Table 1 Perioperative outcomes of standard and extended oral antibiotic prophylaxis groups
Source: Villa JM, et al., “Does Extended Oral Antibiotic Prophylaxis Reduce the Incidence of Periprosthetic Joint Infections after Aseptic Total Hip or Knee Arthroplasty Revisions?”

AAOS Now

Published 3/25/2022
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Ariel DeMaio

Study Questions Whether Extended Oral Antibiotic Prophylaxis Effectively Reduces PJI Risk

In an analysis of 178 aseptic total hip arthroplasty (THA) and total knee arthroplasty (TKA) first-time revisions, extended oral antibiotic (EOA) prophylaxis was associated with a slightly lower risk of periprosthetic joint infection (PJI) compared with standard antibiotic prophylaxis. However, the authors noted that this finding was not statistically significant and called for prospective clinical trials with larger sample sizes to draw a definitive conclusion.

Jesus M. Villa, MD, from the Levitetz Department of Orthopaedic Surgery at Cleveland Clinic Florida, and researchers shared their findings at the AAOS 2022 Annual Meeting. As Dr. Villa explained, a previous retrospective study of more than 2,000 cases of primary THA/TKA cases demonstrated that high-risk patients who received EOA prophylaxis were four times less likely to experience PJI within the first 90 days postoperatively than patients who did not receive such a prophylactic regimen.

In the present analysis, Dr. Villa and coauthors retrospectively reviewed 328 consecutive revisions performed by three surgeons in a single institution between September 2017 and December 2019. The researchers excluded cases with positive intraoperative cultures and/or histology per 2013 Musculoskeletal Infection Society (2013-MSIS) criteria, revisions of hemiarthroplasties or partial arthroplasties, surgeries where foreign material (i.e., mesh) was utilized, revisions addressing metastatic bone disease, and cases where intravenous antibiotics were given more than 24 hours after surgery.

In total, 178 aseptic first-time revision THAs/TKAs were included. Cases were divided according to EOA prophylaxis (where antibiotics were administered for >24 hours; n = 93) and standard prophylaxis (≤24 hours; n = 85).

Demographics (age, gender, race, and ethnicity), BMI, American Society of Anesthesiologists physical status classification (ASA), joint type (hip versus knee), hospital length of stay (LOS), skin-to-skin time, transfusions, discharge disposition (home versus other), and the presence or not of PJI (per 2013-MSIS criteria) after the first-time revision were compared between both groups.

The researchers noted that there were no statistically significant differences in those values between the EOA and standard prophylaxis groups, except for mean skin-to-skin time, which was significantly higher in the EOA group (Table 1).

Over a mean follow-up of 476 days, the incidences of postoperative PJI were not significantly different, at 2.2 percent (n = 2/93) in the EOA prophylaxis group versus 3.5 percent (n = 3/85) in the standard antibiotic prophylaxis group (P = 0.671). This difference translated to a 60 percent reduction in the rate of PJI with EOA prophylaxis, “despite the increased operative time of these cases,” the authors noted. “The literature on this subject is very rare. … Our data suggest that the use of EOA prophylaxis seems beneficial in lengthy aseptic revisions.”

Still, Dr. Villa and coauthors noted that the findings should be viewed in light of certain limitations, including the retrospective nature of the study and the inherent possibility of bias. “However, key baseline characteristics were reviewed in all cases, and the only difference found between both prophylactic groups was that the skin-to-skin time was longer in revisions done with EOA prophylaxis,” they wrote. “This particular factor should have played in favor of the standard group regarding infections.”

The number of procedures analyzed was also small, which the authors noted was due “in part to the strict inclusion and exclusion criteria utilized to make sure that only the first revision of the index primary hip or knee arthroplasty was included and that all cases were indeed aseptic revisions.”

Dr. Villa’s coauthors of “Does Extended Oral Antibiotic Prophylaxis Reduce the Incidence of Periprosthetic Joint Infections after Aseptic Total Hip or Knee Arthroplasty Revisions?” are Tejbir Singh Pannu, MD, MS; William McKenna Braaksma, MD; Carlos A. Higuera Rueda, MD; and Aldo M. Riesgo, MD.

Ariel DeMaio is managing editor of AAOS Now.