Recommendations for the Use of Intravenous Antibiotic Prophylaxis in Primary Total Joint Arthroplasty
This Information Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.
Surgical site infections (SSI) are a major source of postoperative illness, accounting for nearly 25% of all nosocomial infections in the United States each year.1 The Centers for Disease Control and Prevention (CDC) estimate that approximately 500,000 SSIs occur annually in the United States.2 The risks for patients who develop SSIs include:
- 60% more likely to spend time in an intensive care unit
- Five times more likely to be readmitted to the hospital
- Twice the mortality rate as patients without wound infections.3
Studies have demonstrated that prophylactic antibiotics reduce the incidence of infection after orthopaedic surgery in patients without known infection and their use is considered routine for primary total joint arthroplasty.4-7
The National Surgical Infection Prevention Project (SIPP) was initiated in August of 2002 as a joint venture between the Centers for Medicare & Medicaid Services (CMS) and the CDC. By promoting the appropriate selection, timing, and duration of administration of prophylactic antibiotics, the project seeks to reduce the morbidity and mortality related to postoperative infections in the Medicare population. Experts in surgical infection prevention, hospital infection control, and epidemiology developed three performance measures for national surveillance and quality improvement.8 The American Academy of Orthopaedic Surgeons (AAOS) was instrumental in developing the following three measures: 1) the proportion of patients who receive prophylactic antibiotics consistent with current recommendations; 2) the proportion of patients who receive antibiotic prophylaxis within one hour before the surgical incision; and 3) the proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of the end of surgery.8 Preliminary data from this surveillance indicates that antibiotic prophylaxis is not always administered in a manner that is supported by scientific evidence. Inappropriate use of antibiotics does not prevent post-operative infections, but contributes to antibiotic resistance, increases the risk of adverse reactions, predisposes the patient to infections, and increases healthcare costs.
The American Academy of Orthopaedic Surgeons (AAOS) recommends the following evidence-based practices for the appropriate use of intravenous antibiotic prophylaxis in primary total joint arthroplasty to reduce the risk of infection.
The antibiotic used for prophylaxis should be carefully selected, consistent with current recommendations in the literature, taking into account the issues of resistance and patient allergies.
Currently, cefazolin or cefuroxime are the preferred antibiotics for patients undergoing orthopaedic procedures.9-12 Clindamycin or vancomycin may be used for patients with a confirmed beta-lactam allergy. Vancomycin may be used in patients with known colonization with methicillin resistant Staphylococcus aureus (MRSA) or in facilities with recent MRSA outbreaks.13 In multiple studies, exposure to vancomycin is reported as a risk factor in the development of vancomycin-resistant enterococcus (VRE) colonization and infection. Therefore, vancomycin should be reserved for the treatment of serious infection with beta-lactam-resistant organisms or for treatment of infection in patients with life-threatening allergy to beta-lactam antimicrobials.14
Timing and dosage of antibiotic administration should optimize the efficacy of the therapy.
Prophylactic antibiotics should be administered within one hour prior to skin incision.15-19 Due to an extended infusion time, vancomycin should be started within two hours prior to incision. If a proximal tourniquet is used, the antibiotic must be completely infused prior to the inflation of the tourniquet. Dose amount should be proportional to patient weight; for patients >80 kg the doses of Cefazolin should be doubled.20 Additional intraoperative doses of antibiotic are advised if:
1. The duration of the procedure exceeds one to two times the antibiotic’s half-life.
2. There is significant blood loss during the procedure.10,21,22
The general guidelines for frequency of intraoperative administration are as follows:13
Frequency of Administration
Every 2-5 hours
Every 3-4 hours
Every 3-6 hours
Every 6-12 hours
Duration of prophylactic antibiotic administration should not exceed the 24-hour post-operative period.
Prophylactic antibiotics should be discontinued within 24 hours of the end of surgery.9-12, 23-29
Medical literature does not support the continuation of antibiotics until all drains or catheters are removed and provides no evidence of benefit when they are continued past 24 hours.30-47
- Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nationwide nosocomial infection rate: a new need for vital statistics. Am J Epidemiol 1985; 121:159-67.
- Wong ES. Surgical site infection. In: Mayhall DG, editor. Hospital epidemiology and infection control. 2nd ed. Philadelphia: Lippincott; 1999. pp. 189-210.
- Kirkland KB, Briggs JP, Trivette SL, et al. The impact of surgical site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol. 1999; 20:725-730
- Fogelberg EV, Zitzmann EK, Stinchfield FE. Prophylactic penicillin in orthopaedic surgery. J Bone Joint Surg 1970; 52A: 95-98.
- Pavel A, Smith RL, Bakkard A, Larsen AJ. Prophylactic antibiotics in clean orthopaedic surgery. J Bone Joint Surg 1974; 56A: 777-782.
- Boxma H, Broekhuizen T, Patka P, Oosting H. Randomized control trial of a single dose antibiotic prophylaxis in surgical treatment of closed fractures: The Dutch trauma trial. Lancet 1996;347:1133-1137.
- Gillespie WJ, Walenkamp G. Antibiotic prophylaxis for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev 2001;1:CD000244.
- Bratzler, DW, Houck, PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Inf Dis 2004;38:1706-1715.
- Page CP, Bohnen JM, Fletcher JR, et al. Antimicrobial prophylaxis for surgical wounds. Guidelines for clinical care. Arch Surg 1993;128:79-88.
- Dellinger EP, Gross PA, Barrett TL, et al. Quality standard for antimicrobial prophylaxis in surgical procedures. Infectious Diseases Society of America. Clin Inf Dis 1994;18:422-427.
- Antimicrobial prophylaxis in surgery. Med Lett Drugs Ther 2001;43:92-97.
- Gilbert DN, Moellering RC, Sande MA.
- American Society of Health-System Pharmacists ASHP Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery. American Society of Health-System Pharmacists. Am J Health Syst Pharm 1999 Sep 15;56(18):1839-88.
- American Academy of Orthopaedic Surgeons. The use of prophylactic antibiotics in orthopaedic medicine and the emergence of vancomycin-resistant bacteria. 2002. Available at http://www.aaos.org/about/papers/position/1116.asp
- Burke JF. The effective period of preventative antibiotic action in experimental incisions and dermal lesions. Surgery 1961;50:161-168.
- DiPiro JT, Vallner JJ, Bowden TA, et al. Intraoperative serum and tissue activity of cefazolin and cefoxitin. Arch Surg 1985;120:829-832.
- Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical wound infection. N Engl J Med 1992;326:281-286.
- Fukatsu K, Saito H, Matsuda T, et al. Influences of type and duration of antimicrobial prophylaxis on an outbreak of methicillin-resistant Staphylococcus aureus and on the incidence of wound infection. Arch Surg 1997;132:1320-1325.
- Burke JP. Maximizing appropriate antibiotic prophylaxis for surgical patients: an update from LDS hospital, Salt Lake City. Clin Inf Dis 2001;33(Suppl 2):S78-S83.
- Hanssen AD, Osmon DR. The use of prophylactic antimicrobial agents during and after hip arthroplasty. Clin Orthop 1999;369: 124-138.
- Bratzler DW, Houck PM, for the Surgical Infection Prevention Guidelines Writers Workgroup. Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project . Clin Inf Dis 2004;38(12):1706-1715.
- Gross PA, Barrett TL, Dellinger EP, et al. Purpose of quality standards for infectious diseases. Infectious Diseases Society of America. Clin Inf Dis 1994;18:428-430.
- Auerbach AD. Prevention of Surgical site infections. Available at http://www.ahrq.gov/clinic/ptsafety/pdf/ptsafety.pdf
- Pollard JP, Hughes SO, Scott JE, et al. Antibiotic prophylaxis in total hip replacement. Br Med J 1979;1: 707-709.
- Williams DN, Gustilo RB, Beverly R, Kind AC. Bone and serum concentrations of five cephalosporin drugs. Relevance to prophylaxis and treatment in orthopedic surgery. Clin Orthop 1983;179:253-265.
- Nelson CL, Green TG, Porter RA, Warren RD. One day versus seven days of preventative antibiotic therapy in orthopaedic surgery. Clin Orthop 1983;176:258-263.
- Heydemann JS, Nelson CL. Shot-term preventative antibiotics. Clin Orthop 1986;205:184-187.
- Oishi CS, Carrion WV, Hoaglund FT. Use of parenteral prophylactic antibiotics in clean orthopaedic surgery. A review of the literature. Clin Orthop 1993;296:249-255.
- Mauerhan DR, Nelson CL, Smith DL, et al. Prophylaxis against infection in total joint arthroplasty. One day Cefuroxime compared with three days of cefazolin. J Bone Joint Surg 1994;76:39-45.
- Chandratreya A, Giannikas K, Livesley P. To drain or not drain: literature versus practice. J R Coll Surg Edinb 1998 Dec;43(6):404-6.
- Ovadia D, Luger E, Bickels J, Menachem A, Dekel S. Efficacy of closed wound drainage after total joint arthroplasty. A prospective randomized study. J Arthroplasty 1997 Apr;12(3):317-21.
- Jackson JP, Waugh W. Tibial osteotomy for osteoarthritis of the knee. J Bone Joint Surg Br. 1961 Nov; 43-B: 746-51.
- Varley GW, Milner SA. Wound drains in proximal femoral fracture surgery: a randomized prospective trial of 177 patients. J R Coll Surg Edinb 1995 Dec;40(6):416-8.
- Cobb JP. Why use drains? J Bone Joint Surg Br. 1990 Nov;72(6):993-5.
- Hadden WA, McFarlane AG. A comparative study of closed-wound suction drainage vs. no drainage in total hip arthroplasty. J Arthroplasty. 1990;5 Suppl: S21-4.
- Ritter MA, Keating EM, Faris PM. Closed wound drainage in total hip or total knee replacement. A prospective, randomized study. J Bone Joint Surg Am. 1994 Jan;76(1):35-8.
- Reilly TJ, Gradisar IA Jr, Pakan W, Reilly M. The use of postoperative suction drainage in total knee arthroplasty. Clin Orthop. 1986 Jul;(208):238-42.
- Beer KJ, Lombardi AV Jr, Mallory TH, Vaughn BK. The efficacy of suction drains after routine total joint arthroplasty. J Bone Joint Surg Am. 1991 Apr;73(4):584-7.
- Esler CN, Blakeway C, Fiddian NJ. The use of a closed-suction drain in total knee arthroplasty. A prospective, randomized study. J Bone Joint Surg Br. 2003 Mar;85(2):215-7.
- Adalberth G, Bystrom S, Kolstad K, Mallmin H, Milbrink J. Postoperative drainage of knee arthroplasty is not necessary: a randomized study of 90 patients. Acta Orthop Scand. 1998 Oct; 69(5):475-8.
- Niskanen RO, Korkala OL, Haapala J, Kuokkanen HO, Kaukonen JP, Salo SA. Drainage is of no use in primary uncomplicated cemented hip and knee arthroplasty for osteoarthritis: a prospective randomized study. J Arthroplasty. 2000 Aug;15(5):567-9.
- Drinkwater CJ, Neil MJ. Optimal timing of wound drain removal following total joint arthroplasty. J Arthroplasty. 1995 Apr;10(2):185-9.
- Browett JP, Gibbs AN, Copeland SA, Deliss LJ. The use of suction drainage in the operation of meniscectomy. J Bone Joint Surg Br 1978 Nov;60-B(4):516-9.
- Willett KM, Simmons CD, Bentley G. The effect of suction drains after total hip replacement.
J Bone Joint Surg Br. 1988 Aug; 70(4): 607-10.
- Sorensen AI, Sorensen TS. Bacterial growth on suction drain tips. Prospective study of 489 clean orthopedic operations. Acta Orthop Scand. 1991 Oct; 62(5): 451-4.
- Overgaard S, Thomsen NO, Kulinski B, Mossing NB. Closed suction drainage after hip arthroplasty. Prospective study of bacterial contamination in 81 cases. Acta Orthop Scand. 1993 Aug; 64(4): 417-20.
- Manian FA, Meyer PL, Setzer J, Senkel D. Surgical site infections associated with methicillin-resistant Staphylococcus aureus: do postoperative factors play a role? Clin Infect Dis. 2003 Apr 1; 36(7): 863-8. Epub 2003 Mar 18.
- Cruse PJ, Foord R. A five-year prospective study of 23,649 surgical wounds. Arch Surg. 1973 Aug; 107(2): 206-10.
Copyright June 2004 American Academy of Orthopaedic Surgeons.
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