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Trends in orthopaedic antimicrobial prophylaxis in the UK between 2005 and 2011
Abstract
Antimicrobial prophylaxis remains the most powerful tool used to reduce infection rates in orthopaedics but the choice of antibiotic is complex. The aim of this study was to examine trends in antimicrobial prophylaxis in orthopaedic surgery involving the insertion of metalwork between 2005 and 2011.
Two questionnaires (one in 2008 and one in 2011) were sent to all National Health Service trusts in the UK using the Freedom of Information Act.
In total, 87% of trusts that perform orthopaedic surgery responded. The use of cefuroxime more than halved between 2005 and 2011 from 80% to 36% and 78% to 26% in elective surgery and trauma surgery respectively. Combination therapy with flucloxacillin and gentamicin rose from 1% to 32% in elective and 1% to 34% in trauma surgery. Other increasingly popular regimes include teicoplanin and gentamicin (1% to 10% in elective, 1% to 6% in trauma) and co-amoxiclav (3% to 8% in elective, 4% to 14% in trauma). The majority of changes occurred between 2008 and 2010. Over half (56%) of the trusts stated that Clostridium difficile was the main reason for changing regimes.
In 2008 a systematic review involving 11,343 participants failed to show a difference in surgical site infections when comparing different antimicrobial prophylaxis regimes in orthopaedic surgery. Concerns over C difficile and methicillin resistant Staphylococcus aureus have influenced antimicrobial regimes in both trauma and elective surgery. Teicoplanin would be an appropriate choice for antimicrobial prophylaxis in both trauma and elective units but this is not reflected in its current level of popularity.
... Las cefalosporinas tienen un buen perfil de seguridad, una vida media-larga y buena penetración en hueso, sinovia y músculo. 28,29 En 2008, la AAOS recomendó cefazolina o cefuroxima para pacientes que serán sometidos a artroplastia. 19 En el Reino Unido las cefalosporinas no son la primera línea de antibióticos profilácticos en muchos centros, debido a la preocupación de la infección de Clostridium difficile. ...
... 33 En 2011 la flucloxacilina y la gentamicina fueron el régimen profiláctico más utilizado para trauma ortopédico en el Reino Unido. 28 La amoxicilina combinada con ácido clavulánico (un inhibidor de la betalactamasa) es el antibiótico de elección de acuerdo a la Asociación Británica de Ortopedistas. Mientras que no existe evidencia directa para sustentar su uso, se basa en su espectro amplio contra grampositivos, gramnegativos y cobertura de anaerobios. ...
... 33 En . 2020; 16 (1): [24][25][26][27][28][29][30][31][32] www.medigraphic.org.mx estudios experimentales la amoxicilina y clavulanato demostraron tasas de eliminación de bacterias comparables con imipenem y mejores que cefuroxima. ...
... 2,3 Therefore, the importance of suitable antibiotic prophylaxis is of great importance, especially given the estimated 6-fold increase in joint replacement surgery by 2030. 4 However the ideal regime for elective arthroplasty surgery remains controversial with considerable disparity in drug choice and duration. 5 The American Academy of Orthopaedic Surgeons (AAOS) recommended Cephalosporins for prophylaxis (clindamycin or vancomycin for b-lactam allergies) which should be discontinued within 24 h of surgery. 6 However they have found large variations in prophylaxis regimes within the orthopaedic community, highlighting the controversy that exists regarding best practice. ...
... 7,8 In the UK, a recent survey of 136 hospitals found Cephalosporins and Flucloxacillin were used in 75% of elective orthopaedic procedures, with 21 different regimes used in total. 5 The preventative benefits of prophylactic antibiotics need to be balanced against increasing the risk of developing multi-drug resistant organisms including methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. 9 In the last 5 years, there has been an increasing use of Teicoplanin due to ability to use a single dose, coverage of MRSA & C. difficile and effectiveness of treating surgical site infections (SSI). ...
... 9 In the last 5 years, there has been an increasing use of Teicoplanin due to ability to use a single dose, coverage of MRSA & C. difficile and effectiveness of treating surgical site infections (SSI). 5 There are few studies that have compared different antibiotic regimes in primary total knee arthroplasty surgery but these mainly assess cephalosporins. 10e12 Our prospective study compares five different antibiotic regimes used at our institution for elective primary total knee replacement surgery. ...
Aim:
To compare the incidence of surgical site infection with different antibiotic regimes in elective total knee arthroplasty. We hypothesise that a single high dose of Teicoplanin and Gentamicin is as effective as other regimes.
Methods:
A retrospective study of prospectively collected data on a total of 4500 elective knee replacements over a 9-year period was conducted in a district general hospital. Data were collected on antibiotic regime, patient characteristics, infection (treatment, infective agents, sensitivities) and complications.
Results:
Five different antibiotic regimes that have been used in elective knee arthroplasty were identified in our institution. 40 patients in total were identified who had a deep infection. Rates of deep surgical site infection were not significantly different between the five groups (p = 0.83).
Conclusion:
A single pre-operative dose of Teicoplanin and Gentamicin has similar efficacy of prophylaxis to other regimes for patients undergoing primary elective total knee replacements. We recommend the choice of prophylaxis regimen is made locally based on pathogen virulence, drug resistance and cost.
... Furthermore, they have a proven evidence base, good safety profile and are inexpensive. The UK has recently however seen a trend away from using cephalosporins [35]. In 2011, Aujla et al. sent a questionnaire to 195 acute care trusts in the UK enquiring about antibiotic prophylaxis in elective and trauma patients and reasons if new regimes were adopted [35]. ...
... The UK has recently however seen a trend away from using cephalosporins [35]. In 2011, Aujla et al. sent a questionnaire to 195 acute care trusts in the UK enquiring about antibiotic prophylaxis in elective and trauma patients and reasons if new regimes were adopted [35]. The most popular regimes used were cefuroxime alone, flucloxacillin and gentamicin, and co-amoxiclav. ...
An increasing demand for lower limb arthroplasty will lead to a proportionate increase in the need for revision surgery. A notable proportion of revision surgery is secondary to periprosthetic joint infections (PJI). Diagnosing and eradicating PJI can form a very difficult challenge. An important cause of PJI is the formation of a bacterial biofilm on the implant surface. Our review article seeks to describe biofilms; their definitions and formation, common causative bacteria, prophylactic and therapeutic antibiotic therapy.
... 11 Importantly, in vitro data suggested a similar mechanism, although less pronounced, for flucloxacillin, 11 which is of concern as flucloxacillin in many countries is the most used isoxazolyl β-lactam penicillin. 12,13 To our knowledge, only one study has investigated the clinical impact of flucloxacillin use among patients treated with VKA, showing a decrease in INR levels upon concomitant use. 4 Leveraging registry data from a large sample of Swedish anticoagulant patients, we further assessed whether flucloxacillin affects the anticoagulative effect of warfarin. ...
Background Data indicate that codispensing flucloxacillin to patients already on warfarin may result in decreased warfarin efficacy.
Objectives This article investigates the effect of flucloxacillin on warfarin anticoagulation.
Patients and Methods In a retrospective cohort study of warfarin users, using three nationwide registers we included 5,848 patients receiving 10 days flucloxacillin treatment and 201 with ≥30 days treatment. To assess the potential for confounding by indication, we also identified 21,430 individuals initiating phenoxymethylpenicillin. International normalized ratio (INR) values and warfarin doses were calculated day-by-day and proportion of patients with a subtherapeutic INR week-by-week during cotreatment.
Results Following initiation of flucloxacillin with a planned treatment duration of 10 days and ≥30 days, the mean INR decreased from 2.36 (95% confidence interval [CI] 2.34; 2.37) to 2.20 (95% CI 2.19; 2.21) and from 2.24 (95% CI 2.16; 2.32) to 1.96 (95% CI 1.89; 2.02), respectively. Consequently, for individuals with 10 days treatment the proportion of patients with a subtherapeutic INR of < 2 increased from 22% in the week preceding flucloxacillin initiation to 35% in the third week after initiation of flucloxacillin. In patients with 30 days treatment, the proportion increased from 34 to 63% by week 6. In individuals initiating phenoxymethylpenicillin, INR levels did not decrease.
Conclusion One in three patients with 10 days flucloxacillin and almost two in three patients initiating long-term treatment, was exposed to a subsequent subtherapeutic anticoagulant effect. To avoid unnecessary thromboembolic complications, the initiation of flucloxacillin should be accompanied by closer INR monitoring which may be especially important among individuals with lengthy treatments.
... They also have a half-life and good penetration in the bone, joint and muscle (13,12). Regarding the study limitations, it should be noted that some of the cases were excluded from the study due to incomplete information. ...
BACKGROUND AND OBJECTIVE: Postoperative infection has been one of the most frequent problems in orthopedics that the prescription of antibiotics to prevent surgical infection is an effective strategy to reduce infections after surgery.The aim of this study was investigating type and amount of prophylactic antibiotics used in the orthopedic cases administered in Shahid Beheshti Hospital in Babol, northern Iran.
METHODS: This cross-sectional study was conducted on 450 traumatic and non-traumatic patients underwent elective orthopedic surgeries and received antibiotic prophylaxis during 2015-2016. The necessary data were collected from the patients' records using a predesigned checklist. This checklist consisted of demographic information, type and mechanism of trauma and information related to prophylaxis (name of antibiotic, dosage, administration method, time to start prophylaxis, administration intervals and overall prophylaxis duration).
FINDINGS: Out of 450 patients, 300 (66.7%) were male and others were female. The mean age was 42.37±21.53. The most commonly used antibiotic was cefazolin (n=437, 97.3%) and gentamycin (n=276, 62%), and the lowest was amikacin (n=8, 1.8%). Mean duration of use was 4.92±1.8 days, ranging from 1 to 15 days.
CONCLUSION: The results showed that the use of prophylactic antibiotics is high and they should be administered with more precise control. The most commonly used antibiotic for prophylaxis was cefazolin and the least was amikacin.a
... Prophylactic antibiotics are routinely used by orthopaedic surgeons to prevent infection prior to surgical procedures [27], and a survey showed that the percentage of orthopaedic surgeons administering prophylactic antibiotics was higher than 90% [10]. The most commonly prescribed agents are cephalosporins, because of a good safety profile, a long half-life and good penetra-tion in bone, synovium and muscle [28,29]. A first-generation cephalosporin for prophylaxis (cefazolin) was used in the present study according to the relevant national guideline. ...
Objective:
Prophylactic antibiotic use prior to routine knee arthroscopy remains controversial. It is important to know whether antibiotics help decrease the surgical site infection (SSI) rate. Our aims were to assess the efficacy of antibiotic prophylaxis in preventing SSI and to identify risk factors for SSI following routine knee arthroscopy without an implant.
Methods:
A retrospective study was conducted using the electronic medical records at the authors' hospital to identify patients that underwent routine knee arthroscopy without an implant between October 2010 and October 2016. Data on demographics, clinical characteristics and antibiotic administration were extracted. Arthroscopic diagnosis, debridement, partial or complete meniscectomy, arthroscopic shaving and microfracture, removal of loose bodies, synovectomy and lateral retinacular release were included. Complex knee arthroscopy with an implant was excluded. Patients were divided into evaluation (with prophylactic antibiotics) and control (no antibiotic treatment) groups. Continuous variables between groups were compared using the Student's t-test. Data were analyzed using the Chi-squared test for percentages between groups. Multivariate logistic regression was used to identify independent risk factors of SSI.
Results:
Of 1326 patients, 614 (46.3%) received prophylactic antibiotics, while 712 (53.7%) did not. There were seven (0.53%) SSIs. The SSI rate did not differ significantly between patients receiving antibiotics (0.49%, three) and those not (0.56%, four). Five patients (0.37%) had superficial infections, two (0.33%) were in the prophylactic antibiotic group and three (0.42%) were in the other group. Deep infections occurred in two patients (0.15%), one (0.16%) in the prophylactic antibiotic group and one (0.14%) in the other group. The difference between the two groups was not statistically significant (P = 1.0). Age over 50 years was associated with an increased risk of SSI (relative ratio [RR] = 1.469, 95% confidence interval [CI] 1.09-2.13, P = 0.009).
Conclusions:
Prophylactic antibiotic use in routine knee arthroscopy without an implant may not be necessary. Age over 50 years was associated with an increased risk of SSI.
... Eligible studies and study characteristics Figure 1 described the search process flow and results. From a total of 15 potentially eligible studies, 9 were excluded because they were not relevant to the study questions, [18][19][20][21][22][23][24] or review [25]. From the 7 studies eligible for inclusion, 1 was excluded because no detailed numbers of patients having or not having post-operative wound infection, Clostridium difficile infections, or post-operative renal impairment were given [26]. ...
Purpose:
To conduct meta-analyses of all available studies comparing efficacies of prophylactic cefuroxime and prophylactic gentamicin/flucloxacillin (Gen/Flu) in preventing post-operative wound infections and their association with risks of Clostridium difficile infections and post-operative renal impairment.
Methods:
Published studies including both prophylactic cefuroxime and prophylactic Gen/Flu used in surgery were included for meta analysis. Outcomes were analyzed using a random-effect model or a fixed-effect model depending on the heterogeneity across the included studies.
Results:
Gen/Flu prophylaxis showed similar efficacy as cefuroxime prophylaxis in preventing post-operative wound infections and was associated with a significantly lower risk of Clostridium difficile infection, but it was associated with a higher risk of post-operative renal impairment, especially in orthopedic surgery.
Conclusions:
Our findings that Gen/Flu prophylaxis was associated with significantly higher risk of post-operative renal impairment dictate that benefits and risks of Gen/Flu prophylaxis should be carefully assessed and balanced, and each patient should be evaluated individually so that a proper antibiotic prophylaxis regimen could be chosen.
... There has been an increase in the percentage of Trusts using flucloxacillin in combination with gentamicin -from 1.3% in 2005 to 38.4% in 2013. 40 The efficacy of gentamicin depends on local strains and sensitivities, but it is usually active against Enterobacteriaceae, Pseudomonas spp. and MRSA in the United Kingdom, although rates of resistance are increasing. ...
Objectives:
We wanted to investigate regional variations in the organisms reported to be causing peri-prosthetic infections and to report on prophylaxis regimens currently in use across England.
Methods:
Analysis of data routinely collected by Public Health England's (PHE) national surgical site infection database on elective primary hip and knee arthroplasty procedures between April 2010 and March 2013 to investigate regional variations in causative organisms. A separate national survey of 145 hospital Trusts (groups of hospitals under local management) in England routinely performing primary hip and/or knee arthroplasty was carried out by standard email questionnaire.
Results:
Analysis of 189 858 elective primary hip and knee arthroplasty procedures and 1116 surgical site infections found statistically significant variations for some causative organism between regions. There was a 100% response rate to the prophylaxis questionnaire that showed substantial variation between individual trust guidelines. A number of regimens currently in use are inconsistent with the best available evidence.
Conclusions:
The approach towards antibiotic prophylaxis in elective arthroplasty nationwide reveals substantial variation without clear justification. Only seven causative organisms are responsible for 89% of infections affecting primary hip and knee arthroplasty, which cannot justify such widespread variation between prophylactic antibiotic policies. Cite this article: Bone Joint Res 2015;4:181-189.
... There has been an increase in the percentage of Trusts using flucloxacillin in combination with gentamicin-from 1.3% in 2005 to 38.4% in 2013. 40 The efficacy of gentamicin depends on local strains and sensitivities, but it is usually active against Enterobacteriaceae, Pseudomonas spp. and MRSA in the United Kingdom, although rates of resistance are increasing. ...
Objectives: We wanted to investigate regional variations in the organisms reported to be causing peri-prosthetic infections and to report on prophylaxis regimens currently in use across England.
Methods: Analysis of data routinely collected by Public Health England’s (PHE) national surgical site infection database on elective primary hip and knee arthroplasty procedures between April 2010 and March 2013 to investigate regional variations in causative organisms. A separate national survey of 145 hospital Trusts (groups of hospitals under local management) in England routinely performing primary hip and/or knee arthroplasty was carried out by standard email questionnaire.
Results: Analysis of 189 858 elective primary hip and knee arthroplasty procedures and 1116 surgical site infections found statistically significant variations for some causative organism between regions. There was a 100% response rate to the prophylaxis questionnaire that showed substantial variation between individual trust guidelines. A number of regimens currently in use are inconsistent with the best available evidence.
Conclusions: The approach towards antibiotic prophylaxis in elective arthroplasty nationwide reveals substantial variation without clear justification. Only seven causative organisms are responsible for 89% of infections affecting primary hip and knee arthroplasty, which cannot justify such widespread variation between prophylactic antibiotic policies.
Cite this article: Bone Joint Res 2015;4:181–189.
Guidelines for prophylactic antibiotic administration in total joint replacement vary considerably in terms of drug, dosage, route of administration and duration of cover. Despite the range of treatment options available, infection remains the most common reason for arthroplasty failure in the decades following a procedure, simultaneously increasing health care costs and lowering patient satisfaction considerably. This work aims to evaluate whether there are benefits to administering further doses of antibiotic post-arthroplasty, in addition to the recommendations of current protocols. We present a review of evidence surrounding infection rates in a variety of prophylactic regimens, and weigh this against further considerations such as cost to the patient and risks of nephrotoxicity. In summary, the available evidence does not suggest a benefit to administering additional doses post-arthroplasty in most cases. However, further doses may benefit those deemed at high risk of infection, or those in areas of high methicillin-resistant Staphylococcus aureus prevalence.
Background
Infection in orthopedic surgery is one of the most dreaded complications. It is associated with prolonged morbidity, disability, and increased mortality. One of the cornerstones of the prevention of infections is antibiotic prophylaxis. This study assessed the practice of antibiotic prophylaxis in arthroplasty surgeries in our local hospital.
Methods
One hundred and seventy-one elective joint replacement patients were retrospectively analyzed for documentation of antibiotic plan in postoperative instruction, choice of antibiotic, dose, and dosage. Compliance with the dosage (duration and frequency) of antibiotic prophylaxis was compared among patients who underwent different operations, among patients whose operation notes had antibiotics plans, and among those patients whose operation notes lacked this information.
Results
Ninety-six females and 75 males with a mean age of 71.4±9.8 years who underwent hip replacement, knee replacement, or shoulder replacement were included in this study. Preoperative and postoperative antibiotics were received by 100% and 94.7% of patients, respectively. In 19.3%, there was no instruction about postoperative antibiotics while 4% missed at least one postoperative dose. The dosage of postoperative prophylactic antibiotics was variable as 26.3% of the patients experienced delayed administration of doses. Not having intravenous access, failure to prescribe antibiotics, and prescribing antibiotics in the "once only" rather than "regular medication" section of the medication chart were the reasons for improper timing of antibiotic doses. Observing surgical safety checklist was effective in ensuring preoperative antibiotic administration, whereas failing to document antibiotic plan in operation note was associated with poor compliance with postoperative dosage. Interprofessional participation is crucial to compliance with antibiotic prophylaxis practice.
Conclusion
This study identified key areas for improvement in our antibiotics prophylaxis practice. It resulted in implementing strategies to improve staff's awareness about the importance of timely administration of prophylactic antibiotics and proper documentation by all team members.
Objectives: To compare prosthetic joint infection (PJI) and acute kidney injury (AKI) rates among cohorts before and after changing our hospital's antimicrobial prophylactic regimen from cefuroxime to teicoplanin plus gentamicin. Methods: We retrospectively studied all patients undergoing primary total joint arthroplasty at our hospital 18 months pre- and post-implementation of the change in practice. All deep infections identified during follow-up were assessed against the European Bone and Joint Infection Society (EBJIS) definitions for PJI. Survival analysis using Cox regression was employed to adjust for differences in baseline characteristics and compare the risk of PJI between the groups. AKIs were identified using pathology records and categorized according to the KDIGO (Kidney Disease – Improving Global Outcomes) criteria. AKI rates were calculated for the pre- and post-intervention periods. Results: Of 1994 evaluable patients, 1114 (55.9 %) received cefuroxime only (pre-intervention group) and 880 (44.1 %) patients received teicoplanin plus gentamicin (post-intervention group). The overall rate of PJI in our study was 1.50 % (30 of 1994), with a lower PJI rate in the post-intervention group (0.57 %; 5 of 880) compared with the pre-intervention group (2.24 %; 25 of 1114). A corresponding risk reduction for PJI of 75.2 % (95 % CI of 35.2–90.5; p=0.004) was seen in the post-intervention group, which was most pronounced for early-onset and delayed infections due to coagulase-negative staphylococci (CoNS) and cefuroxime-resistant Enterobacteriaceae. Significantly higher AKI rates were seen in the post-intervention group; however, 84 % of cases (32 of 38) were stage 1, and there were no differences in the rate of stage-2 or -3 AKI. Conclusions: Teicoplanin plus gentamicin was associated with a significant reduction in PJI rates compared with cefuroxime. Increases in stage-1 AKI were seen with teicoplanin plus gentamicin.
The recently published Prophylactic Antibiotic Regimens In Tumor Surgery (PARITY) trial found no benefit in extending antibiotic prophylaxis from 24 hours to five days after endoprosthetic reconstruction for lower limb bone tumours. PARITY is the first randomized controlled trial in orthopaedic oncology and is a huge step forward in understanding antibiotic prophylaxis. However, significant gaps remain, including questions around antibiotic choice, particularly in the UK, where cephalosporins are avoided due to concerns of Clostridioides difficile infection. We present a review of the evidence for antibiotic choice, dosing, and timing, and a brief description of PARITY, its implication for practice, and the remaining gaps in our understanding.
Cite this article: Bone Joint J 2023;105-B(8):850–856.
Prevention remains the best way to avoid the dire consequences of infection after total joint arthroplasty. Still, there is no isolated preventive measure that can fully eradicate prosthetic joint infection. Effective prophylaxis must rely on the combined action of numerous strategies in order to fight various different events that ultimately lead to clinically relevant infections. The operating theatre is the primordial moment along this process, but prevention of PJI must start before and continues well after.
Background:
Perioperative acute kidney injury (AKI) can be associated with lower limb arthroplasty and increases morbidity, length of stay, and mortality. AKI is more prevalent in some antibiotic regimes compared with others. The aim of the present study is to assess the impact of cefuroxime (CEF), with or without gentamicin (±G), on AKI rates.
Methods:
A prospective cohort study involving patients undergoing hip or knee arthroplasty was performed, between September 1, 2015 and November 30, 2016. Prophylactic intravenous antibiotics were administered according to local policy. AKI was graded according to the validated Acute Kidney Injury Network criteria based on the changes from baseline serum creatinine values. Propensity score matching was performed to identify risk factors. The local audit department approved the study. Appropriate statistical analyses were performed.
Results:
A total of 2560 met the inclusion criteria, with a female preponderance (1447/2560; 56.5%). The mean age was 67.5 ± 10.7 years, with males being significantly younger (65.9 ± 10.9 vs 68.7 ± 10.4 years). AKI developed in 32 cases (1.25%). There was no difference in AKI rates between CEF alone and CEF in combination with gentamicin (1.07% vs 1.36%; P = .524). Overall 31/32 cases were Acute Kidney Injury Network stage I. AKI did not affect the length of stay. Postoperative infection rate was 7/2560 (0.27%). There were no incidences of Clostridium difficile-associated diarrhea. Multivariate analysis demonstrated an increased AKI risk with the use of intravenous gentamicin.
Conclusion:
C ± G yields low rates of infection and AKI compared with high-dose penicillin-based regimes. It is a safe and effective choice for lower limb arthroplasty.
Aim:
The aim of this study was to study potential cytochrome P450 induction by dicloxacillin.
Methods:
We performed an open-label randomized two-phase 5-drug clinical pharmacokinetic cocktail crossover study in 12 healthy men with and without pretreatment with 1g dicloxacillin three times daily for 10 days. Plasma and urine was collected over 24 hours and the concentration of all five drugs and their primary metabolites was determined using a LC-MS/MS method. Cryopreserved primary human hepatocytes were exposed to dicloxacillin for 48h and changes in gene expression and enzyme activity of CYP3A4, CYP2C9, CYP2B6 and CYP1A2 was investigated. Activation of nuclear receptors by dicloxacillin was assessed using luciferase assays.
Results:
Ten days of treatment with dicloxacillin resulted in a clinically and statistically significant reduction in the area under the plasma concentration-time curve from 0-24h of omeprazole (CYP2C19) (geometric mean ratio (GMR) [95% confidence interval (CI)]: 0.33 [0.24-0.45]), tolbutamide (CYP2C9) (GMR [95% CI]: 0.73 [0.65-0.81]) and midazolam (CYP3A4) (GMR [95% CI]: 0.54 [0.41-0.72]). Additionally, other relevant pharmacokinetic parameters were affected indicating induction of CYP2C and CYP3A4-mediated metabolism by dicloxacillin. Investigations in primary hepatocytes showed statistically significant dose-dependent increase in P450 expression and activity by dicloxacillin, caused by activation of pregnane X receptor.
Conclusions:
Dicloxacillin is an inducer of CYP2C- and CYP3A-mediated drug metabolism and we recommend caution when prescribing dicloxacillin to users of drugs with a narrow therapeutic window.
Worldwide, osteosynthesis of extracapsular proximal femur fractures is routinely performed. Meanwhile, in cases of osteoporosis and/or comminuted fractures several complications can occur in old patients, leading to revision to an arthroplasty. Primary arthroplasty can minimize these complications allowing the patient to walk immediately with full weight bearing. The implantation of the prosthesis is not demanding provided the operation is planned accurately using templates and full size radiographs and provided one uses the correct surgical approach. The aim of this article is to present the operative technique, the results, the rationale for this indication and to discuss this point of view in relation to the literature.
Deep infection after total hip arthroplasty is a serious complication. Despite recent progress in diagnosis and treatment it is still a major source of morbidity and mortality and prevention is therefore of the utmost importance.
Unfortunately, among the many measures advocated to prevent infection, only some are based on strong scientific evidence. Pre-operative, peri-operative, intra-operative, and post-operative strategies to minimize infection and optimize patient outcomes will be discussed focussing on everyday clinical practice.
Prophylactic antibiotics can decrease the risk of wound infection and have been routinely employed in orthopaedic surgery for decades. Despite their widespread use, questions still surround the selection of antibiotics for prophylaxis, timing and duration of administration. The health economic costs associated with wound infections are significant, and the judicious but appropriate use of antibiotics can reduce this risk.
This review examines the evidence behind commonly debated topics in antibiotic prophylaxis and highlights the uses and advantages of some commonly used antibiotics.
Cite this article: Bone Joint J 2016;98-B:1014–19.
The surgical profession has come a long way since the catastrophic infection rates that plagued our profession prior to Lord Lister’s promotion, and the eventual widespread implementation of aseptic antiseptic technique.[1][1],[2][2] The successive advance in health care that along with
Unlabelled:
Trauma, elective orthopaedics, and an aging population will result in an increasing health burden and work load. The move to surgical podiatrists in the National Health Service within the United Kingdom will shift the surgical workload away from orthopaedic surgeons. A devastating complication of foot and ankle surgery is postoperative infection. While postoperative infection is multifactorial in etiology, concomitant diabetes mellitus increases the general risk of trauma and orthopaedic surgical site infections up to 8-fold. We therefore undertook a prospective study of our unit antibiotic prophylaxis regimes. Fifty patients participated. Swabs were obtained using aseptic technique from the plantar aspect of the feet, between the toes, and subsequently cultured on agar plates. Specimens were then incubated for 48 hours before being exposed to antibiotic plates. Cultured organisms were classified as susceptible to an antibiotic regimen if susceptibility to cefuroxime, or susceptibility to either drug of the flucloxacillin/gentamicin combination, was demonstrated. Statistical analysis e was performed. A P value <.05 was considered significant. Fifty patients were recruited, 26 (52%) were male. Mean age of 53 ± 19.4 years. The cohort included 15 diabetic, of which 11 (73.3%) insulin-dependent, and 35 nondiabetic patients. Comparing flucloxacillin/gentamicin against cefuroxime overall, susceptibility was noted in 84% and 70%, respectively (P = .096). Resistance to cefuroxime was significantly higher in diabetics than in nondiabetics (53% vs 25%, P = .046). The same pattern was observed for the flucloxacillin/gentamicin regimen (33% vs 9%, P = .049). While both regimens are active against colonizing organisms in this prospective observational study, flucloxacillin and gentamicin provide greater coverage overall. We have demonstrated that the use of flucloxacillin/gentamicin provides better coverage against commensal bacterial flora compared with cefuroxime alone. This is of even greater importance in the case of the specific high-risk subgroups, such as diabetic patients.
Levels of evidence:
Level IV: Case Series.
Clostridium difficile infection (CDI) has emerged as a leading challenge in the control of healthcare-associated infection (HCAI). The epidemiology of CDI has changed dramatically, this is associated with emergence of 'hypervirulent' strains, particularly PCR ribotype 027. Despite the epidemic spread of these strains, there are recent reports of decreasing incidence from healthcare facilities where multi-facetted targeted control programs have been implemented. We consider these changes in epidemiology and reflect on the tools available to control CDI in the hospital setting. The precise repertoire of measures adopted and emphasis on different interventions will vary, not only between healthcare systems, but also within different institutions within the same healthcare system. Finally, we consider both the sustainability of reductions already achieved, and the potential to reduce CDI further. This takes account of newly emerging data on more recent changes in the epidemiology of CDI, and the potential of novel interventions to decrease the burden of disease.
Toxin-producing Clostridium difficile is the commonest bacterial cause of nosocomial diarrhoea and is a well recognized cause of hospital outbreaks in elderly care units. High C. difficile disease rates have been associated with the use of broad-spectrum antibiotics, especially cephalosporins. An outbreak of C. difficile infection in the elderly care unit at Gloucestershire Royal NHS Trust continued despite increased ward cleaning and strict implementation of infection control measures. A restrictive antibiotic policy that would maintain colonization resistance in the gastrointestinal tract was introduced throughout this unit. Patients admitted with suspected infection were prescribed intravenous (i.v.) benzylpenicillin 1.2-1.8 g every 6 h to cover streptococcal infections and i.v. trimethoprim 200 mg twice daily to cover urinary tract pathogens and Haemophilus influenzae. If the patient had septic shock a single iv dose of gentamicin was given (120- 180 mg) to cover more resistant gram-negative bacilli. The following were monitored before and after the policy change. The number of cases of C. difficile toxin-positive diarrhoea; cefuroxime and total antibiotic use on the elderly care wards; patient mortality rates; and length of hospital stay: two hundred and fifty-two and 234 patients respectively with a discharge diagnosis of infection were admitted before and after the antibiotic policy change. Mortality rates and length of hospital stay were unchanged. Cefuroxime prescribing and total antibiotic prescribing costs fell by 5150 pounds sterling and 8622 pounds sterling respectively in the 7 month period after the change. Thirty-seven cases of C. difficile diarrhoea occurred in the period before and 16 in the period after the policy change. The incidence of C. difficile diarrhoea and of cefuroxime use has remained low since then. The use of narrow-spectrum antibiotics for hospital treatment of community-acquired infections in the elderly should be encouraged. Outbreaks of C. difficile diarrhoea should be managed with the combined approach of infection control and strict antibiotic policies.
In April 2010, the Department of Health introduced the hip fracture best practice. Among the clinical criteria required to earn remuneration is surgery within 36 h of admission. However, early surgery may mean that methicillin-resistant Staphylococcus aureus (MRSA) colonisation status is not known before surgery, and therefore, appropriate antibiotic prophylaxis may not be administered. In view of this, our department's policy is to administer an additional dose of teicoplanin to patients with unknown MRSA status along with routine antimicrobial prophylaxis.
The purpose of this study was to provide a safe and effective antimicrobial prophylaxis for hip fracture patients.
We prospectively collected details of demographics and antimicrobial prophylaxis for all patients admitted with a hip fracture in November 2011. This was repeated in February 2012 after an educational and advertising drive to improve compliance with departmental antimicrobial policy. Microbiology results were obtained from the hospital microbiology database. A cost-benefit analysis was undertaken to assess this regime.
A total of 144 hip fracture patients were admitted during the 2 months. The average admission to surgery time was 32 h, and the average MRSA swab processing time was 35 h. 86 % of patients reached theatre with unknown MRSA status. Compliance with the departmental antimicrobial policy improved from 25 % in November 2011 to 76 % in February 2012. Potential savings of £40,000 were calculated.
With best practice tariff resulting in 86 % of patients reaching theatre with unknown MRSA status, we advocate an additional single dose of teicoplanin to cover against possible MRSA colonisation.
Prosthetic joint infections remain a major complication of arthroplasty. At present, local and international guidelines recommend cefazolin as a surgical antibiotic prophylaxis at the time of arthroplasty. This retrospective cohort study conducted across 10 hospitals over a 3-year period (January 2006 to December 2008) investigated the epidemiology and microbiological etiology of prosthetic joint infections. There were 163 cases of prosthetic joint infection identified. From a review of the microbiological culture results, methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative staphylococci were isolated in 45% of infections. In addition, polymicrobial infections, particularly those involving Gram-negative bacilli and enterococcal species, were common (36%). The majority (88%) of patients received cefazolin as an antibiotic prophylaxis at the time of arthroplasty. In 63% of patients in this cohort, the microorganisms subsequently obtained were not susceptible to the antibiotic prophylaxis administered. The results of this study highlight the importance of ongoing reviews of the local ecology of prosthetic joint infection, demonstrating that the spectrum of pathogens involved is broad. The results should inform empirical antibiotic therapy. This report also provokes discussion about infection control strategies, including changing surgical antibiotic prophylaxis to a combination of glycopeptide and cefazolin, to reduce the incidence of infections due to methicillin-resistant staphylococci.
The objective of this study was to determine the effectiveness of screening and successful treatment of methicillin-resistant Staphylococcus aureus (MRSA) colonisation in elective orthopaedic patients on the subsequent risk of developing a surgical site infection (SSI) with MRSA.
We screened 5933 elective orthopaedic in-patients for MRSA at pre-operative assessment. Of these, 108 (1.8%) were colonised with MRSA and 90 subsequently underwent surgery. Despite effective eradication therapy, six of these (6.7%) had an SSI within one year of surgery. Among these infections, deep sepsis occurred in four cases (4.4%) and superficial infection in two (2.2%). The responsible organism in four of the six cases was MRSA. Further analysis showed that patients undergoing surgery for joint replacement of the lower limb were at significantly increased risk of an SSI if previously colonised with MRSA.
We conclude that previously MRSA-colonised patients undergoing elective surgery are at an increased risk of an SSI compared with other elective patients, and that this risk is significant for those undergoing joint replacement of the lower limb. Furthermore, when an infection occurs, it is likely to be due to MRSA.
To determine whether a change in prophylactic antibiotic protocol for orthopaedic surgeries may reduce the frequency of Clostridium difficile-associated diarrhoeal infections.
Records of 1331 patients who underwent trauma or elective surgeries involving implantation of metalwork were reviewed. 231 trauma and 394 elective patients who received intravenous cefuroxime-based antibiotic prophylaxis between August 2006 and January 2007 were compared with 216 trauma and 490 elective patients who received a single dose of gentamicin and flucloxacillin or teicoplanin for antibiotic prophylaxis between August 2007 and January 2008. Diarrhoeal faecal specimens of 148 (33%) trauma patients and 106 (12%) elective patients were examined. The outcome variables were the rates of C difficile infection and early deep wound infection.
There were 32 cases of C difficile-associated diarrhoeal infection and 28 cases of early deep wound infection. The frequency of C difficile-associated diarrhoeal infection decreased after use of the new antibiotic protocol (from 4 to 1%, p = 0.004), particularly in the trauma patients (from 8 to 3%, p = 0.02); in the elective patients the difference was not significant (from 1 to 0.5%, p = 0.27). The change of antibiotic protocol did not significantly affect the incidence of deep wound infections in the trauma (p = 0.46) or elective (p = 0.90) patients. The rate of C difficile infection was 8-fold higher in the trauma than elective patients, both before and after the change of protocol.
Changing antibiotic protocol is one way of reducing the incidence of C difficile-associated diarrhoeal infections in orthopaedic patients, without increasing the rate of deep wound infections.
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.
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.
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.
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.
We report the prevalence and incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonisation during the patient journey for patients admitted to orthopaedic and trauma wards. Patients were swabbed for MRSA colonisation on admission, transfer, and discharge from hospital. Elective patients undergoing major joint surgery were also swabbed at a pre-operative assessment clinic. Of the 559 patients admitted, 323 (101 elective, 192 trauma and 30 non-orthopaedic) were included in the study. Of these, 27 elective (27%), 41 trauma (21%), and seven non-orthopaedic (23%) patients were colonised with MRSA at any time during the audit period. There is a high prevalence of MRSA colonisation in patients admitted to the orthopaedic and trauma wards in our setting. A policy of pre-admission screening, though able to identify MRSA carriage, does not guarantee that patients are not colonised in the period between screening and admission. We suggest to screen for MRSA all patients admitted to an orthopaedic ward.
To determine the value of ultraclean air in operating rooms, 8,052 operations for total hip- or knee-joint replacement were followed up for 1-4 years. For operations done in ultraclean air, bacterial contamination of the wound, deep joint sepsis, and major wound sepsis were substantially less than for operations done in conventionally ventilated rooms. Sepsis was also less frequent when prophylactic antibiotics had been given. The two precautions acted independently so that the incidence of sepsis after operation in ultraclean air and with antibiotics was much less than that when either was used alone. Wound sepsis was associated with an enhanced risk of joint sepsis. Staphylococcus aureus was the commonest joint pathogen, but infections with other organisms, often considered to be of low pathogenicity, were almost as numerous. Most S. aureus infections were traced to sources in the operating room.
The effect of five days of antibiotic prophylaxis with cefazolin injections (beginning just before surgery) on postoperative infections (beginning just before surgery) on postoperative infectious complications was evaluated in a double-blind, randomised, placebo-controlled trial in nine centres on 2137 patients undergoing hip replacement. Antibiotic prophylaxis reduced the number of hip infections significantly from 3.3% (placebo) to 0.9% (cefazolin). Positive peroperative blood samples and positive bacteriological examination of the drain were risk factors for hip infection but the prognostic value of obesity, diabetes, or previous hip surgery was not confirmed. Development of a urinary infection was not related to hip infection. Hip infections were less common in the four centres with hypersterile operating theatres, and the benefits of prophylactic antibiotics were restricted to patients having hip replacement operations in conventional theatres.
Operating in ultraclean air and the prophylactic use of antibiotics have been found to reduce the incidence of joint sepsis confirmed at re-operation, after total hip or knee-joint replacement. The reduction was about 2-fold when operations were done in ultraclean air, 4·5-fold when body-exhaust suits also were worn, and about 3- to 4-fold when antibiotics had been given prophylactically. The effects of ultraclean air and antibiotics were additive. Wound sepsis recognized during post-operative hospital stay was, however, reduced by these measures only when it had been classed as major wound sepsis. This was reported after 2·3% of operations done without antibiotic cover in conventionally ventilated operating rooms.
Joint sepsis was much more frequent after wound infection and especially after major wound sepsis, although most cases of joint sepsis were not preceded by recognized wound sepsis. This was particularly noticeable after major wound sepsis associated with Staphylococcus aureus; after 37 such infections the same species was subsequently found in the septic joint of 11 patients. The sources of wound colonization with Staph. aureus , when this was not followed by joint sepsis, appeared to differ widely from those where joint sepsis occurred later. Operating-room sources could bo found for most of the latter and the risk of infection appeared to be similar with respect to any carrier in the operating room whether a member of the operating team or tho patient. For wound colonization that was not followed by joint sepsis, operating-room sources could only be inferred for fewer than half and of these more than one half appeared to be related to strains carried by the patient at the time of operation.
During tho follow-up period, which averaged about 2¼ years with a maximum of four years, there were, in addition to the 86 instances of deep joint sepsis confirmed at re-operation, 85 instances in which sepsis in the joint was suspected during this period but was not confirmed, because re-operation on the joint was not done. The incidence of suspected joint sepsis was, like that of confirmed joint sepsis, less after operations done in ultraclean air: 1/2·5, or with prophylactic antibiotics, 1/2·3
Although re-operation was more frequent on tho knee-joint than on the hip, and pain after the initial operation was more frequent after knee operations, there was no evidence that this was the result of any increased risk of infection.
There was some indication of an increased risk of joint sepsis and of major wound sepsis, after operations on patients with rheumatoid arthritis compared with other diagnoses. The increase could have been as much as twofold but, because of the small numbers involved, the statistical limitations of the study render these differences only marginally significant.
When wound washout samples had been obtained from the surgical wound after the insertion of the prosthesis the risk of subsequent joint sepsis was found to be considerably greater for those patients from whose wounds larger numbers of bateria were isolated than from those of other patients at the same hospital.
In a multicentre study of sepsis after total hip or knee replacement the operations performed by each surgeon were allocated at random between control and ultraclean-air operating rooms. Records were obtained from over 8000 such operations. In the patients whose prostheses were inserted in an operating room ventilated by an ultraclean-air system the incidence of joint sepsis confirmed at reoperation within the next one to four years was about half that of patients who had had the operation in a conventionally ventilated room at the same hospital. When whole-body exhaust-ventilated suits had been worn by the operating team in a theatre ventilated by an ultraclean-air system the incidence of sepsis was about a quarter of that found after operations performed with conventional ventilation. When all groups in the trial were considered together the analysis showed deep sepsis after 63 out of 4133 operations in the control group (1.5%) and after 23 out of 3922 operations in the ultraclean-air groups (0.6%) (ratio 2.6, 95% confidence limits 1.6-4.2; p less than 0.001). The design of the study did not include a strictly controlled test of the effect of prophylactic antibiotics, but their use was associated with a lower incidence of sepsis than in patients who had received no antibiotic prophylaxis at their operations (0.6% (34/5831) v 2.3% (52/2221); ratio 4.0).
Two patients on antibiotic prophylaxis with cephradine after orthopaedic implant surgery developed pseudomembranous colitis. Routine administration of antibiotics after such surgery is the policy at many centres. Development of diarrhoea in these patients should be viewed seriously lest this condition is overlooked. Despite recent advances, pseudomembranous colitis can still have a fatal outcome.
Toxin-producing Clostridium difficile is the commonest bacterial cause of nosocomial diarrhoea and is a well recognized cause of hospital outbreaks in elderly care units. High C. difficile disease rates have been associated with the use of broad-spectrum antibiotics, especially cephalosporins. An outbreak of C. difficile infection in the elderly care unit at Gloucestershire Royal NHS Trust continued despite increased ward cleaning and strict implementation of infection control measures. A restrictive antibiotic policy that would maintain colonization resistance in the gastrointestinal tract was introduced throughout this unit. Patients admitted with suspected infection were prescribed intravenous (i.v.) benzylpenicillin 1.2-1.8 g every 6 h to cover streptococcal infections and i.v. trimethoprim 200 mg twice daily to cover urinary tract pathogens and Haemophilus influenzae. If the patient had septic shock a single iv dose of gentamicin was given (120-180 mg) to cover more resistant gram-negative bacilli. The following were monitored before and after the policy change. The number of cases of C. difficile toxin-positive diarrhoea; cefuroxime and total antibiotic use on the elderly care wards; patient mortality rates; and length of hospital stay: two hundred and fifty-two and 234 patients respectively with a discharge diagnosis of infection were admitted before and after the antibiotic policy change. Mortality rates and length of hospital stay were unchanged. Cefuroxime prescribing and total antibiotic prescribing costs fell by 5150 pounds sterling and 8622 pounds sterling respectively in the 7 month period after the change. Thirty-seven cases of C. difficile diarrhoea occurred in the period before and 16 in the period after the policy change. The incidence of C. difficile diarrhoea and of cefuroxime use has remained low since then. The use of narrow-spectrum antibiotics for hospital treatment of community-acquired infections in the elderly should be encouraged. Outbreaks of C. difficile diarrhoea should be managed with the combined approach of infection control and strict antibiotic policies.
Orthopaedic joint replacement is generally considered 'clean' surgery characterized by a low incidence of infection. In recent years the use of a clean theatre environment, high local concentrations of antibiotic in the cement and systemic antibiotic prophylaxis have been recognized as important measures to reduce infection rates significantly, and this has been supported by clinical trials. Staphylococcus aureus and Staphylococcus epidermidis cause at least half of all orthopaedic surgical infections. Gram-negative bacilli are involved to a much lesser extent (10-30%). First- and second-generation cephalosporins are currently considered by most authors as standard prophylaxis in elective orthopaedic surgery. In the light of the increasing incidence of methicillin resistance in coagulase-positive and -negative staphylococci, it is becoming more important for antibiotics to act efficiently against such organisms if they are to be of value in prophylaxis in orthopaedic surgery. A combined, single-dose of vancomycin/gentamicin has been used successfully in an open, controlled study in patients undergoing total joint arthroplasty but, given the disadvantages associated with the use of vancomycin, teicoplanin may be an alternative choice in such procedures. This review analyses four comparative trials of the efficacy and safety of teicoplanin, two with cefamandole, one with cefuroxime and one with cephazolin, as prophylaxis in orthopaedic total joint replacement surgery.
From January 1991 to June 1997, patients undergoing primary elective monolateral or bilateral total knee replacement (TKR) were consecutively enrolled in a prospective, open clinical study on the efficacy and safety of regional prophylaxis with teicoplanin (TEC). Those scheduled for monolateral TKR (115 patients) received 400 mg of TEC in 100 ml of saline as a 5-min infusion into a foot vein of the leg to be operated on immediately after the tourniquet was inflated to 400 mm Hg (ca. 50 kPa). For patients undergoing bilateral surgery (45 patients), regional administration of TEC was also repeated for the second knee operation. Follow-up ranged from a minimum of 2 years to 8 years. None of the patients experienced local or systemic adverse effects following regional administration of TEC. In the immediate postoperative and 2-year follow-up periods, only one superficial infection of the primary site attributable to intraoperative contamination (prophylaxis failure) out of the 205 prostheses implanted was observed. Deep infections involving the prosthesis did not occur. Infectious complications at distant sites were observed in nine cases (urinary tract infection due to Escherichia coli in eight cases, and Salmonella enteritidis gastroenteritis in one case) in the immediate postoperative period; they all were rapidly cured after antibiotic treatment. A delayed prosthetic infection, related to hematogenous spread of the etiological agent and therefore not considered a prophylactic failure, was observed in a patient who had undergone TKR 5 years before. Regional administration of TEC in monolateral and bilateral TKR appears to be a safe and valuable prophylactic technique.
A total of 3,051 methicillin-susceptible Staphylococcus aureus (MSSA) isolates and methicillin-resistant S. aureus (MRSA) isolates in Europe were compared. MRSA isolates constituted 25% of all isolates and were more prevalent in southern
Europe. MRSA isolates appeared to be more prevalent in intensive care units than in outpatient departments. Only a small minority
of MSSA isolates were multidrug resistant, whereas the majority of MRSA isolates were multidrug resistant.
We studied the effects of antibiotic prophylaxis, systemically and in bone cement, on the revision rate of cemented total hip arthroplasties (THAs) in data from the Norwegian Arthroplasty Register during the period 1987-2001. To have comparable groups, only THAs performed because of primary osteoarthritis, using cemented implants with documented good results, and high-viscosity cement were included. If systemic antibiotic prophylaxis had been given, only operations with cephalosporin or penicillin were selected. Cox-estimated survival relative revision risks (RR) are presented with adjustment for differences among groups in gender, age, cement brand, type of systemic antibiotic prophylaxis, type of prosthesis, type of operating room, and duration of the operation. Of 22,170 THAs studied, 696 THAs (3.1%) were revised, 440 (2.0%) for aseptic loosening and 102 (0.5%) for deep infection. We found the lowest risk of revision when the antibiotic prophylaxis was given both systemically and in the cement (15,676 THAs). Compared to this combined regime, patients who received antibiotic prophylaxis only systemically (5,960 THAs) had a 1.4 times higher revision rate with all reasons for revision as endpoint (p = 0.001), 1.3 times higher with aseptic loosening (p = 0.02) and 1.8 times higher with infection as the endpoint (p = 0.01). With the combined antibiotic regime, the results were better if antibiotics were given 4 times on the day of surgery (2,194 THAs), as compared to once (1,424 THAs) (p < 0.001), twice (2,680 THAs) (p < 0.001), or 3 times (5,522 THAs) (p = 0.02). Those who received systemic prophylaxis a single day 1, 2 or 3 times, as compared to 4 times, had a revision rate 1.8-3.5 times higher with all reasons for revision as endpoint, 1.5-3.1 times higher with aseptic loosening, and 2.7-6.8 times higher with infection. When we compared systemic prophylaxis 4 times in 1 day, no further improvement resulted in those given systemic prophylaxis for 2 days (1,928 THAs) or 3 days (717 THAs). In a subset of data including only the Charnley prosthesis, we obtained similar results. This observational study shows that the best results were recorded when antibiotic prophylaxis was given both systemically and in the bone cement, and if the systemic antibiotic was given 4 times on the day of surgery.
Prophylactic antibiotics in surgery are intended to prevent morbidity and mortality, as well as to reduce the duration and cost of hospitalisation. The indications for prophylaxis, and its effectiveness, should be evaluated with these criteria in mind. The basis for antibiotic prophylaxis in surgery is either provision of an effective concentration of antibiotic in the tissue site at the time of potential contamination, or (primarily in the case of colorectal surgery) to reduce the inoculum of potentially contaminating bacteria.
Cephalosporins are the antibiotics most widely used for prophylaxis in surgery, and have clearly been shown to reduce postoperative morbidity in vaginal hysterectomy, resection of head and neck cancers, vascular grafting, total joint replacement, repair of hip fractures, and high risk gastroduodenal surgery. They are probably also useful in cardiac surgery, abdominal hysterectomy, caesarean section, and colorectal surgery.
For orthopaedic, cardiac, gynaecological, and gastroduodenal procedures it is important to select an antibiotic with proven clinical activity against Gram-positive organisms. For head and neck surgery, the spectrum of activity should also include oral anaerobes and Enterobacteriaceae. For biliary surgery an antibiotic effective against both Gram-positive and Gram-negative organisms may offer at least theoretical advantages, while for appendicectomy a cephamycin represents the most appropriate choice. In colorectal procedures, activity against B. fragilis is the major consideration in selecting an antibiotic for systemic prophylaxis.
When intra-abdominal sepsis occurs following surgery, a potentially wide range of bacteria may be implicated, but in practice such infections are due to a small number of species, with B. fragilis most commonly implicated. The most useful cephalosporins in this setting are those active against both aerobic Gram-negative bacteria and anaerobes, especially B. fragilis. In practice, an aminoglycoside is often administered concomitantly. Importantly, prompt surgical treatment is the cornerstone of management of abdominal sepsis, and empirical antibiotic therapy should be adjusted as needed when culture and sensitivity tests become available.
A woman underwent joint replacement surgery with prophylactic antibiotic cover, and subsequently died as a result of pseudomembranous colitis. We have noted a high incidence of antibiotic diarrhoea with cephradine, and suggest that if administration of prophylactic antibiotics is restricted to 3 days or less, the incidence of diarrhoea would diminish, and the therapeutic value of the antibiotics would be maintained.Une malade ayant subi une arthroplastie totale sous couvert d'une antibiothrapie prventive est dcde dans les suites du fait d'une colite pseudo-membraneuse.Les auteurs ont observ frquemment la survenue de diarrhe chez les oprs recevant de la Cphradine titre prophylactique. Ils estiment que si la dure de ce traitement est rduite trois jours, ou mme moins, la frquence de la diarrhe diminuera tandis que l'efficacit de l'antibiothrapie prventive se maintiendra.
A randomized multicenter study was carried out in 12 centers in Italy to compare administration of a single dose of teicoplanin
(400 mg i.v. bolus at time of anesthesia) versus that of five doses of cefazolin over a 24-h period (2 g at induction of anesthesia
and 1 g every 6 h postoperatively, i.v. bolus) as antimicrobial prophylaxis in patients undergoing hip or knee arthroplasty.
Of 860 patients enrolled, 427 received teicoplanin and 433 cefazolin. A total of 846 patients (422 teicoplanin and 424 cefazolin)
were evaluable for safety and 826 patients for efficacy. Six patients (1.5%) in the teicoplanin group and seven patients (1.7%)
in the cefazolin group developed a surgical wound infection during their postoperative hospital stay: this difference was
not significant. Proven or suspected infections involving other body systems occurred in 114 patients (57 in each group).
Seven hundred ninety-two patients completed a 3-month evaluation and 738 patients a 12-month evaluation; the success rates
in evaluable patients at these observation times were 99.2% and 99.7% for teicoplanin and 99.2% and 99.7% for cefazolin, respectively.
Adverse events occurred in three (0.7%) teicoplanin patients and nine (2.1%) cefazolin patients (P=0.083). A single preoperative dose of teicoplanin ensures adequate surgical antisepsis, with results comparable to a standard
multiple-dose regimen of cefazolin.
Using the Freedom of Information Act, a five-point questionnaire was sent to all NHS Trusts in the United Kingdom: Eighty
two per cent of NHS Trusts in the UK who had an orthopaedic department replied. The top three antimicrobial prophylaxis regimes
in orthopaedic surgery were cefuroxime alone (trauma 48%, elective 56%), flucloxacillin plus gentamicin (trauma 16%, elective
19%) and co-amoxiclav alone (trauma 10%, elective 5.6%). Forty nine per cent of Trusts involved changed antimicrobial prophylaxis
regimes between August 2005 and July 2008, to restrict the use of cefuroxime. There was a 74% difference in C. difficile rates in Trusts who use cefuroxime when compared to any other antimicrobial regime. In Trusts that changed away from cefuroxime,
there was a 33% reduction in C. difficile rates. Clostridium difficile rates were six times higher in trauma than elective surgery across the UK. Few Trusts (trauma 7.7%, elective 7.6%) used antimicrobial
prophylaxis regimes that have a low-risk association with C. difficile infection.
KeywordsAntimicrobial prophylaxis–
Clostridium difficile
–Cephalosporins
Understanding how the function of the lower extremity joints during everyday movements following surgery to treat cam femoro-acetabular impingement is essential to assess whether surgical intervention effectively restores the normal biomechanics of the hip. The purpose of this study was to compare preoperative and postoperative lower-extremity joint and pelvic angular displacements during maximal depth squatting of patients with unilateral symptomatic cam femoro-acetabular impingement.
Ten participants were compared with respect to their preoperative and postoperative test results. The participants were between eighteen and fifty years of age and had a positive impingement test and visible cam deformity on anteroposterior and Dunn view radiographs. Postoperative testing for each participant occurred between eight and thirty-two months following surgical intervention. Three-dimensional lower-limb joint and pelvic kinematics of participants were collected during maximal depth squats.
Postoperatively, participants squatted to a greater mean maximal depth than they did preoperatively. Postoperative knee flexion and ankle dorsiflexion angles of the affected extremity at maximal depth were significantly greater than preoperative values. The postoperative sum of all joint angles of the affected limb at maximal squat depth was significantly larger than the preoperative sum. No significant differences were detected between the preoperative and postoperative measurements of the patients with cam impingement with respect to the kinematics of the affected hip at maximal squat depth, the pelvic angular displacements at maximal squat depth, or the overall pelvic range of motion during maximal deep squatting (p > 0.05).
The squat performance improved postoperatively, likely because of the combined effects of increased knee and ankle angles as well as a greater acetabular opening and thus reduced anterior femoral head coverage, allowing increased posterior pelvic pitch during the descent phase of the squat.
Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
With the trend toward pay-for-performance standards plus the increasing incidence and prevalence of periprosthetic joint infection (PJI), orthopaedic surgeons must reconsider all potential infection control measures. Both airborne and nonairborne bacterial contamination must be reduced in the operating room.
Analysis of airborne bacterial reduction technologies includes evaluation of (1) the effectiveness of laminar air flow (LAF) and ultraviolet light (UVL); (2) the financial and potential health costs of each; and (3) an examination of current national and international standards, and guidelines.
We systematically reviewed the literature from Ovid, PubMed (Medline), Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA, NHSEED, CINAHLPLUS, and Google Scholar published until June 2010 focusing on ultraclean air, ultraviolet light, and laminar air.
High-level data demonstrating substantial PJI reduction of any infection control method may not be feasible as a result of the relatively low rates of occurrence and the expense and difficulty of conducting a large enough study with adequate power. UVL has potentially unacceptable health costs and the Centers for Disease Control and Prevention (CDC) recommends against its use. European countries have standardized LAF and it is used by the majority of American joint surgeons.
Both LAF and UVL reduce PJI. The absence of a high level of evidence from randomized trials is not proof of ineffectiveness. The historically high cost of LAF has decreased substantially. Only LAF has been standardized by several European countries. The CDC recommends further study of LAF but recommends UVL not be used secondary to documented potential health risks to personnel.
Antibiotic prophylaxis is routinely administered during joint replacement surgery and may predispose patients to Clostridium difficile-associated disease (CDAD). The primary aim of this study was to determine the incidence of this following joint replacement, using a cefuroxime-based regimen. Patients developing CDAD were compared with a control group of patients without CDAD. The incidence of the former was 1.7 per 1000 primary joint replacements. Those patients prescribed additional antibiotics had a higher incidence of CDAD (p = 0.047), but there was no difference between the two groups in relation to the use of gastroprotective agents (p = 0.703). A trial of a new prophylaxis regimen would require 43 198 patients in each arm to show a reduction of one case per 1000 procedures. Cefuroxime-based antibiotic prophylaxis is safe in patients undergoing primary elective joint replacement.
Advanced-stage osteonecrosis and a large area of necrotic bone are known risk factors for failure of transtrochanteric rotational osteotomy of the hip in patients with osteonecrosis. The purpose of this study was to determine whether there are other risk factors for failure of this osteotomy.
One hundred and five patients (113 hips) underwent an anterior transtrochanteric rotational osteotomy for the treatment of femoral head osteonecrosis and were followed for a mean of 51.3 months postoperatively. Radiographic failure was defined as secondary collapse or osteoarthritic change. Multivariate analysis was performed to assess factors associated with secondary collapse and osteophyte formation. The Kaplan-Meier product-limit method was used to estimate survival.
Secondary collapse occurred in twenty-seven hips (24%), and fourteen hips (12%) were converted to a total hip arthroplasty. At the time of the most recent follow-up, the hip scores according to the system of Merle d'Aubigné et al. ranged from 6 to 18 points (mean, 15.8 points). Multivariate analysis showed that the stage of the necrosis (III or greater) (hazard ratio = 3.28; 95% confidence interval = 1.49 to 7.24), age of the patient (forty years or older) (hazard ratio = 1.08; 95% confidence interval = 1.02 to 1.14), body mass index (> or = 24 kg/m(2)) (hazard ratio = 1.19; 95% confidence interval = 1.03 to 1.38), and extent of the necrosis (a combined necrotic angle of > or = 230 degrees ) (hazard ratio = 1.08; 95% confidence interval = 1.04 to 1.11) were associated with secondary collapse. Seven of the eighty-six hips without collapse showed progression to osteoarthritis. The survival rate at 110 months was 63.4% (95% confidence interval = 51.1% to 75.7%) with total hip arthroplasty or radiographic failure as the end point and 56.0% (95% confidence interval = 44.6% to 67.4%) with total hip arthroplasty, radiographic failure, or loss to follow-up as the end point.
Our study showed that age, body mass index, and the stage and extent of the osteonecrosis were determining factors for secondary collapse, unsatisfactory clinical results, and conversion to total hip arthroplasty. These factors should be considered when selecting patients for a transtrochanteric rotational osteotomy.
Ultraclean air (UCA) in operating theatres is defined as <10 colony-forming units (cfu)/m(3). The current European standards for surgical gowns are contained in EN13795 but these do not include containment of bacterial dispersal as a standard test. A trial in 2003 found that there were bacterial air counts of 1 cfu/m(3) with Rotecno gowns and 0.5 cfu/m(3) with body exhaust suits in total knee arthroplasty (TKA). This study compared bacterial air counts using Rotecno gowns with a new type of occlusive gown made from Gore liquid-proof fabric, which were superior to the Rotecno gowns on standard EN13795 laboratory testing. Fifty-six joint replacements were allocated randomly either to Rotecno or to Gore gowns with stratification into TKA, total hip arthroplasty (THA) or revision THA. Airborne bacteria were collected from within 30 cm of the wound for the first 10 min of surgery using a Casella slit sampler. The new gowns were associated with higher air counts (3.7 cfu/m(3)) than the Rotecno gowns (1.2 cfu/m(3)) (P<0.001). Three of the Gore samples exceeded the clean air standard of 10 cfu/m(3). In TKA patients, the existing Rotecno gowns, now many years old, had higher air counts (2.0 cfu/m(3)) than in the 2003 trial (0.8 cfu/m(3)) (P<0.001). The new gowns were superior in standard laboratory tests but not superior at preventing airborne bacterial dispersal. Rotecno gowns, although many years old, were still effective. This study highlights the importance of testing new materials in a clinical environment with UCA; in-vitro testing alone is probably not an adequate assessment.
The current measures employed by consultant orthopaedic surgeons in Scotland to prevent infection were established by postal questionnaire. Our findings were compared with those of a similar study carried out 5 years previously. An increasing number of surgeons use routine systemic antibiotic prophylaxis for total hip arthroplasty (99% versus 91% 5 years ago), in treating compound fractures (89% versus 75% 5 years ago) and for internal fixation of closed fractures with metal implants (49% versus 12% 5 years ago). Cephalosporins are increasingly used as the antibiotic of choice. By starting antibiotics earlier than the day of surgery or continuing for more than 24 h after surgery, just over half the surgeons questioned administer antibiotics for longer than would seem to be necessary for elective surgery.
Worldwide, cephalosporins are the most widely used antibiotics for surgical prophylaxis. These drugs are recommended for prophylaxis because of their good safety profile, excellent antimicrobial activity against most of the bacteria causing postoperative wound infection, satisfactory penetration into critical tissues and, most importantly, a strong track record of efficacy in clinical trials. There are still unresolved questions about the choice of cephalosporin and the timing and duration of administration. In vaginal hysterectomy, Caesarian section, and biliary tract surgery a single preoperative dose of any one of several cephalosporins has been used effectively. There are no apparent benefits in using a longer course for prophylaxis, nor for choosing a third-generation cephalosporin rather than a first- or second-generation cephalosporin. Several cephalosporins have been employed successfully in cardiac surgery, mostly in trials using a 24-48 h regimen. A recent study with a single preoperative dose of ceftriaxone has produced favourable results. In elective colorectal surgery definitive conclusions are difficult because of limited controlled studies. The best results have been achieved with an oral bowel preparation such as neomycin-erythromycin. Metronidazole, combined with another agent to suppress facultative bacteria, has also produced excellent reduction in wound infections. While it is not firmly established that a systemic cephalosporin contributes to the proven good effects of an oral bowel preparation, there is evidence that the choice of the cephalosporin should be based, in part, on its activity against anaerobic bacteria.
The relative merits of different antibiotic regimens for prophylaxis in orthopaedic implant surgery are difficult to evaluate because of the low frequency of infection. Factors other than infection prevention may influence choice. We have compared 400 mg teicoplanin given intravenously on induction of anaesthesia with three perioperative injections of cefuroxime, in 146 patients undergoing total hip or total knee replacement. These interim results suggest that cefuroxime selects for increased extraintestinal carriage of faecal streptococci and teicoplanin for Proteus species. There were no significant differences between the regimen in the acquisition of coagulase-negative staphylococci or Clostridium difficile, post-operative diarrhoea, wound healing or wound infection. Both regimens were equally safe.
Prophylactic antibiotics in surgery are intended to prevent morbidity and mortality, as well as to reduce the duration and cost of hospitalisation. The indications for prophylaxis, and its effectiveness, should be evaluated with these criteria in mind. The basis for antibiotic prophylaxis in surgery is either provision of an effective concentration of antibiotic in the tissue site at the time of potential contamination, or (primarily in the case of colorectal surgery) to reduce the inoculum of potentially contaminating bacteria. Cephalosporins are the antibiotics most widely used for prophylaxis in surgery, and have clearly been shown to reduce postoperative morbidity in vaginal hysterectomy, resection of head and neck cancers, vascular grafting, total joint replacement, repair of hip fractures, and high risk gastroduodenal surgery. They are probably also useful in cardiac surgery, abdominal hysterectomy, caesarean section, and colorectal surgery. For orthopaedic, cardiac, gynaecological, and gastroduodenal procedures it is important to select an antibiotic with proven clinical activity against Gram-positive organisms. For head and neck surgery, the spectrum of activity should also include oral anaerobes and Enterobacteriaceae. For biliary surgery an antibiotic effective against both Gram-positive and Gram-negative organisms may offer at least theoretical advantages, while for appendicectomy a cephamycin represents the most appropriate choice. In colorectal procedures, activity against B. fragilis is the major consideration in selecting an antibiotic for systemic prophylaxis. When intra-abdominal sepsis occurs following surgery, a potentially wide range of bacteria may be implicated, but in practice such infections are due to a small number of species, with B. fragilis most commonly implicated. The most useful cephalosporins in this setting are those active against both aerobic Gram-negative bacteria and anaerobes, especially B. fragilis. In practice, an aminoglycoside is often administered concomitantly. Importantly, prompt surgical treatment is the cornerstone of management of abdominal sepsis, and empirical antibiotic therapy should be adjusted as needed when culture and sensitivity tests become available.
We report 16 orthopaedic patients who had antibiotic-associated diarrhoea (pseudomembranous colitis) after operation. There was an association with the use of cephradine and with the prolongation of prophylaxis for more than three peri-operative doses. Five cases occurred as a cluster, suggesting that the causative agent, Clostridium difficile, may be infectious in some situations.
A woman underwent joint replacement surgery with prophylactic antibiotic cover, and subsequently died as a result of pseudomembranous colitis. We have noted a high incidence of antibiotic diarrhoea with cephradine, and suggest that if administration of prophylactic antibiotics is restricted to 3 days or less, the incidence of diarrhoea would diminish, and the therapeutic value of the antibiotics would be maintained.
Antibiotics were given for prophylaxis in hip fracture patients to a randomized group of patients with hip fractures (417) treated by operation during 3 years. After excluding those patients with history of penicillin sensitivity, and those patients already receiving antibiotics at the time of fracture, 348 patients were randomly assigned to a treatment (sodium nafcillin) or control (glucose) group. Either antibiotic or placebo was given before, during, and after operation. The incidence of postoperative would infection was 7 in 145 (4.8%) in the control group, and 1 in 135 (0.8%) in the treatment group, a statistically significant difference (P=0.041). The incidence of postoperative wound hematomas was high in each group, possibly because of the routine use of sodium warfarin. Subsequent infection developed in a few of these hematomas, with similar incidence in the control (4 in 145) and treatment (6 in 135) groups.
A double-blind prospective study involving 1,591 clean orthopaedic surgical procedures was performed to test the effectiveness of preoperative and intraoperative antibiotics in reducing the postoperative infection rate. The antibiotic and placebo groups were analyzed for factors known to predispose to infection. A decrease in the over-all postoperative infection rate from 5 per cent in the placebo group to 2.8 per cent in the antibiotic group was found.
In a prospective, controlled, single-blind study the efficacy of teicoplanin versus cefamandole in preventing infections in total hip replacement was investigated in 496 consecutive patients. A single intravenous dose of teicoplanin (400 mg) was as effective as two intravenous doses of cefamandole (2 g before and 1 g after surgery). No major complications were observed in either group. Infective wound complications were observed only in the cefamandole group. These infections, although not dangerous for the patients, required supplementary antibiotic treatment in all cases. Teicoplanin is a reasonable choice as a prophylactic agent in orthopaedic surgery when a high risk of infection due to staphylococci is present.
To better define the role of multiple risk factors for cytotoxic Clostridium difficile-associated diarrhea.
Case-control study.
A Veterans Affairs Medical Center.
Thirty-three case patients with C difficile-associated diarrhea. Two control groups were used: one group consisted of 32 patients from the same ward as the case patients, and one group consisted of 34 patients with nosocomial diarrhea and negative C difficile toxin assays.
None.
Multivariate analyses revealed that exposure to second- or third-generation cephalosporins was the most important independent risk factor, even after controlling for other antimicrobial use (odds ratio [OR] = 8.3, 95% confidence interval [CI95] = 1.4 to 48.9 compared to ward controls; OR = 9.6, CI95 = 2.1 to 44.1 compared with diarrhea controls). Persons exposed to two or more antimicrobials simultaneously were at substantially elevated risk (OR = 18.7, CI95 = 4.1 to 85.8 compared with ward controls; OR = 21.5, CI95 = 3.2 to 141.9 compared with diarrhea controls).
Physicians should consider carefully the appropriateness of second- and third-generation cephalosporin use and combination antimicrobial therapy, especially during nosocomial C difficile-associated diarrhea outbreaks (Infect Control Hosp Epidemiol 1994;15:88-94).
Data were collected prospectively from 59 patients receiving vancomycin and 20 patients receiving teicoplanin. The mean daily drug cost was 52.40 pounds for teicoplanin and 31.13 pounds for vancomycin; the 95% Confidence Intervals (CI) for the difference in mean drug costs varied between 14.40 pounds and 28.10 pounds in favour of vancomycin. Use of a loading dose of teicoplanin significantly increased mean daily drug costs if the duration of treatment was less than 10 days. Costs of preparation, administration and monitoring were consistently higher for vancomycin than for teicoplanin and inclusion of these costs reduced the difference in mean daily costs to 13.01 pounds (95% CI 6.10 to 19.90 pounds). In Dundee 11 of 20 patients who received teicoplanin had received some of their treatment after discharge from the hospital and a survey of UK hospitals confirmed that teicoplanin treatment after discharge is being used in a wide range of conditions. The median proportion of teicoplanin treatment in Dundee given after discharge was 28.4% for each patient who received the drug: the median proportion of non-inpatient therapy was 50% per patient of those who received any teicoplanin treatment after discharge. Assuming that teicoplanin costs 20 pounds per day more than vancomycin, use of teicoplanin implies an investment of 70.42 pounds to gain one hospital day through earlier discharge of patients receiving teicoplanin.
Methicillin-resistant Staphylococcus aureus (MRSA) infection has emerged in patients who do not have the established risk factors. The national burden and clinical effect of this novel presentation of MRSA disease are unclear.
We evaluated MRSA infections in patients identified from population-based surveillance in Baltimore and Atlanta and from hospital-laboratory-based sentinel surveillance of 12 hospitals in Minnesota. Information was obtained by interviewing patients and by reviewing their medical records. Infections were classified as community-associated [correction] MRSA disease if no established risk factors were identified.
From 2001 through 2002, 1647 cases of community-associated [correction] MRSA infection were reported, representing between 8 and 20 percent of all MRSA isolates. The annual disease incidence varied according to site (25.7 cases per 100,000 population in Atlanta vs. 18.0 per 100,000 in Baltimore) and was significantly higher among persons less than two years old than among those who were two years of age or older (relative risk, 1.51; 95 percent confidence interval, 1.19 to 1.92) and among blacks than among whites in Atlanta (age-adjusted relative risk, 2.74; 95 percent confidence interval, 2.44 to 3.07). Six percent of cases were invasive, and 77 percent involved skin and soft tissue. The infecting strain of MRSA was often (73 percent) resistant to prescribed antimicrobial agents. Among patients with skin or soft-tissue infections, therapy to which the infecting strain was resistant did not appear to be associated with adverse patient-reported outcomes. Overall, 23 percent of patients were hospitalized for the MRSA infection.
Community-associated MRSA infections are now a common and serious problem. These infections usually involve the skin, especially among children, and hospitalization is common.
Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections have emerged among patients without health care-associated risk factors. Understanding the epidemiology of CA-MRSA is critical for developing control measures.
At a 464-bed public hospital in Chicago and its more than 100 associated clinics, surveillance of soft tissue, abscess fluid, joint fluid, and bone cultures for S aureus was performed. We estimated rates of infection and geographic and other risks for CA-MRSA through laboratory-based surveillance and a case-control study.
The incidence of CA-MRSA skin and soft tissue infections increased from 24.0 cases per 100,000 people in 2000 to 164.2 cases per 100,000 people in 2005 (relative risk, 6.84 [2005 vs 2000]). Risk factors were incarceration (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.00-3.67), African American race/ethnicity (OR, 1.91; 95% CI, 1.28-2.87), and residence at a group of geographically proximate public housing complexes (OR, 2.50; 95% CI, 1.25-4.98); older age was inversely related (OR, 0.89; 95% CI, 0.82-0.96 [for each decade increase]). Of 73 strains tested, 79% were pulsed-field gel electrophoresis type USA300.
Clonal CA-MRSA infection has emerged among Chicago's urban poor. It has occurred in addition to, not in place of, methicillin-susceptible S aureus infection. Epidemiological analysis suggests that control measures could focus initially on core groups that have contributed disproportionately to risk, although CA-MRSA becomes endemic as it disseminates within communities.
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.
Current concepts for clean air and total joint arthroplasty: laminar airflow and ultraviolet radiation
- R P Evans
Evans RP. Current concepts for clean air and total joint arthroplasty: laminar
airflow and ultraviolet radiation. Clin Orthop Relat Res 2011; 469: 945-953.
Reducing Clostridium difficile infection and mortality in fracture neck of femur patients
- A Gulihar
- M Nixon
- G Taylor
Gulihar A, Nixon M, Taylor G. Reducing Clostridium difficile infection and
mortality in fracture neck of femur patients. J Bone Joint Surg Br 2010; 92
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C difficile infection: morbidity and mortality following fracture neck of femur
- R Kakwani
- D Chakrabarti
- K Katam
- K Wahab
Kakwani R, Chakrabarti D, Katam K, Wahab K. C difficile infection: morbidity
and mortality following fracture neck of femur. J Bone Joint Surg Br 2011; 93
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A comparison of teicoplanin vs cefamandole in orthopaedic surgical prophylaxis
- R A Mollan
- C H Webb
- M Haddock
Mollan RA, Webb CH, Haddock M. A comparison of teicoplanin vs cefamandole
in orthopaedic surgical prophylaxis. In: Program and Abstracts of the 7th