗生素预防感染。     

Perioperative Antibiotikaprophylaxe bei aseptischen Eingriffen in der Orthopädie

Disagreement exists on the topic of antibiotic prophylaxis in aseptic orthopedic surgery. No evidence on the usefulness of prophylactic antibiotic administration exists with regard to non-complex aseptic surgeries without placement of osteosynthetic material. Likewise, no undisputed evidence exists on the usefulness of antibiotic prophylaxis with regard to aseptic orthopedic surgeries involving placement of osteosynthetic material. However, the majority of experts agree on antibiotic prophylaxis in the latter cases. In contrast clear evidence does exist regarding the usefulness of antibiotic prophylaxis with first- or second-generation cephalosporins for surgeries of the hip involving fracture treatment or prosthetic replacement. The prophylactic use of glycopeptides should be confined to cases of high MRSA or MRSE risk. Administration of prophylactic antibiotics should precede incision time by around 30 min and tourniquet inflation by at least 10 min. Antibiotic administration may be repeated in the OR when surgery lasts longer than 3 h. The use of local antibiotics in bone cement has not proven useful as a prophylactic measure.     

Efficacy of cefazolin, cefamandole, and gentamicin as prophylactic agents in cardiac surgery. Results of a prospective, randomized, double-blind trial in 1030 patients.

In an effort to develop an improved regimen of antibiotic prophylaxis in cardiac surgery, 1030 patients who were to have elective cardiothoracic surgery involving a median sternotomy were selected at random to receive cefamandole or cefazolin, with or without gentamicin, in a prospective double-blind study. Cefazolin was significantly less effective than cefamandole at both the sternal (1.8% vs. 0.4%, respectively, p less than 0.05) and donor sites (1.3% vs. 0%, respectively, p less than 0.02). Seven Staphylococcus aureus infections occurred among cefazolin recipients as compared with no such infections among the patients receiving cefamandole (p less than 0.01). All five wound infections yielding fungi or gentamicin-resistant gram-negative rods occurred in patients who had received gentamicin as a second prophylactic agent. These data suggest that gentamicin has no role as a prophylactic antibiotic in cardiac surgery and that, compared with cefamandole, cefazolin offers unreliable prophylaxis against deep infection at both the sternal and donor sites.     

Reducing the risk of deep wound infection in primary joint arthroplasty with antibiotic bone cement

Despite significant advances in intraoperative antimicrobial procedures, deep wound infection remains the most serious complication associated with primary, cemented total joint arthroplasty. A systematic review was conducted to evaluate studies of antibiotic bone cement prophylaxis for reducing the risk of deep wound infection. The literature included 22 articles providing estimates of the prophylactic effectiveness of antibiotic cement. In reducing deep wound infection, antibiotic cement was consistently superior to plain cement, similar to systematic antiobiotics, and independent and additive in effect when combined with other prophylactic measures. Randomized controlled trials in particular had important methodological limitations. However, the collective results nearly unanimously favored prophylactic use of antibiotic cement in primary arthoplasty procedures.     

Prophylactic parenteral antibiotics in clean neurosurgical procedures: a review

Clean surgical procedures carry a risk of postoperative wound infection that is less than 5% in most hospitals. The use of prophylactic antibiotic agents in clean neurosurgical cases is controversial, and the neurosurgical literature through 1980 contains no controlled clinical trials to study its effectiveness in such cases. A report of 1732 consecutive procedures without a single postoperative wound infection in patients receiving systemic gentamicin, vancomycin, and streptomycin irrigation fluids is often quoted by neurosurgeons; however, these results have not yet been duplicated by others. Since 1980, there have been several controlled trials that support the use in clean neurosurgical cases of prophylactic antibiotics, including the vancomycin/gentamicin/streptomycin regimen and the first-generation cephalosporins. A report in 1986 of 1602 cases without a primary wound infection supports the use of a single perioperative dose of cefazolin. A review of causative organisms in postoperative wound infections demonstrates the preponderance of Gram-positive pathogens. Therefore, when antibiotic prophylaxis is indicated, adequate Gram-positive bacterial coverage, including protection against Staphylococcus infection, is required. With consideration of the present data, the cost of antibiotic therapy, and the danger of drug toxicity, a short perioperative regimen of cefazolin as prophylaxis is preferred in clean neurosurgical cases.     

Post-tympanostomy tube otorrhea: a meta-analysis.

INTRODUCTION: Post-tympanostomy tube otorrhea is the most common complication of tympanostomy tube placement. The incidence of this problem varies from 3.4% to 74%. Trials that study post-tympanostomy tube otorrhea may involve valid randomization "by patient" or "by ear." In an attempt to define "best practice," we conduct a meta-analysis to quantify the benefit of using topical prophylactic antibiotic drops in the postoperative period. We then compare our findings with previous results found in the literature. METHODS: We selected randomized studies for which antibiotic drops had been used for at least 48 hours after tympanostomy tube insertion. Nine studies, 3 "by ear" and 6 "by patient," met our inclusion criteria. The odds ratio and 95% confidence intervals were calculated for each to conduct the meta-analysis. RESULTS: Overall, prophylaxis appears to be effective at reducing the incidence of post-tympanostomy tube otorrhea. The odds ratios for all studies were less than 1.0. However, none of the 3 "by ear" studies and only 3 of the 6 "by patient" studies were statistically significant. The mean odds ratio was 52%, suggesting that prophylaxis may reduce the incidence of post-tympanostomy tube otorrhea by half. CONCLUSION: This meta-analysis suggests that routine post-tympanostomy tube prophylaxis is beneficial, but this finding is dependent on selection criteria used. EBM rating: A-1a.     

Evolution of antimicrobial prophylaxis in cardiovascular surgery.

OBJECTIVE: To examine the optimal duration of antibiotic prophylaxis in major cardiovascular surgery. MTHODSs: In the past 15 years, four prospective randomized, controlled studies, conducted by the same group of authors, compared seven prophylactic antimicrobial regimens in 2970 patients undergoing major cardiovascular surgery. In 1980/81, a 4-day cefazolin (CFZ) prophylaxis was compared with a 2-day cefuroxime (CFX) administration (n=566). In 1982/83, a 2-day CFX prophylaxis was compared with a two shot ceftriaxone (CRO) prophylaxis (n=512). In 1984/87, a 1-day CFZ prophylaxis was compared with a single shot prophylaxis of CRO (n=883). In 1994/1995, a 4 day combination of amoxicillin (AM) and netilmicin (NET) prophylaxis was compared with a single shot prophylaxis of CFX (n=1009). RESULTS: Total infection rate varied between 4.5 and 5.7%, despite different antimicrobial regimen used and their varying duration. Wound infection rate was 1.1% (range 0.4-2.5%), sepsis rate was 0.8% (range 0.4-1.6%), pneumonia rate 2% (0.7-2.9%), urinary tract infection rate 0.4% (range 0-1.4%), and central venous catheter-related infection rate was 0.4% (0-1%). The 30-day mortality rate was 1.3% (range 0.4-2%). All these differences were not statistically significant. CONCLUSIONS: A low infection rate (range 4.5-5.7%) occurred despite changes in duration of various prophylactic antibiotic regimen with cephalosporins of first, second or third generation. As a single shot prophylaxis could nowadays successfully be used in cardiovascular surgery, no postoperative antibiotics should be used, unless an intraoperative or a postoperative infection is documented or in presence of major perioperative complications.     

Antibiotic prophylaxis in incisional hernia repair using a prosthesis

Antibiotic prophylaxis in clean surgery with implantation of prosthetic material is widely accepted, although there are no studies on its use in abdominal incisional hernia repair. The objective was to evaluate antibiotic chemoprophylaxis in incisional herniorrhaphy with the implantation of prosthetic material. A prospective non-randomized study (1990–1998) was conducted to analyse 216 patients undergoing surgery for abdominal incisional hernia who required a prosthesis (polypropylene) in the reconstruction and who met the criteria for clean surgery. Risk factors were observed in 31.5%, the most frequent being diabetes and obesity. The incisional hernia was located mostly in the abdominal midline and in 64.4% measured over 10 cm. Antibiotic prophylaxis was administered in 140 patients (64.8%) via the systemic route, the antibiotics being first- or second-generation cephalosporins or amoxicillin-clavulanic acid. Surgical wound infection occurred in 39 patients (18.1%), 19 who had received antibiotic prophylaxis (13.6%) and 20 who had not (26.3%). In multivariate analysis using logistic regression, the variables with statistical significance for local septic infection were antibiotic prophylaxis and number of risk factors. We can conclude therefore that antibiotic chemoprophylaxis is useful in abdominal incisional herniorrhaphy surgery with implantation of prosthetic material for reducing local septic complications. Electronic Publication     

Prophylactic and Preventive Antibiotic Therapy: Timing, Duration and Economics

Previous studies have demonstrated that administered antibiotics must be active against major anticipated pathogens and must have reached sufficient concentrations in the tissue or body fluid at risk by the time of bacterial challenge if prophylactic therapy is to be maximally effective in reducing the infection rate of potentially contaminated surgery. The need for continuing antibiotic prophylaxis beyond the day of operation, however, has been uncertain. In a prospective, randomized, double-blind study of 220 patients undergoing elective gastric, biliary or colonic surgery, perioperative administration of cefamandole plus five days of placebo was compared to perioperative plus five days of postoperative antibiotic therapy; no significant difference was found between the groups in the rate of infection of wound (6 and 5%, respectively), peritoneum (2% each) and elsewhere (6% and 5%). In another prospective, randomized, nonblind study of 451 determinant cases of 1,624 patients undergoing emergency laparotomy, cephalothin was instituted preoperatively but after peritoneal contamination had occurred (i.e., abdominal trauma, etc.); continued postoperative antibiotic again failed to reduce further the wound and peritoneal infection rates, as noted on comparing perioperative therapy alone (infection rates 8 and 4%, respectively) with perioperative plus 5-7 days of postoperative treatment (10% and 5%, respectively). Analysis of these data, as well as of the extra expenses incurred by 463 patients because of infection in a previous prophylactic antibiotic study, revealed an average additional expenditure of $2,686.00 for each instance of postoperative infection of the wound and/or peritoneum; whereas savings of $300.00 per patient at risk were obtained whenever appropriate prophylactic antibiotic had been given.     

Urinary tract infections after pelvic floor gynecological surgery: prevalence and effect of antimicrobial prophylaxis. A systematic review

We evaluated the prevalence of urinary tract infection (UTI) after pelvic floor operations for non-malignant etiology and the effectiveness of antibiotic prophylaxis. This was made possible by a review of the evidence from relevant randomized controlled trials (RCTs). Nineteen out of 879 initially identified studies met the criteria for inclusion in our review. Four RCTs compared an antibiotic prophylactic regimen with placebo, 11 two different prophylactic antibiotic regimens, and four had three different treatment arms. Among placebo recipients undergoing pelvic floor surgery, 10-64% developed UTI. In contrast, UTI after pelvic floor gynecological surgery occurred in 0-15% of the patients who received cephalosporins as antibiotic prophylaxis; the likelihood for postoperative UTI was higher for patients receiving cotrimoxazole (28%), ampicillin/sulbactam (13.6%), metronidazole plus ampicillin (20%), metronidazole (10-22.7%), or ciprofloxacin (27.2%). The use of a cephalosporin as perioperative antimicrobial prophylaxis is the optimal regimen in preventing UTIs after pelvic floor surgery.     

Wound infection during the Yom Kippur war: observations concerning antibiotic prophylaxis and therapy.

Eighty-eight episodes of wound associated infection were identified among 624 consecutively admitted battlefield casualties. Ninety-one per cent of infections occurred during the administration of antibiotic therapy or prophylaxis and 65% were associated with the use of multiple antibacterial agents. Gram negative bacillary and mixed microbial infection predominated and were found to increase in relative incidence after the second day of hospitalization. Appropriate therapy, based on disc sensitivity testing, was administered in only 33% of infectious episodes. The practice of antibiotic wound prophylaxis may contribute to the incidence and nature of infection in battlefield wounds. Problems unique to the handling of battlefield wounded are discussed in comparing the present data with those of other war associated and civilian studies.     

Antibiotic treatment for prevention of infectious complications in joint replacement

Prophylactic antibiotic treatment is mandatory in every operation involving an orthopedic implant. Carefully selected and correctly administered antibiotics can provide effective protection of the implant from bacterial colonization. The prevention of deep wound infection in joint replacement includes several procedures and measures which constitute three basic groups: 1) Promotion of patient's ability to resist infection (careful pre-operative preparation, elimination of potential infectious loci, good nutritional status, etc). 2) Optimal conditions for the operative wound (surgical technique, prophylactic antibiotics). 3) Reduction of the number of bacteria brought in the wound (control measures, super-sterile operating theatres). Clear rules for the system of prophylactic antibiotic treatment should be adopted. A program in which responsibility for antibiotic administration was shifted from the nursing staff to the anesthesiologist in the operating theatre showed improved outcomes and reduced costs. Poor timing of prophylactic antibiotic administration is one of the basic mistakes. If the wound happened to be contaminated during surgery, the first three post-operative hours would be most decisive for the development of infection. An effective bactericidal concentration of antibiotic should be present in tissues and serum immediately after surgery has begun. Therefore the appropriate time for antibiotic application is before a skin incision is made, and not after the operation has started; the highest serum and bone tissue levels appear 20 to 30 min. after intravenous antibiotic injection. To allow antibiotics to reach target tissues, they should be introduced at least 10 min. before tourniquet application. For long surgical procedures or when blood loss is high, an additional dose of antibiotics is recommended during the operation. If a sample for bacterial cultivation is required, antibiotic administration is postponed until during surgery. However, this is used only in indicated cases when deep infection is suspected and no assessment of the causative agent is available. Otherwise this approach carries a high risk of infectious complications in aseptic revision arthroplasty. Long-term, unjustified administration of antibiotics leads to an increase in resistance to the antibiotic involved. Some studies show that a day's course is as effective as a seven-day one. A shorter antibiotic course decreases the costs, reduces side-effects and minimizes the development of resistance. An optimal duration of antibiotic treatment has not been defined yet, and is still a hot issue for discussion. Many authors recommend one pre-operative antibiotic dose and, according to the kind of antibiotic, agree to its 24-hour administration in order to lower the toxic effect of antibiotic and to prevent selection of resistant microorganisms. The choice of suitable antibiotics for prophylactic treatment should be based on the range of agents causing joint replacement infections and the pharmacological properties of the drug. This should have minimal toxicity, should be well tolerated by the patient and, from the epidemiological point of view, should have a low risk of inducing resistance because of frequent use. Naturally, it is not possible to include all antibiotics against all causative agents and therefore attention should be paid, in the first place, to Gram-positive bacteria, i. e., staphylococci and streptococci, which are the most common causes of infectious complications associated with joint replacement. Because of difficulties related to the right choice of antibiotic, it is recommended to keep a record of complications in each patient in order to provide feedback and to facilitate the establishment of reliable antibiotic-based prevention. The prevention of infection in orthopedics is a comprehensive issue. It cannot be expected that prophylactic antibiotic treatment will compensate for mistakes made in operative protocols, for inadequate operative techniques, for shortcomings in operating theatre equipment or insufficient preparation of patients.     

Cost-effectiveness of prophylactic antibiotics in head and neck surgery

Studies undertaken at the Eye and Ear Hospital of Pittsburgh indicate that antibiotic prophylaxis can reduce the incidence of patient morbidity. In this article we will demonstrate the effect of antibiotic prophylaxis on the economics of major head and neck surgery. One hundred and one patients were assigned to one of four treatment protocols, three of which entailed 1 day of a perioperative prophylactic antibiotic and the fourth a placebo. The study was conducted in a double-blind, randomized fashion. Patients receiving a placebo experienced an infection rate of 78%. Patients receiving cefazolin experienced an infection rate of 33%. Ten percent of patients treated with cefoperazone or cefotaxime developed postoperative wound infection. Postoperative hospitalization averaged 17.9 days for patients who did not develop postoperative wound infection, in contrast to an average of 32.6 days for patients with postoperative would infection. The added cost of postoperative infection justifies the added use of the newer, more expensive antibiotics in view of the reduced postoperative morbidity and postoperative hospitalization.     

The place of antibiotics in preventing wound infection after clean operations in an Indian hospital: a prospective, randomised, controlled clinical trial.

Two hundred patients in a major Indian hospital who were undergoing clean operations participated in a prospective, randomised, controlled clinical trial of the effectiveness of systemic antibiotics in preventing wound infectious. Of the patients on antibiotics 12.6% developed wound infections and of those not on antibiotics 13.3% did--a difference of no significance. Other factors analysed which included age, duration of operation, place on the operating list and length of the incision did not appear to effect the incidence of infection. Wound infection delayed the discharge of the patient from hospital by seven days. Avoiding antibiotic prophylaxis in these operations would have saved our hospital 12,500 pounds a year. We suggest that prophylactic antibiotics are ineffective in preventing wound infection after clean operations in India. Their use is wasteful and should be discouraged.     

Perioperative Antiinfektivaprophylaxe in der Kardiochirurgie

Background

Antibiotic prophylaxis in cardiac surgery can improve the outcome of cardiothoracic procedures. Therefore, selection of the correct antimicrobial agent, the duration of administration, the time point of administration, and the correct dose have an influence on the success of cardiac surgery. This article gives an overview of daily practices and options pertaining to antibiotic prophylaxis in cardiac surgery.

Materials and methods

A selective literature review was carried out in PubMed.

Results

First- and second-generation cephalosporins are the most frequently administered antibiotics for prophylaxis in cardiac surgery. Most of the pathogens causing surgical site infections are addressed by this group. Vancomycin is a good choice for MRSA-positive patients, or in clinics with a high MRSA prevalence. Duration should not exceed 24 hours. The best time point for administration is during the last hour prior to the first incision. A higher dose than is standard for the particular antibiotic is not beneficial.

Conclusion

Most data exist for first- and second-generation cephalosporins, which are well suited for this indication. To date, there are no German guidelines for antibiotic prophylaxis in cardiac surgery.

     

Antibiotic Prophylaxis for the Prevention of Infection after Major Limb Amputation

BackgroundMajor limb amputation is often required by patients with a limited capacity to tolerate post-operative complications. Amputation stump infection is common and may necessitate re-amputation, potentially exposing a vulnerable patient to further serious complications. Effective antibiotic strategies should be employed to reduce wound infection after major amputation.MethodsOnline databases were searched to identify studies regarding reduction in wound infection following major limb amputation. Only four randomised studies were identified comparing antibiotic prophylaxis with control; a further three evaluated the efficacy of specific antibiotics. Study design, end-points and outcome data were recorded. The data were too heterogeneous for formal meta-analysis.ResultsProphylactic antibiotics significantly reduced rates of stump infection in all studies, and were associated with a reduced rate of re-amputation in one. Where investigated, the type of antibiotic did not affect rates of infection. In non-randomised studies, infection with methicillin resistant Staphylococcus aureus (MRSA) increased the risk of complications and post-operative death.ConclusionIt is agreed that prophylactic antibiotics are part of the standard of care for amputation surgery, and this is supported by limited, mostly historical-controlled data. Evolution of the bacterial threat means that future studies should assess the role and type of prophylaxis for patients with existing bacterial colonisation or infection.