Top

Clinical Orthopaedics and Related Research®

Published in:

01-10-2012 | Symposium: 2011 Musculoskeletal Infection Society

Does Dual Antibiotic Prophylaxis Better Prevent Surgical Site Infections in Total Joint Arthroplasty?

Authors: Amy Sewick, MD, Amun Makani, MD, Chia Wu, MD, Judith O’Donnell, MD, Keith D. Baldwin, MD, MPH, MSPT, Gwo-Chin Lee, MD

Published in: Clinical Orthopaedics and Related Research® | Issue 10/2012

Abstract

Introduction

It is unclear which antibiotic regimen provides the best prophylaxis against surgical site infection (SSI) in patients undergoing hip and knee surgery.

Questions/purposes

Therefore, we determined whether dual antibiotic prophylaxis (1) reduced the rate of SSI compared to single antibiotic prophylaxis and (2) altered the microbiology of SSI.

Methods

We retrospectively reviewed 1828 primary THAs and TKAs performed between September 1, 2008 and December 31, 2010. We divided patients into two groups: (1) those who received a dual prophylactic antibiotic regimen of cefazolin and vancomycin (unless allergy), or (2) received cefazolin (unless allergy) as the sole prophylactic antibiotic. There were 701 males and 1127 females with an average age of 56 years (range, 15–97 years). We limited followup to 1 year, presuming subsequent infections were not related to the initial surgery.

Results

During this period, there were 22 SSIs (1.2%). The infection rates for dual antibiotic prophylaxis compared to a single antibiotic regimen were 1.1% and 1.4%, respectively. Of 1328 patients treated with dual antibiotic prophylaxis, only one (0.08%) SSI was culture positive for methicillin resistant Staphylococcus aureus (MRSA), while four of 500 patients (0.8%) receiving only cefazolin prophylaxis had culture positive MRSA infection at the time of reoperation.

Conclusion

The addition of vancomycin as a prophylactic antibiotic agent apparently did not reduce the rate of SSI compared to cefazolin alone. Use of vancomycin in addition to cefazolin appeared to reduce the incidence of MRSA infections; however, the number needed to treat to prevent a single MRSA infection was very high.

Level of Evidence

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

American Academy of Orthopaedic Surgeons Advisory Statement: Recommendations for the use of intravenous antibiotic prophylaxis in primary total joint arthroplasty. Available at: http://www.aaos.org/about/papers/advistmt/1027.asp. Accessed August 27, 2011.

Ayliffe GA. Role of the environment of the operative suite in surgical wound infection. Rev Infect Dis. 1991;13(Suppl. 10):S800–S804.PubMedCrossRef

Bauer TW, Parvizi J, Kobayashi N, Krebs V. Diagnosis of periprosthetic infection. J Bone Joint Surg Am. 2006;88:869–882.PubMedCrossRef

Boxma H, Broekhuizen T, Patka P, Oosting H. Randomized control trial of a single dose antibiotic prophylaxis in surgical treatment of closed fractures: the Dutch Trauma Trial. Lancet. 1996;347:1133–1137.PubMedCrossRef

Bozic KJ, Katz P, Cisternas M, Ono L, Ries MD, Showstack J. Hospital resource utilization for primary and revision total hip arthroplasty. J Bone Joint Surg Am. 2005;87:570–576.PubMedCrossRef

Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91:128–133.PubMedCrossRef

Bozic KJ, Kurtz SM, Lau E, Ong K, Chiu V, Vail TP, Rubash HE, Berry DJ. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res. 2010;468:45–51.PubMedCrossRef

Bratzler DW, Houck PM; Surgical Infection Prevention Guideline Writers Workgroup. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Am J Surg. 2005;189:395–404.

Dale WB, Peter MH. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004;38:1706–1715.CrossRef

10.

Darouiche RO. Treatment of infections associated with surgical implants. N Engl J Med. 2004;350:1422–1429.PubMedCrossRef

11.

Douglas P, Asimus M, Swan J, Spigelman A. Prevention of orthopaedic wound infections: a quality improvement project. J Qual Clin Pract. 2001;21:149–153.PubMedCrossRef

12.

Dreghorn CR, Hamblen DL. Revision arthroplasty: a high price to pay. BMJ. 1989;296:648–649.CrossRef

13.

Fierobe L, Decré D, Mùller C, Lucet JC, Marmuse JP, Mantz J, Desmonts JM. Methicillin-resistant Staphylococcus aureus as a causative agent of postoperative intra-abdominal infection: relation to nasal colonization. Clin Infect Dis. 1999;29:1231–1238.PubMedCrossRef

14.

Finkelstein R, Rabino G, Mashiah T, Bar-El Y, Adler Z, Kertzman V, Cohen O, Milo S. Vancomycin versus cefazolin prophylaxis for cardiac surgery in the setting of a high prevalence of methicillin-resistant staphylococcal infections. J Thorac Cardiovasc Surg. 2002;123:326–332.PubMedCrossRef

15.

Gavin KL, Konigsberg BS. Infection following total knee arthroplasty: prevention and management. J Bone Joint Surg Am. 2011;93:1167–1175.

16.

Gobran SR, Goldman S, Ferdinand F, Wertan MA, Trace C, Grunkemeier GL, Wu Y, Sutter FP. Outcomes after usage of a quality initiative program for off-pump coronary artery bypass surgery; a comparison with on-pump surgery. Ann Thorac Surg. 2004;78:2015–2021.PubMedCrossRef

17.

Gupta K, Strymish J, Abi-Haidar Y, Williams SA, Itani KM. Preoperative nasal methicillin-resistant Staphylococcus aureus status, surgical prophylaxis, and risk-adjusted postoperative outcomes in veterans. Infect Control Hosp Epidemiol. 2011;32:791–796.PubMedCrossRef

18.

Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol. 1992;13:606–608.PubMedCrossRef

19.

Jiranek WA, Hanssen AD, Greenwald AS. Antibiotic-loaded bone cement for infection prophylaxis in total joint replacement. J Bone Joint Surg Am. 2006;88:2487–2500.PubMedCrossRef

20.

Kim DH, Spencer M, Davidson SM, Li L, Shaw JD, Gulczynski D, Hunter DJ, Martha JF, Miley GB, Parazin SJ, Dejoie P, Richmond JC. Institutional prescreening for detection and eradication of MRS in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am. 2010;92:1820–1826.PubMedCrossRef

21.

Laupacis A, Sackett DL, Roberts RS. An assessment of clinically useful measures of the consequences of treatment. N Engl J Med. 1988;318:1728–1733.PubMedCrossRef

22.

Leung F, Richards CJ, Garbuz DS, Masri BA, Duncan CP. Two stage total hip arthroplasty: how often does it control methicillin-resistant infection? Clin Orthop Relat Res. 2011;469:1009–1015.PubMedCrossRef

23.

Lidwell OM, Lowbury EJ, Whyte W, Blowers R, Stanley SJ, Lowe D. Effects of ultraclean air in operating rooms on deep sepsis in the joint after total hip or knee replacement: a randomised study. Br Med J (Clin Res Ed). 1982;285:10–14.CrossRef

24.

Lynch RJ, Englesbe MJ, Sturm L, Bitar A, Budhiraj K, Kolla S, Polyachenko Y, Duck MG, Campbell DA Jr. Measurement of foot traffic in the operating room: implications for infection control. Am J Med Qual. 2009;24:45–52.PubMedCrossRef

25.

Malangoni MA, Cheadle WG, Dodson TF, Dohmen PM, Jones D, Katariya K, Kolvekar S, Urban JA. New opportunities for reducing risk of surgical site infection. Surg Infect (Larchmt). 2006;7(Suppl. 1):S23–S39.CrossRef

26.

Mangram AJ. A brief overview of the 1999 CDC guideline for the prevention of surgical site infection: centers for disease control and prevention. J Chemother. 2001;13:35–39.PubMed

27.

Marculescu CE, Osmon DR. Antibiotic prophylaxis in orthopaedic prosthetic surgery. Infect Dis Clinic N Am. 2009;19:931–946.CrossRef

28.

Meehan J, Jamali AA, Nguyen, H. Prophylactic antibiotics in hip and knee arthroplasty. J Bone Joint Surg Am. 2009;91:2480–2489.PubMedCrossRef

29.

Merrer J, Desbouchages L, Serazin V, Razafimamonjy J, Pauthier F, Leneveu M. Comparison of routine prophylaxis with vancomycin or cefazolin for femoral neck fracture surgery: microbiological and clinical outcomes. Infect Control Hosp Epidemiol. 2006;27:1366–1371.PubMedCrossRef

30.

Miller LG, McKinnell JA, Vollmer ME, Spellberg B. Impact of methicillin-resistant Staphylococcus aureus prevalence among S. aureus isolates on surgical site infection risk after coronary artery bypass surgery. Infect Control Hosp Epidemiol. 2011;32:342–350.PubMedCrossRef

31.

Peel TN, Dowsey MM, Daffy JR, Stanley PA, Choong PF, Buising KL. Risk factors for prosthetic hip and knee infections according to arthroplasty site. J Hosp Infect. 2011;79:129–133.PubMedCrossRef

32.

Perencevich EN, Sands KE, Cosgrove SE, Guadagnoli E, Meara E, Platt R. Health and economic impact of surgical site infections diagnosed after hospital discharge. Emerg Infect Dis. 2003;9:196–203.PubMedCrossRef

33.

Prokuski L. Prophylactic antibiotics in orthopaedic surgery. J Am Acad Orthop Surg. 2008;16:283–293.PubMed

34.

Ridgeway S, Wilson J, Charlet A, Kafatos G, Pearson A, Coello R. Infection of the surgical site after arthroplasty of the hip. J Bone Joint Surg Br. 2005;87:844–850.PubMedCrossRef

35.

Ritter MA, Barzilauskas CD, Faris PM, Keating PM. Vancomycin prophylaxis and elective total joint arthroplasty. Orthopedics. 1989;12:1333–1336.PubMed

36.

Thomas C, Cadwallader HL, Riley TV. Surgical-site infections after orthopaedic surgery: statewide surveillance using linked administrative databases. J Hosp Infect. 2004;57:25–30.PubMedCrossRef

37.

Tyllianakis ME, Karageorgos ACh, Marangos MN, Saridis AG, Lambiris EE. Antibiotic prophylaxis in primary hip and knee arthroplasty: comparison between cefuroxime and two specific antistaphylococcal agents. J Arthroplasty. 2010;25:1078–1082.PubMedCrossRef

38.

van Kasteren ME, Mannien J, Kullberg BJ, de Boer AS, Nagelkerke NJ, Ridderhof M, Wille JC, Gyssens IC. Quality improvement of surgical prophylaxis in Dutch hospitals: evaluation of a multi-site intervention by time series analysis. J Antimicrob Chemother. 2005;56:1094–1102.PubMedCrossRef

39.

Walsh EE, Greene L, Kirshner R. Sustained reduction in methicillin-resistant Staphylococcus aureus wound infections after cardiothoracic surgery. Arch Intern Med. 2011;171:68–73.PubMedCrossRef

40.

Wiesel BB, Esterhai JJ. Chapter 4: Prophylaxis of musculoskeletal infection. In Calhoun JJ and Mader JT (eds). Musculoskeletal Infections. Marcel Dekker, Inc., New York, NY. 2003;115–129.

41.

Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351:1645–1654.PubMedCrossRef

Title: Does Dual Antibiotic Prophylaxis Better Prevent Surgical Site Infections in Total Joint Arthroplasty?
Authors: Amy Sewick, MD
Amun Makani, MD
Chia Wu, MD
Judith O’Donnell, MD
Keith D. Baldwin, MD, MPH, MSPT
Gwo-Chin Lee, MD
Publication date: 01-10-2012
Publisher: Springer-Verlag
Published in: Clinical Orthopaedics and Related Research® / Issue 10/2012
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-012-2255-1

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Does Dual Antibiotic Prophylaxis Better Prevent Surgical Site Infections in Total Joint Arthroplasty?

Abstract

Introduction

Questions/purposes

Methods

Results

Conclusion

Level of Evidence

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Introduction

Questions/purposes

Methods

Results

Conclusion

Level of Evidence

Please log in to get access to this content

Other articles of this Issue 10/2012

Measuring Acetabular Component Version After THA: CT or Plain Radiograph?

2011 Musculoskeletal Infection Society: Editorial Comment

In Vivo Three-dimensional Motion Analysis of Chronic Radial Head Dislocations

Case Report: Bilateral Femoral Neck Fractures in a Child and a Rare Complication of Slipped Capital Epiphysis After Internal Fixation

Complex Ankle Arthrodesis Using the Ilizarov Method Yields High Rate of Fusion

Culture-negative Periprosthetic Joint Infection Does Not Preclude Infection Control