Download Prevention of prosthetic joint infections Authors Elie Berbari, MD

Prevention of prosthetic joint infections
Authors
Elie Berbari, MD, FIDSA
Larry M Baddour, MD, FIDSA
Section Editor
Daniel J Sexton, MD
Deputy Editor
Elinor L Baron, MD, DTMH
Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Apr 2013. | This topic last updated: May 2, 2013.
INTRODUCTION — Periprosthetic joint infection occurs in 1 to 2 percent of joint replacement
surgeries and is one of the leading causes of arthroplasty failure. Treatment of these
infections requires multiple surgical interventions and prolonged antibiotic therapy, and is
associated with a failure rate in upwards of 10 to 20 percent of cases. Given the difficulty in
treating prosthetic joint infections (PJIs), prevention of infection is clearly desirable.
The issues relating to the prevention of PJIs will be reviewed here. The clinical
manifestations, diagnosis, and treatment of these infections are discussed separately.
(See "Clinical manifestations and diagnosis of prosthetic joint infections" and "Treatment of
prosthetic joint infections".)
BEFORE AND DURING JOINT REPLACEMENT SURGERY — The following discussion will
emphasize general prevention measures before and during joint replacement surgery that
are consistent with the guidelines from the National Surgical Infection Prevention Project
(table 1) [1,2], the guidelines from the Medical Letter (table 2) [3], the American Society of
Health-System Pharmacists (ASHP) [4] and an Advisory Statement from the American
Academy of Orthopaedic Surgeons [5]. The recommendations discussed here are
emphasized and tracked by the Surgical Care Improvement Project (SCIP), a national quality
partnership of organizations interested in improving surgical care by significantly reducing
surgical complications. A general discussion of preventing surgical site infection is presented
separately. (See "Overview of control measures to prevent surgical site infection".)
Preoperative antimicrobial prophylaxis is standard for all patients undergoing joint
replacement [2,3,5]. Data supporting this recommendation come from trials that included
patients undergoing joint replacement as well as other orthopedic procedures, such as
surgical repair of hip and other closed fractures and internal fixation by nails, plates, screws,
or wires [6-8].
Support for preoperative antimicrobial prophylaxis also comes from a later prospective
observational study of 1922 patients who underwent elective total hip arthroplasty [9].
Surgical site infection (SSI) (superficial and deep) occurred in 50 patients (2.6 percent). The
major risk factor for infection was the administration of antimicrobial prophylaxis after incision
(odds ratio 2.8), with a trend toward lower rates of SSI in the 1679 patients (87 percent) who
were given antimicrobial therapy within 60 minutes prior to incision. A similar benefit of
antimicrobial prophylaxis soon before incision has been noted in patients undergoing elective
clean or clean-contaminated surgery (table 3) [10].
Based upon such observations, antimicrobial therapy should be given within 60 minutes of
the first incision (usually at the induction of anesthesia). Standard practice in the setting of a
proximal tourniquet has been to complete infusion of the antibiotic before inflation of the
tourniquet, although data from a single-center randomized blinded controlled trial involving
908 patients suggest that administering prophylactic antibiotics just prior to tourniquet
release is equally effective [11]. These data also suggest that administering antibiotics after
obtaining intraoperative cultures and immediately before tourniquet release may be
reasonable for patients undergoing replacement arthroplasty in whom the risk of preexisting
infection of the prosthesis is highly suspected [12].
The recommended regimen for patients with relatively normal renal function is cefazolin (1 g
IV if less than 80 kg and 2 g IV if more than 80 kg) orcefuroxime (1.5 g IV) [2,3,5].
(See "Overview of control measures to prevent surgical site infection", section on 'Timing of
prophylaxis'.)
We generally prefer cefazolin because of its greater intrinsic activity against staphylococci,
narrower side effect profile and antimicrobial spectrum, and much lower cost,
although cefuroxime has been recommended as an alternative choice [2].
Patients with type I allergy to beta-lactams can receive either vancomycin or clindamycin.
Vancomycin is administered at a dose of 1 g (10 to 15mg/kg) parenterally and repeated once
postoperatively at 12 hours [2,3]. Due to a prolonged infusion time, vancomycin should be
initiated within two hours of the incision. Clindamycin is administered at a dose of 600 to 900
mg IV and repeated twice postoperatively at six hour intervals. Clindamycin provides less
reliable coverage against coagulase-negative staphylococci and methicillin-resistant
Staphylococcus aureus (MRSA).
Vancomycin is also commonly used in patients at high risk for MRSA or in institutions in
which there is a "high rate of MRSA infection" even though current guidelines do not clearly
define minimum criteria for "high rates" [2].
With respect to the optimal duration of antimicrobial prophylaxis, a meta-analysis of patients
undergoing hip fracture surgery concluded that one dose of an intravenous antibiotic seemed
as effective as multiple doses [6]. However, we agree with a review from the National
Surgical Infection Prevention Project that there is insufficient evidence to support single-dose
regimens but that therapy beyond 24 hours after surgery is not likely to be beneficial, and
continuing therapy until suction drains are removed is not necessary [2,13].
We agree with the Medical Letter guidelines and the American Academy of Orthopaedic
Surgeons Advisory Statement that repeat dosing is warranted when major blood loss occurs
during the procedure or, in patients with normal renal function, the procedure lasts more than
one to two times the half-life of the antibiotic [3,5]. In such settings, we suggest
administering cefazolin (1 g IV if less than 80 kg and 2 g IV if more than 80 kg) at two to five
hour intervals or cefuroxime (1.5 g IV) at three to four hour intervals. The duration of
prophylaxis should not exceed 24 hours. (See"Overview of control measures to prevent
surgical site infection", section on 'Repeat dosing'.)
The National Surgical Infection Prevention Project guidelines also made the following
recommendations (table 1) [1]:
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All patients should be carefully screened for occult or minor infections prior to joint
replacement. Postponing surgery should be considered if there is any active infection.
Optimal control of hyperglycemia should be achieved prior to elective surgery in
patients with diabetes mellitus. Preoperative urine cultures should be obtained if there
are signs or symptoms or a recent history of a urinary tract infection.
Immunosuppressive medications should be tapered to the lowest dose possible. It is
uncertain whether methotrexate should be temporarily discontinued in patients with
rheumatoid arthritis (RA) undergoing elective orthopaedic surgery. A systematic
review found that continuing low doses of methotrexate seemed to be safe during the
perioperative period in patients with RA in the absence of relevant comorbid
conditionsand/or risk factors associated with infection [14]. When possible, the
discontinuation of TNF-alpha blockers several weeks prior to elective orthopedic
surgery is suggested [14].
Any evidence of a wound infection or wound skin necrosis that occurs in a patient
who has undergone joint replacement should be promptly and aggressively treated
with local wound measures and antibiotic therapy directed against the likely
pathogens.
S. aureus nasal screening and decolonization and chlorhexidine body wash prior to joint
replacement surgery can reduce the risk of PJI [15]. Nasal screening for the presence of S.
aureus is typically performed within three months prior to surgery. If positive, mupirocin nasal
application twice daily for five days is appropriate [4,15]. Other techniques to prevent
infection include use of laminar flow in the operating room and body-exhaust surgical suits
[1,16]. It is not clear that any of these measures are essential. As an example, prospective
and controlled studies demonstrated a decrease in rates of surgical site infections in total hip
and knee prosthesis procedures when laminar airflow technology was used [17,18].
However, the value and cost-effectiveness of laminar airflow is questionable when surgery
occurs in modern facilities that have high rates of air exchange and when antimicrobial
prophylaxis is given [19-21]. In a case control study of 26,505 patients undergoing total hip or
knee replacement, the infection rate was 1.8 percent and laminar flow ventilation was not a
significant factor in reducing infections in a univariate analysis [22]. (See "Overview of control
measures to prevent surgical site infection".)
Use of antibiotic-impregnated cement can reduce the rate of infection (See "Treatment of
prosthetic joint infections".)
ANTIBIOTIC PROPHYLAXIS PRIOR TO INVASIVE PROCEDURES — There is no
evidence to suggest that patients with prosthetic joints undergoing procedures should receive
antibiotic prophylaxis in the absence of other indications, such as heart valve disease
requiring endocarditis prophylaxis or a surgical procedure for which antibiotics are given to
prevent a surgical site infection. Several organizations have issued guidelines to this effect.
Dental procedures — Patients with orthopedic implants should maintain good dental
hygiene [23], and oral infections in patients with prosthetic joints should be treated promptly.
Dental procedures are not associated with an increased risk of prosthetic joint infection (PJI)
and use of routine antibiotic prophylaxis prior to dental procedures does not alter the risk of
subsequent total hip or knee infection [24,25]. There have been fewer than 25 reported
cases of late-onset PJI after dental procedures, and the association between dental
treatment and PJI in these cases is circumstantial at best. In addition, there are no
experimental observations suggesting a link between bacteremia induced from a dental
procedure and PJI. In a case control study based on Medicare Current Beneficiary Survey
(MCBS) data from 1997 to 2006 including cases with PJI and matched controls with total
arthroplasty but no PJI, there was no significant association between dental procedures and
PJI risk [26].
In view of these observations, the American Academy of Oral Medicine [27], the American
Dental Association (ADA) in conjunction with the American Academy of Orthopedic Surgeons
(AAOS) [28], and the British Society for Antimicrobial Chemotherapy [29] all advise against
universal use of antimicrobial prophylaxis prior to dental procedures for prevention of PJI. In
2013, the ADA and AAOS published a joint guideline on the prevention of orthopedic implant
infections in patients undergoing dental procedures; it states that there is no convincing
evidence to support routine use of prophylactic antibiotics in patients with prosthetic joints
who undergo dental procedures [23].
It is our practice to advise against use of antimicrobial therapy for patients with prosthetic
joints undergoing routine dental procedures, such as cleaning, scaling of teeth, or filling of a
dental cavity.
Urologic and gastrointestinal procedures — The American Urological Association and the
American Academy of Orthopedics issued similar recommendations for patients with a
prosthetic joint who undergo a urologic procedure [30]. Most such patients do not need
antibiotic prophylaxis to prevent bacteremia and possible secondary seeding of the joint.
However, the guidelines state that prophylaxis can be considered in some patients,
especially those with immunosuppression undergoing a higher risk procedure for bacteremia,
such as lithotripsy or surgery involving bowel segments.
The American Society of Gastrointestinal Endoscopist (ASGE) issued guidelines against the
use of antimicrobial prophylaxis prior to gastrointestinal endoscopies in this setting [31].
SUMMARY AND RECOMMENDATIONS
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Prevention of prosthetic joint infection (PJI) is important due to the difficulty in treating
PJIs. (See "Treatment of prosthetic joint infections".)
Preoperative antimicrobial prophylaxis is standard for all patients undergoing joint
replacement. The recommended regimen is cefazolin (2 g if <120 kg; 3 g if ≥120 kg)
or cefuroxime (1.5 g) given intravenously at the induction of anesthesia and repeated
for two doses postoperatively at two to five and three to four hour intervals,
respectively. (See 'Before and during joint replacement surgery' above.)
Patients with type I allergy to beta-lactams can receive vancomycin (1 g [10 to
15 mg/kg] IV and repeated once postoperatively at 12 hours) orclindamycin (600 to
900 mg IV and repeated twice postoperatively at six hour intervals). Vancomycin is
also commonly used in patients at high risk for methicillin-resistant Staphylococcus
aureus (MRSA) or in institutions in which there is a "high rate of MRSA infection,"
even though current guidelines do not define minimum criteria for "high rates.”
(See 'Before and during joint replacement surgery' above.)
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We recommend that antibiotic prophylaxis NOT be administered prior to dental
procedures for immunocompetent patients with history of prosthetic joint implantation
more than two years previously (Grade 1B). (See 'Dental procedures' above.)
There is no evidence to suggest that patients with prosthetic joints undergoing
procedures (eg, dental, urologic, gastrointestinal) should receive antibiotic
prophylaxis to prevent a subsequent infection of the prosthesis. (See 'Antibiotic
prophylaxis prior to invasive procedures'above.)
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