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 We also contacted authors to identify unpublished trials.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.     

Postoperative management of total joint replacements

Total joint replacement has been one of the major breakthroughs in the field of orthopedics during the past 25 years. Performance of these procedures has enabled many severely disabled individuals to resume a virtually normal way of life. Unlike many other operative procedures, however, the ultimate success of total joint replacement depends not only on the surgery itself, but on appropriate preoperative planning and postoperative management. This does not end when the patient leaves the hospital but should be made a part of the patient's way of life forever. With an appropriate postoperative routine, the average patient can expect many years of satisfactory use of his or her total joint. A realistic approach must be adopted and certain simple restrictions and limitations must be clearly borne in mind. The patient must be conscious of the fact that although the artificial joint causes little or no pain and functions extremely well, it is, in fact, an artificial joint and not a normal joint. In simple terms he or she must be instructed to use it, not abuse it.     

Antibiotic prophylaxis in allo-arthroplastic hip joint surgery

Summary The indication and the efficacy of antibiotic prophylaxis in endoprosthetic operations are discussed with reference to prospective studies.After parenteral administration of 80 mg gentamicin the antibiotic concentrations in the serum and in the wound exudate were studied for 2 to 6 hrs after administration. During this observation period the gentamicin concentrations in the wound exudate were about equal to those in the serum.A comparison of the concentrations after parenteral and after local administration of gentamicin showed much higher concentrations in the wound exudate when gentamicin was administered with the bone cement.

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Antibiotische Prophylaxe bei allo-arthroplastischen HüfteingriffenKonzentrationsbestimmungen im Wundsekret nach parenteraler Verabreichung von Gentamycin

Zusammenfassung Anhand prospektiver Untersuchungen werden die Indikation und Wirksamkeit einer Antibioticumprophylaxe bei Endoprothesenoperationen erörtert.Nach parenteraler Gabe von 80 mg Gentamycin wurden für 2–6 Std nach der Applikation die Wirkstoffkonzentrationen im Serum und Redonsekret untersucht. Während des Beobachtungszeitraumes entsprachen die Gentamycinkonzentrationen im Wundsekret in etwa den Serumkonzentrationen.Ein Vergleich der Konzentrationen nach parenteraler und lokaler Gentamycinapplikation zeigte wesentlich höhere Wundsekretkonzentrationen, wenn Gentamycin mit dem Knochenzement verabreicht wurde.

     

Antibiotic prophylaxis for total joint replacement surgery: results of a survey of Canadian orthopedic surgeons

Background

The role of perioperative antibiotic prophylaxis in total joint replacement (TJR) surgery is well established. Whereas guidelines have been published in some countries, in Canada controversy persists concerning the best clinical practice for perioperative antibiotic prophylaxis in TJR.

Methods

We conducted a survey of 590 practising orthopedic surgeons performing TJR in Canada to assess current antibiotic prophylaxis practice. The survey included questions pertaining to antibiotic prophylaxis indications, antibiotic choice, dosing, route and timing of administration in the primary and revision arthroplasty setting, as well as postoperative wound drainage evaluation and management.

Results

The response rate after 2 mail-outs was 410 of 590 (69.5%). Current antibiotic prophylaxis regimens varied widely among surgeons, underscoring the controversy that exists regarding what constitutes best clinical practice.

Conclusion

Opinions regarding use of perioperative antibiotic prophylaxis in TJR vary widely among orthopedic surgeons in Canada, illustrating the controversy as to what constitutes best clinical practice. This survey also points to a lack of consensus about the current management of postoperative wound drainage.     

Clinical studies and postoperative results of 51 nonambulatory rheumatoid patients with total joint replacements

Between October 1971 and June 1984, total joint replacement was performed on 51 nonambulatory patients with rheumatoid arthritis (RA). These nonambulatory patients showed high RA activity, and many presented with extra-articular symptoms with reference to the heart, lung, etc. During follow-up, 13 patients died of diseases unrelated to the operation, and the whereabouts of other 3 patients were unknown. Thus, the total joint replacement was evaluated in the remaining 35 patients. The walking ability was improved in 27 patients. However, the hoped-for results were not attained in relation to various aspects of the activities of daily life. Complications developed in 6 joints of 6 patients. The factors responsible for poor results were loss of motivation, muscle weakness, reduced function of the upper extremities, osteoporosis, cervical spinal cord injury, etc. From these results, it is emphasized that properly-timed surgery at the right level can prevent RA patient from becoming nonambulatory.     

Infected joint replacements in HIV-positive patients with haemophilia

Joint replacement in HIV-positive patients remains uncommon, with most experience gained in patients with haemophilia. We analysed retrospectively the outcome of 102 replacement arthroplasties in 73 HIV-positive patients from eight specialist haemophilia centres. Of these, 91 were primary procedures. The mean age of the patients at surgery was 39 years, and the median follow-up was for five years. The overall rate of deep sepsis was 18.7% for primary procedures and 36.3% for revisions. This is a much higher rate of infection than that seen in normal populations. A total of 44% of infections resolved fully after medical and/or surgical treatment. The benefits of arthroplasty in haemophilic patients are well established but the rates of complications are high. As this large study has demonstrated, high rates of infection occur, but survivorship analysis strongly suggests that most patients already diagnosed with HIV infection at the time of surgery should derive many years of symptomatic relief after a successful joint replacement. Careful counselling and education of both patients and healthcare workers before operation are therefore essential.     

Borderline indications for use of cement in total joint replacements.

In order to delineate the borderline indications for the cemented and uncemented total hip replacements, we need to evaluate the existing success rates with these procedures. The long term success rates with cemented total hip replacements done using an intramedullary methylmethacrylate plug, doughy Simplex bone cement introduced in a retrograde fashion via a cement gun, and collared cobalt-chrome femoral components with rounded corners were reviewed at eleven year follow-up. The patients ranged in ages from 20 to 84 years (mean 57 years). Among the 105 patients in the group followed up at a minimum of 10 years 97% of the femoral components remained rigidly fixed. These results suggest that the cemented femoral components give satisfactory results to the vast majority of patients over eleven years. Further improvements in the use of cement for prosthetic fixation were made since then. The strength of the cement-prosthesis interface is now considerably enhanced by precoating the prosthesis industrially with a thin layer of methacrylate and or by using texture prosthesis. The strength of cement is considerably improved by techniques such as centrifuging the cement after mixing, or mixing the cement in vacuum. These techniques appear promising and may further enhance the fixation of the prostheses to the skeleton.     

Secondarily infected total joint replacements by hematogenous spread.

Three fatal cases of infections that followed total joint replacement are repoarted, in each of which a hematogenous source of infection was identified. There also were five non-fatal cases presumable arising hematogenously which were reported in the literature. It is emphasized that concomitant disease, including active rheumatoid arthritis, may predispose to this complication.     

Antibiotic prophylaxis for surgery in morbidly obese patients

The rate of wound infections in morbidly obese patients who underwent gastroplasty surgery at our institution was 16.5% compared with a rate of 2.5% in normal-weight patients who underwent clean-contaminated surgery. Both groups received 1 gm of cefazolin intramuscularly before surgery was performed. We hypothesized that this regimen of prophylaxis did not provide adequate tissue levels in the morbidly obese. Morbidly obese patients who were undergoing gastroplasty were randomly selected to receive 1 gm cefazolin in the buttock fat, buttock muscle, or by intravenous injection. A fourth group of morbidly obese patients received 2 gm of cefazolin intravenously. Normal-weight patients who were undergoing upper abdominal surgery received 1 gm of cefazolin intravenously. At incision and closure, both blood and tissue levels of cefazolin were significantly (p less than 0.001) lower for all morbidly obese patients who received 1 gm cefazolin when compared with the blood and tissue levels of the drug found in normal-weight patients. The cefazolin levels obtained were below the minimal inhibitory concentrations of greater than 2 micrograms/ml for gram-positive cocci and of greater than 4 micrograms/ml for gram-negative rods. Only when the morbidly obese patient received 2 gm cefazolin were both the serum and adipose tissue levels adequate. For a 4-month period, all morbidly obese patients received 2 gm cefazolin prophylaxis, and the wound infection rate dropped to 5.6% compared with the previous rate of 16.5% (p less than 0.03). We conclude that antibiotic prophylaxis must be specially tailored to the needs of these obese patients.     

Cefazolin versus cefamandole for prophylaxis during total joint arthroplasty

A prospective, randomized, double-blind comparison of cefazolin versus cefamandole was carried out to evaluate safety and efficacy and to determine bone and serum antibiotic concentrations in patients undergoing total joint arthroplasty. Dosages were 1 g of cefazolin before surgery followed by 500 mg every eight hours for six doses, versus 2 g of cefamandole before surgery followed by 1 g every eight hours for six doses. Intraoperative doses were given during prolonged procedures. No significant adverse drug reactions were clearly attributable to either drug. Among 48 patients receiving cefazolin there was one postoperative wound infection and one distant site infection. Among 49 patients receiving cefamandole, there were two postoperative wound infections and two distant site infections. No deep wound infections occurred in either group during at least 48 months of follow-up study. In hip specimens removed at surgery, the mean antibiotic concentrations were 1.6 +/- 1.4 micrograms/g for cefazolin recipients, compared with 5.7 +/- 5.9 micrograms/g for cefamandole recipients (p less than .001). In knee specimens, the mean antibiotic concentrations were 0.64 +/- 0.57 microgram/g for cefazolin recipients compared to 3.8 +/- 3.4 micrograms/g for cefamandole recipients (p = .004). Cefazolin given at one-half the dose of cefamandole appeared to be equally safe and effective but resulted in lower bone concentrations of antibiotic.     

Antibiotic prophylaxis for high risk patients undergoing cholecystectomy

An open, randomised clinical trial was performed on 435 high risk patients who underwent open cholecystectomy between 1 = January 1993. and 31. December 1995. The patients were divided into three groups. Group 1 (AMOX/CLAV, N = 179) was treated with 1.2 g i.v. amoxicillin/clavulanic acid, the patients in Group 2 (COMPARATOR, N = 164) were given other antibiotics commonly used for prophylaxis in biliary surgery (cefamandole, cefuroxime, cefotaxim). Group 3 (CONTROL, N = 92) contained patients without any risk factors for infectious complication. In this group we did not use antibiotic prophylaxis. The results were analysed with Student t, and x2 methods. The wound infection rate in Group 1 was 2.76% versus 5.48% in Group 2. The difference was significant if the patients were older than 65 years or the preoperative hospitalisation was longer than 5 days. The concentration of amoxycillin/calavulanic acid was measured in the serum, in the wall of the gall bladder, in the bile obtained both from the gall bladder and the major bile duct. The observed levels were higher than the therapeutic concentration in the serum and in the bile gained from the major bile duct, whereas lower in the gall bladder wall, and in the bile gained from the gall bladder. Systemic antibiotic prophylaxis is required for open cholecystectomy in high risk patients.     

Two-day cefamandole versus five-day cephazolin prophylaxis in 965 total hip replacements

Summary The aim of this trial was to compare a 5-day course of cephazolin with a regimen of 2 days of cefamandole in 965 total hip replacements (488 in the cefamandole group and 477 in the cephazolin group). The effect of the prophylactic antibiotic on the bacterial colonization of drains (mean duration of drainage: 3.2±0.3 days) and on the susceptibility of colonizing organisms was assessed. No significant difference was observed in the percentage of infected drains between the two groups. The cefamandole group had a lower rate of Gram-negative organisms (23% versus 44%, p<0.01). The rate of deep infections within one year after operation was 0.7% in the cefamandole group versus 0.5% in the cephazolin group, and the difference is not significant. Cefamandole given for two days appears to be an effective prophylaxis against sepsis in total hip replacements.Clinicians taking part were members of the Groupe d'Etude du Traitement Préventif de l'Infection dans les Arthroplasties: M. Bombart (Villeneuve-Saint-Georges), P. Desche (Dracy-le-Fort), D. Goutallier (Créteil), J. Guegen (Cannes), J. F. Kouvalchouk (Suresnes), M. Margeot (Clamart), F. Mazas (Bicêtre), J. Y. Nordin (Bobigny), D. Patte (Melun), M. Postel (Paris), D. Schmitt (Nancy)     

Antibiotic prophylaxis in patients undergoing prostatectomy

The value of antibiotic prophylaxis in patients undergoing prostatectomy was assessed in a randomized study using three schedules of gentamicin administration. All three gentamicin schedules were effective in lowering the incidence of postoperative bacteriuria, with a single dose of gentamicin two hours preoperatively being the most effective. Antibiotic prophylaxis did not significantly affect the clinical course.     

DVT prophylaxis strategies following total joint arthroplasty

Routine prophylaxis against venous thromboembolism is indicated following total joint arthroplasty. Prophylactic strategies differ in efficacy and safety, and variable risk exists among patients. Many strategies have been successfully used for chemoprophylaxis as well as mechanical prophylaxis with the use of pneumatic compression. Advances in battery technology and pump miniaturization have expanded the use of pneumatic compression in the post-discharge setting with mobile devices. Pneumatic compression is contraindicated in certain patients, and not all patients tolerate the devices. Mobile pneumatic compression is a valuable adjunct to venous thromboembolic risk mitigation strategies, but does not eliminate the need for pharmacologic agents.     

Vancomycin prophylaxis and elective total joint arthroplasty

A series of 201 consecutive patients treated with unilateral or bilateral total joint arthroplasty were given a single-dose prophylactic antibiotic regimen consisting of 1 g vancomycin infused over 1 hour on the morning of surgery and 80 g gentamicin given upon arrival in the operating room. Bactericidal blood levels were maintained during and for 24 hours after surgery. Elevated serum creatinine levels developed postsurgically in 8 patients but returned to normal. No serious hypersensitivity reactions occurred; minor reactions responded to antihistamine therapy. No postoperative infections were reported. Cost of administration compared favorably with 24- and 48-hour regimens employing cephalosporins. The investigators concluded that a combined single dose vancomycin/gentamicin regimen is a safe, effective, and cost efficient method of orthopedic implant prophylaxis.     

Antibiotic prophylaxis and tourniquet inflation in total knee arthroplasty

Twenty-four patients receiving total knee arthroplasty (TKA) were randomized into one of three groups based on tourniquet inflation one, two, or five minutes after administration 1 g cefazolin. Simultaneous serum, soft-tissue, and bone samples were obtained at regular intervals during surgery. All soft-tissue and bone samples were corrected for cefazolin content. The percentage of cefazolin penetration into soft tissue and bone was calculated using the area under the concentration time curve. Adequate cefazolin concentrations for soft tissue and bone were defined as greater than or equal to 4 x minimum inhibitory concentration90 (MIC90 = 1 microgram/ml) of cefazolin to Staphylococcus aureus and coagulase-negative staphylococci. Patients were similar in age, actual body weight, creatinine clearance, and length of tourniquet inflation. The median percentage of cefazolin penetration into soft tissue and bone for the five-, two-, and one-minute groups was 14.5% and 4.6%, 6.7% and 3.0%, and 5.9% and 4.6%, respectively; the percentage of penetration into soft tissue between the five- and one-minute groups was statistically significant. A higher percentage of patients achieved the desired cefazolin concentration (greater than or equal to 4 micrograms/g) if a five-minute interval was selected. The five-minute group achieved the highest mean ratios of concentration to MIC compared with the two- and one-minute groups, although the differences were not statistically significant. The standard 1 g of cefazolin with a five-minute interval between administration and tourniquet inflation resulted in adequate mean soft-tissue and bone concentrations for prophylaxis during TKA with a tourniquet time less than two hours. Additional doses are not warranted after tourniquet release.