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Clinical Orthopaedics and Related Research®

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01-10-2014 | Clinical Research

What are the Patterns of Prophylactic Postoperative Oral Antibiotic Use After Foot and Ankle Surgery?

Authors: David J. Ruta, MD, Anish R. Kadakia, MD, Todd A. Irwin, MD

Published in: Clinical Orthopaedics and Related Research® | Issue 10/2014

Abstract

Background

The CDC estimates 23% of healthcare-associated infections to be surgical site infections, with alarming prevalence of antibiotic-resistant organisms. While there is consensus regarding preoperative prophylaxis, orthopaedic surgeons’ use of prophylactic postoperative oral antibiotics is less defined.

Questions/purposes

We investigated surgeons’ use of prophylactic postoperative oral antibiotics after elective outpatient foot or ankle procedures, identifying (1) frequency of use, (2) regimen preferences, (3) personal indications, and (4) associated experience and demographics.

Methods

Using a cross-sectional survey design, a questionnaire was emailed to all active and candidate members of the American Orthopaedic Foot and Ankle Society. Supplementary questions captured demographic information. We invited 1136 members to participate; 22 addresses produced delivery failure messages, leaving 1114 members as potential participants. After nonresponses and exclusions, 312 (28%) responses were analyzed. Statistical analysis used Pearson’s chi-square test, Fisher’s exact test, and multivariate regression.

Results

The majority (75%) of respondents reported use of prophylactic postoperative oral antibiotics. Most users (69%) prescribed to fewer than 25% of patients, although 16% prescribed for all elective cases. The most frequent regimen was cephalexin 500 mg four times a day (63%) and the most common duration was 5 to 7 days (50%). Surgeons’ most common indications were previous infection (71%), medical comorbidities (65%), and previous wound-healing difficulties (56%). Those who do and do not prescribe prophylactic postoperative oral antibiotics showed no difference in surgical site infection rate or any demographic category.

Conclusions

Surgeons’ reported use of prophylactic postoperative oral antibiotics after elective foot or ankle surgery was common, without demographic association. Commonalities were identified in antibiotic regimen and personal indications for this practice. Comparative clinical studies are warranted to elucidate the efficacy of prophylactic postoperative oral antibiotics and establish evidence-based guidelines for their use.

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Abubaker AO, Rollert MK. Postoperative antibiotic prophylaxis in mandibular fractures: a preliminary randomized, double-blind, and placebo-controlled clinical study. J Oral Maxillofac Surg. 2001;59:1415–1419.CrossRefPubMed

American Academy of Orthopaedic Surgeons Patient Safety Committee, Evans RP. Surgical site infection prevention and control: an emerging paradigm. J Bone Joint Surg Am. 2009;91(suppl 6):2–9.CrossRefPubMed

Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett. 2012;10:73–78; quiz 79–80.

Baumhauer JF, Pinzur MS, Daniels TR, Lin SS, Beasley W, Donahue RM, DiGiovanni CW. Survey on the need for bone graft in foot and ankle fusion surgery. Foot Ankle Int. 2013;34:1629–1633.CrossRefPubMed

Bhandari M, Fong K, Sprague S, Williams D, Petrisor B. Variability in the definition and perceived causes of delayed unions and nonunions: a cross-sectional, multinational survey of orthopaedic surgeons. J Bone Joint Surg Am. 2012;94:e1091–e1096.CrossRefPubMed

Bhandari M, Guyatt GH, Tornetta P 3rd, Swiontkowski MF, Hanson B, Sprague S, Syed A, Schemitsch EH. Current practice in the intramedullary nailing of tibial shaft fractures: an international survey. J Trauma. 2002;53:725–732.CrossRefPubMed

Bibbo C, Patel DV, Gehrmann RM, Lin SS. Chlorhexidine provides superior skin decontamination in foot and ankle surgery: a prospective randomized study. Clin Orthop Relat Res. 2005;438:204–208.CrossRefPubMed

Blotter RH, Connolly E, Wasan A, Chapman MW. Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus. Foot Ankle Int. 1999;20:687–694.CrossRefPubMed

Boyd RJ, Burke JF, Colton T. A double-blind clinical trial of prophylactic antibiotics in hip fractures. J Bone Joint Surg Am. 1973;55:1251–1258.PubMed

10.

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.CrossRefPubMed

11.

Brendle TA. Surgical Care Improvement Project and the perioperative nurse’s role. AORN J. 2007;86:94–101.CrossRefPubMed

12.

Brooks RA, Hollinghurst D, Ribbans WJ, Severn M. Bacterial recolonization during foot surgery: a prospective randomized study of toe preparation techniques. Foot Ankle Int. 2001;22:347–350.PubMed

13.

Campoccia D, Montanaro L, Arciola CR. The significance of infection related to orthopedic devices and issues of antibiotic resistance. Biomaterials. 2006;27:2331–2339.CrossRefPubMed

14.

Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992;326:281–286.CrossRefPubMed

15.

Clayton JL, Bazakas A, Lee CN, Hultman CS, Halvorson EG. Once is not enough: withholding postoperative prophylactic antibiotics in prosthetic breast reconstruction is associated with an increased risk of infection. Plast Reconstr Surg. 2012;130:495–502.CrossRefPubMedCentralPubMed

16.

Connolly JF, Csencsitz TA. Limb threatening neuropathic complications from ankle fractures in patients with diabetes. Clin Orthop Relat Res. 1998;348:212–219.PubMed

17.

Costigan W, Thordarson DB, Debnath UK. Operative management of ankle fractures in patients with diabetes mellitus. Foot Ankle Int. 2007;28:32–37.CrossRefPubMed

18.

Della Rocca GJ, Sprague S, Dosanjh S, Schemitsch EH, Bhandari M. Orthopaedic surgeons’ knowledge and misconceptions in the identification of intimate partner violence against women. Clin Orthop Relat Res. 2013;471:1074–1080.CrossRefPubMedCentralPubMed

19.

Dellinger EP, Gross PA, Barrett TL, Krause PJ, Martone WJ, McGowan JE Jr, Sweet RL, Wenzel RP. Quality standard for antimicrobial prophylaxis in surgical procedures. Infectious Diseases Society of America. Clin Infect Dis. 1994;18:422–427.CrossRefPubMed

20.

DiGiovanni BF, Moore AM, Zlotnicki JP, Pinney SJ. Preferred management of recalcitrant plantar fasciitis among orthopaedic foot and ankle surgeons. Foot Ankle Int. 2012;33:507–512.CrossRefPubMed

21.

Donley BG, Philbin T, Tomford JW, Sferra JJ. Foot and ankle infections after surgery. Clin Orthop Relat Res. 2001;391:162–170.CrossRefPubMed

22.

Dunn WR, Schackman BR, Walsh C, Lyman S, Jones EC, Warren RF, Marx RG. Variation in orthopaedic surgeons’ perceptions about the indications for rotator cuff surgery. J Bone Joint Surg Am. 2005;87:1978–1984.CrossRefPubMed

23.

Flynn JM, Rodriguez-del Rio F, Piza PA. Closed ankle fractures in the diabetic patient. Foot Ankle Int. 2000;21:311–319.PubMed

24.

Fogelberg EV, Zitzmann EK, Stinchfield FE. Prophylactic penicillin in orthopaedic surgery. J Bone Joint Surg Am. 1970;52:95–98.PubMed

25.

Gardner MJ, Streubel PN, McCormick JJ, Klein SE, Johnson JE, Ricci WM. Surgeon practices regarding operative treatment of posterior malleolus fractures. Foot Ankle Int. 2011;32:385–393.CrossRefPubMed

26.

Gatell JM, Riba J, Lozano ML, Mana J, Ramon R, Garcia SanMiguel J. Prophylactic cefamandole in orthopaedic surgery. J Bone Joint Surg Am. 1984;66:1219–1222.PubMed

27.

Goldberg AJ, Sharp RJ, Cooke P. Ankle replacement: current practice of foot & ankle surgeons in the United Kingdom. Foot Ankle Int. 2009;30:950–954.CrossRefPubMed

28.

Goucher NR, Coughlin MJ. Covering of the toes during hindfoot and ankle surgery: a randomized, controlled, clinical study. Foot Ankle Int. 2007;28:413–415.CrossRefPubMed

29.

Helm R. The results of ankle arthrodesis. J Bone Joint Surg Br. 1990;72:141–143.PubMed

30.

Hort KR, DeOrio JK. Residual bacterial contamination after surgical preparation of the foot or ankle with or without alcohol. Foot Ankle Int. 2002;23:946–948.PubMed

31.

Johnson JE, Klein SE, Putnam RM. Corticosteroid injections in the treatment of foot & ankle disorders: an AOFAS survey. Foot Ankle Int. 2011;32:394–399.CrossRefPubMed

32.

Jones KB, Maiers-Yelden KA, Marsh JL, Zimmerman MB, Estin M, Saltzman CL. Ankle fractures in patients with diabetes mellitus. J Bone Joint Surg Br. 2005;87:489–495.CrossRefPubMed

33.

Kakar S, Tornetta P 3rd, Schemitsch EH, Swiontkowski MF, Koval K, Hanson BP, Jonsson A, Bhandari M; International Hip Fracture Research Collaborative. Technical considerations in the operative management of femoral neck fractures in elderly patients: a multinational survey. J Trauma. 2007;63:641–646.CrossRefPubMed

34.

Kitaoka HB, Patzer GL. Clinical results of the Mayo total ankle arthroplasty. J Bone Joint Surg Am. 1996;78:1658–1664.PubMed

35.

Knobe M, Gradl G, Ladenburger A, Tarkin IS, Pape HC. Unstable intertrochanteric femur fractures: is there a consensus on definition and treatment in Germany? Clin Orthop Relat Res. 2013;471:2831–2840.CrossRefPubMedCentralPubMed

36.

Koval KJ, Zhou W, Sparks MJ, Cantu RV, Hecht P, Lurie J. Complications after ankle fracture in elderly patients. Foot Ankle Int. 2007;28:1249–1255.CrossRefPubMed

37.

Kwon JY, Diwan A, Susarla S. Effect of surgeon training, fracture, and patient variables on calcaneal fracture management. Foot Ankle Int. 2011;32:262–271.CrossRefPubMed

38.

Leach WJ, Fordyce MJ. Audit of ankle fracture fixation in the elderly. J R Coll Surg Edinb. 1994;39:124–127.PubMed

39.

Lee J, Singletary R, Schmader K, Anderson DJ, Bolognesi M, Kaye KS. Surgical site infection in the elderly following orthopaedic surgery: risk factors and outcomes. J Bone Joint Surg Am. 2006;88:1705–1712.CrossRefPubMed

40.

Lidgren L, Lindberg L. Post-operative wound infections in clean orthopaedic surgery: review of a 5-year material. Acta Orthop Scand. 1974;45:161–169.CrossRefPubMed

41.

Liu DZ, Dubbins JA, Louie O, Said HK, Neligan PC, Mathes DW. Duration of antibiotics after microsurgical breast reconstruction does not change surgical infection rate. Plast Reconstr Surg. 2012;129:362–367.CrossRefPubMed

42.

McGrory BJ, York SC, Iorio R, Macaulay W, Pelker RR, Parsley BS, Teeny SM. Current practices of AAHKS members in the treatment of adult osteonecrosis of the femoral head. J Bone Joint Surg Am. 2007;89:1194–1204.CrossRefPubMed

43.

Miller AG, Margules A, Raikin SM. Risk factors for wound complications after ankle fracture surgery. J Bone Joint Surg Am. 2012;94:2047–2052.CrossRefPubMed

44.

Myers TG, Lowery NJ, Frykberg RG, Wukich DK. Ankle and hindfoot fusions: comparison of outcomes in patients with and without diabetes. Foot Ankle Int. 2012;33:20–28.CrossRefPubMed

45.

Neumayer L, Hosokawa P, Itani K, El-Tamer M, Henderson WG, Khuri SF. Multivariable predictors of postoperative surgical site infection after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg. 2007;204:1178–1187.CrossRefPubMed

46.

Oishi CS, Carrion WV, Hoaglund FT. Use of parenteral prophylactic antibiotics in clean orthopaedic surgery: a review of the literature. Clin Orthop Relat Res. 1993;296:249–255.PubMed

47.

Ostrander RV, Botte MJ, Brage ME. Efficacy of surgical preparation solutions in foot and ankle surgery. J Bone Joint Surg Am. 2005;87:980–985.CrossRefPubMed

48.

Ostrander RV, Brage ME, Botte MJ. Bacterial skin contamination after surgical preparation in foot and ankle surgery. Clin Orthop Relat Res. 2003;406:246–252.CrossRefPubMed

49.

Pagliaro AJ, Michelson JD, Mizel MS. Results of operative fixation of unstable ankle fractures in geriatric patients. Foot Ankle Int. 2001;22:399–402.PubMed

50.

Paiement GD, Renaud E, Dagenais G, Gosselin RA. Double-blind randomized prospective study of the efficacy of antibiotic prophylaxis for open reduction and internal fixation of closed ankle fractures. J Orthop Trauma. 1994;8:64–66.CrossRefPubMed

51.

Pavel A, Smith RL, Ballard A, Larsen IJ. Prophylactic antibiotics in clean orthopaedic surgery. J Bone Joint Surg Am. 1974;56:777–782.PubMed

52.

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

53.

Rice LB. Antimicrobial resistance in gram-positive bacteria. Am J Infect Control. 2006;34(5 suppl 1):S11–S19; discussion S64–S73.CrossRefPubMed

54.

Rosenberger LH, Politano AD, Sawyer RG. The surgical care improvement project and prevention of post-operative infection, including surgical site infection. Surg Infect (Larchmt). 2011;12:163–168.CrossRefPubMed

55.

Sabharwal S, Passannante MR. Venous thromboembolism in children: preliminary results of a survey of POSNA members. J Pediatr Orthop. 2013;33:852–856.CrossRefPubMed

56.

Schizas C, Kulik G. Decision-making in lumbar spinal stenosis: a survey on the influence of the morphology of the dural sac. J Bone Joint Surg Br. 2012;94:98–101.CrossRefPubMed

57.

Sievert DM, Ricks P, Edwards JR, Schneider A, Patel J, Srinivasan A, Kallen A, Limbago B, Fridkin S; National Healthcare Safety Network (NHSN) Team and Participating NHSN Facilities. Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009–2010. Infect Control Hosp Epidemiol. 2013;34:1–14.

58.

Sinisaari I, Patiala H, Bostman O, Makela EA, Hirvensalo E, Partio EK, Tormala P, Rokkanen P. Metallic or absorbable implants for ankle fractures: a comparative study of infections in 3,111 cases. Acta Orthop Scand. 1996;67:16–18.CrossRefPubMed

59.

SooHoo NF, Krenek L, Eagan MJ, Gurbani B, Ko CY, Zingmond DS. Complication rates following open reduction and internal fixation of ankle fractures. J Bone Joint Surg Am. 2009;91:1042–1049.CrossRefPubMed

60.

Stevens DB. Postoperative orthopaedic infections: a study of etiological mechanisms. J Bone Joint Surg Am. 1964;46:96–102.PubMed

61.

Taylor GJ, Bannister GC, Calder S. Perioperative wound infection in elective orthopaedic surgery. J Hosp Infect. 1990;16:241–247.CrossRefPubMed

62.

Watts AC, Brenkel IJ. A postal survey of current thromboprophylactic practices of consultant orthopaedic surgeons in the treatment of fracture of the hip. J Bone Joint Surg Br. 2005;87:296–300.CrossRefPubMed

63.

Wolf EW, Hodge W, Spielfogel WD. Periungual bacterial flora in the human foot. J Foot Surg. 1991;30:253–263.PubMed

64.

Wukich DK, Lowery NJ, McMillen RL, Frykberg RG. Postoperative infection rates in foot and ankle surgery: a comparison of patients with and without diabetes mellitus. J Bone Joint Surg Am. 2010;92:287–295.CrossRefPubMed

65.

Zacharias J, Largen PS, Crosby LA. Results of preprocedure and postprocedure toe cultures in orthopaedic surgery. Foot Ankle Int. 1998;19:166–168.CrossRefPubMed

66.

Zgonis T, Jolly GP, Garbalosa JC. The efficacy of prophylactic intravenous antibiotics in elective foot and ankle surgery. J Foot Ankle Surg. 2004;43:97–103.CrossRefPubMed

Title: What are the Patterns of Prophylactic Postoperative Oral Antibiotic Use After Foot and Ankle Surgery?
Authors: David J. Ruta, MD
Anish R. Kadakia, MD
Todd A. Irwin, MD
Publication date: 01-10-2014
Publisher: Springer US
Published in: Clinical Orthopaedics and Related Research® / Issue 10/2014
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-014-3733-4

At a glance: The STEP trials

Springer Medicine

What are the Patterns of Prophylactic Postoperative Oral Antibiotic Use After Foot and Ankle Surgery?

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

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