Antibiotics in Orthopedic Surgery
Transcript of Antibiotics in Orthopedic Surgery
Prophylactic Antibiotics in
Orthopedic SurgeryLaura Prokuski, MD
Associate ProfessorUniversity of Wisconsin
Department of Orthopedics and RehabilitationMadison, WI
Hospital Interventions Quality Improvement Organization Support
Surgical Site Infections
• 500,000 per year among an estimated 27 million procedures in the United States
• Most common nosocomial infection
Surgical Site Infections
• Patients with SSI are:
– 5 x more likely to be readmitted to hospital
– 60% more likely to reside in ICU
– Twice as likely to die
Surgical Site Infections
• Economic impact– Readmission to hospital– Surgical debridement– Prolonged antibiotics– Monitoring of antibiotic
toxicity– Delayed reconstruction
Staphylococcus epidermidis
Pathogenesis of Surgical Site Infections
• Bacteria contaminate every surgical wound
• The amount of bacteria required to cause infection in a wound is variable and depends on– Virulence of organism– Condition of wound– Presence of nonbiologic substances– Host immune competence
Pathogenesis of Surgical Site Infections
• Hematogenous Dissemination
Pathogenesis of Surgical Site Infections
• Bacteria have adaptive strategies to increase virulence– Antibiotic resistance– Surface compounds that inhibit
phagocytosis and facilitate adherence to implants, shielding them from immune defenses
Glycocalyx
Surgical Antibiotic Prophylaxis
• Can’t sterilize wound
• Minimize intraoperative contamination of the wound to a level that won’t overwhelm host defenses
Optimal Surgical Antibiotic Prophylaxis
• Antimicrobial active against most common pathogens in wound
• Safe• Inexpensive• Adequate concentrations present in the serum
and tissue during the entire time the wound is open
• Smallest impact possible nor the normal bacterial flora or the patient the biogram of the community
Antibiotic Prophylaxis in Orthopedic Surgery
• Choice of antimicrobial
• Timing of administration
• Duration of use
Penicillin
Choice of Antimicrobial Agent
• Organisms of concern: aerobic Gram + cocci
Penicillin
Choice of Antimicrobial Agent
• Cephalosporins are first choice
– Cefazolin– Cefuroxime
Penicillin
Choice of Antimicrobial Agent
• Beta-lactam allergy?– True allergy
• Urticaria, pruritis, bronchospasm, hypotension
– Adverse drug reaction• Drug fever, drug-induced hypersensitivity
Penicillin
Choice of Antimicrobial Agent
• Beta-lactam allergy?– Incidence of adverse reactions to
cephalosporins among patients with reported penicillin allergy is rare
– Patients with a history of penicillin allergy and negative penicillin skin test results are not at increased risk of an adverse reaction to cephalosporins
Penicillin
Choice of Antimicrobial Agent
• Beta-lactam allergy?– Targeted allergy consultation and penicillin
allergy skin testing can decrease prophylactic vancomycin use in patients undergoing elective orthopedic surgery
Penicillin
Choice of Antimicrobial Agent
• True Beta-lactam allergy
– Clindamycin– Vancomycin
Penicillin
Vancomycin and MRSA
• Routine use of vancomycin is discouraged– Promotes vancomycin resistance
• Current or previous infection with MRSA, and known MRSA colonization, are indications to choose vancomycin for surgical prophylaxis
Penicillin
Vancomycin and MRSA
• MRSA colonization may be higher among patients who have spent more than 5 days in an institutional setting
• Preoperative nasal swabbing can detect 80-90% of MRSA carriers and may be a helpful screening test for elective surgery
Penicillin
Vancomycin and MRSA
• No evidence that routine use of vancomycin instead of cephalosporins for prophylaxis in institutions with perceived high rates of MRSA infection will result in fewer SSIs
• Cardiac surgery study: the choice of antimicrobial used for prophylaxis changed the infecting organism, but did not alter the infection rate
Penicillin
Recommendations for Choice of Antimicrobial
• Cephalosporins preferred
• True beta-lactam allergy: clindamycin or vancomycin
• Current or prior MRSA infection, MRSA colonization: vancomycin
Penicillin
Timing of Administration• Burke 1961 administering antibiotics before
or shortly after the inoculation of skin with S. aureus markedly reduced the inflammatory response
• With each delay of an hour in antibiotic administration the inflammatory lesion became larger
Penicillin
Timing of Administration
• Prospective analysis of patients undergoing a variety of clean and clean-contaminated procedures showed patients receiving antibiotics 2 hours before incision had lowest SSI rates
Penicillin
Timing of Administration
• Infusion of cephalosporins and clindamycin should begin within 60 minutes before incision, and be completed at the time of incision
• Infusion of vancomycin should begin 2 hours before incision and should be completed at the time of incision
Penicillin
Timing of Administration
• Administration of the antimicrobial at the time of anesthesia induction is safe and results in adequate tissue drug levels at the time of incisions
Penicillin
Timing of Administration with Use of Tourniquet
• Analysis of cefuroxime levels in soft tissue and bone demonstrated 10 minutes is needed between infusion and tourniquet inflation to achieve adequate tissue levels for prophylaxis
Penicillin
Intraoperative Redosing
• Duration of procedure exceeds 1-2 times the antimicrobial’s half-life
• Significant blood loss during the procedure
Penicillin
Every 6-12 hoursVancomycin
Every 3-6 hoursClindamycin
Every 3-4 hoursCefuroxime
Every 2-5 hoursCefazolin
FrequencyAntibiotic
Recommendations for Timing of Administration
• May be the single most important step in preventing SSI (given the right agent was chosen)
• Cephalosporins, clindamycin: Completion of infusion within 1 hour of incision
• Vancomycin: Completion of infusion within 1 hour of incision; start earlier to accommodate longer infusion time
• Redosing with length of procedure and/or blood loss
Penicillin
Duration of Antimicrobial Use
• The shortest effective duration of antimicrobial administration for preventing postoperative infection is not known
Penicillin
Duration of Antimicrobial Use
• The majority of published evidence demonstrates that antimicrobial prophylaxis after wound closure does not provide additional protection from SSI
Penicillin
Duration of Antimicrobial Use
• Continuing antibiotic prophylaxis longer than 24 hours after wound closure is not beneficial and may contribute to the development of antimicrobial resistance
Penicillin
Duration of Antimicrobial Use
• Continuing prophylactic antibiotics for the duration drains and catheters are in place has not been shown to reduce SSI rates
• Remove catheters and drains promptly
Penicillin
Recommendations for Duration of Antimicrobial Use
• Single-dose prophylaxis
• Multiple-dose prophylaxis not to exceed 24 hours
Penicillin
Antibiotic Prophylaxis in Orthopedic Surgery
Subspecialties• Spine• Arthroscopy• Pediatrics• Foot and Ankle• Hand• Trauma• Major Joint Arthroplasty
Penicillin
Spine Surgery• Early retrospective studies generally supported
• Later randomized trials did not overwhelmingly prove efficacy
• Meta-analysis provided statistically significant evidence that prophylactic antibiotic use reduces SSI in spinal surgery
Penicillin
Spine Surgery
• Spine surgery studies confirm importance of timing of administration and redosing after extended duration of procedure and/or blood loss
Penicillin
Recommendations
• Prophylactic antibiotics are recommended in spine surgery
Penicillin
Arthroscopy• Incidence of infection extremely low (0.2%)
• Two main studies do not demonstrate reduced SSI rate in arthroscopic procedures when prophylactic antibiotics are used
Penicillin
Concerns…• Many procedures are not exclusively
arthroscopic, and require incisions (ACL reconstruction)
• Some prolonged surgical times
• More complex arthroscopic procedures involve the use of implants
Penicillin
Arthroscopy Recommendations• No study has examined the effect of
prophylactic antibiotics along the spectrum of contemporary arthroscopic procedures
• The studies available are few, and may not be sufficiently designed or powered to provide meaningful recommendations about the use of prophylactic antibiotics in arthroscopic procedures
Penicillin
Pediatric Orthopedic Surgery
• Pediatric patients are subject to the same procedures as adults, but pediatric-specific data is sparse
• Pediatric tissue and physiology is markedly different from adults
Penicillin
Pediatric Orthopedic Surgery
• Case-control study to identify risk factors for SSIs after spinal fusion in children found that antibiotic prophylaxis was more frequently suboptimal in patients who developed an SSI
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Pediatric Orthopedic Surgery Recommendations
• No definitive conclusions
• Extrapolate (justifiably?) recommendations from adult studies
Penicillin
Foot and Ankle
• Few studies available
• Retrospective study on non-traumatic, non-revision surgery showed no decrease in SSI rate when prophylactic antibiotics used
• Prospective analysis of outpatient ankle fractures demonstrated no benefit from prophylactic antibiotics
Penicillin
Foot and Ankle
• No data on diabetics undergoing foot surgery
Penicillin
Foot and Ankle
• No definitive conclusions can be drawn regarding the efficacy of antibiotic prophylaxis in patients undergoing foot and ankle surgery
Penicillin
Clean Elective Hand Surgery
• Prophylactic antibiotics have not been proven efficacious in clean, elective hand procedures
• Some recommendations exist to use prophylactic antibiotics in reconstructive procedures involving large flaps, procedures of prolonged duration, and arthroplasty
• Properly designed and powered studies do not exist to answer these questions definitively
Penicillin
Orthopedic Trauma
• Preoperative prophylactic antibiotics are beneficial in reducing SSIs after operative treatment of hip fractures
• Prophylactic antibiotics have also been shown effective in reducing SSI with internal fixation of other closed fractures
• Single dose prophylaxis equivalent effect to multi-dose prophylaxis
Orthopedic Trauma
• Antibiotics are critical in reducing the infection risk after open fractures
Penicillin
Orthopedic Trauma Recommendations
• Prophylactic antibiotics should be used in patients undergoing internal fixation of closed and open fractures
Penicillin
Hip and Knee Arthroplasty• Low infection rate• Consequences are
severe
Hip and Knee Arthroplasty
• Prophylactic antibiotics have been shown to reduce the incidence of infection after primary hip and knee arthroplasty
Penicillin
Hip and Knee Arthroplasty
• Cephalosporins preferred agent
• Vancomycin has been proven to be a successful prophylactic agent
Penicillin
Hip and Knee Arthroplasty
• Optimal duration of antimicrobial prophylaxis is not known
• No benefit established by extending prophylaxis beyond 24 hours
• No benefit established by continuing prophylaxis until all drains and catheters have been removed
Penicillin
Hip and Knee Arthroplasty Recommendations
• Prophylactic antibiotics should be used
• Duration should not exceed 24 hours
Penicillin
Antibiotic Irrigation• Not proven to reduce surgical site infection in:
– Spine surgery– Hand surgery– Arthroplasty– Open lower extremity fractures
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Antibiotic Irrigation Concerns• Adverse reactions to topically applied
antibiotics occur– Anaphylaxis with bacitracin– Neomycin neuromuscular blocking agent– Renal failure neomycin-polymyxin-bacitracin– Hypersensitivity reactions
Penicillin
Antibiotic Irrigation Concerns• Cost of acquiring, storing, mixing, dispensing
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Antibiotic Irrigation Concerns• May contribute to antibiotic resistance
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Resistant StrainsRare
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Resistant Strains Dominant
Antimicrobial Exposure
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Antibiotic Irrigation is not Recommended
Penicillin
Prophylactic Antibiotics in Orthopedic Surgery
• Proven effective in reducing SSIs in– Spine surgery– Fracture fixation– Major joint arthroplasty
Prophylactic Antibiotics in Orthopedic Surgery
• Data inadequate on the effect of prophylactic antibiotics in– Foot and ankle surgery– Pediatric orthopedic surgery– Hand/upper extremity procedures not
considered clean, elective, and short duration
– Contemporary complex arthroscopic procedures
Prophylactic Antibiotics in Orthopedic Surgery
• Efficacy of prophylactic antibiotics unproven in– Clean, elective hand procedures lasting less
than 2 hours– Simple arthroscopic procedures
Prophylactic Antibiotics in Orthopedic Surgery
• Cephalosporins agents of choice– True beta-lactam allergy– MRSA colonization/infection
• Timing of administration 1-2 hours before incision
• Redose• Duration not longer than 24 hours
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