Download Literature Search for Tourniquet application as it relates to Antibiotic

Antibiotic treatment for prevention of infectious complications in joint
replacement
Jahoda D. Nyc O. Pokorny D. Landor I. Sosna A.
Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) Acta Chirurgiae
Orthopaedicae et Traumatologiae Cechoslovaca. 73(2):108-14, 2006 Apr.
[English Abstract. Journal Article. Research Support, Non-U.S. Gov't. Review] UI: 16735008
Prophylactic antibiotic treatment is mandatory in every operation involving an orthopedic implant.
Carefully selected and correctly administered antibiotics can provide effective protection of the implant
from bacterial colonization. The prevention of deep wound infection in joint replacement includes
several procedures and measures which constitute three basic groups: 1) Promotion of patient's ability
to resist infection (careful pre-operative preparation, elimination of potential infectious loci, good
nutritional status, etc). 2) Optimal conditions for the operative wound (surgical technique, prophylactic
antibiotics). 3) Reduction of the number of bacteria brought in the wound (control measures, supersterile operating theatres). Clear rules for the system of prophylactic antibiotic treatment should be
adopted. A program in which responsibility for antibiotic administration was shifted from the nursing
staff to the anaesthesiologist in the operating theatre showed improved outcomes and reduced costs.
Poor timing of prophylactic antibiotic administration is one of the basic mistakes. If the wound
happened to be contaminated during surgery, the first three post-operative hours would be most
decisive for the development of infection. An effective bactericidal concentration of antibiotic should be
present in tissues and serum immediately after surgery has begun. Therefore the appropriate time for
antibiotic application is before a skin incision is made, and not after the operation has started; the
highest serum and bone tissue levels appear 20 to 30 min. after intravenous antibiotic injection. To
allow antibiotics to reach target tissues, they should be introduced at least 10 min. before tourniquet
application. For long surgical procedures or when blood loss is high, an additional dose of antibiotics is
recommended during the operation. If a sample for bacterial cultivation is required, antibiotic
administration is postponed until during surgery. However, this is used only in indicated cases when
deep infection is suspected and no assessment of the causative agent is available. Otherwise this
approach carries a high risk of infectious complications in aseptic revision arthroplasty. Long-term,
unjustified administration of antibiotics leads to an increase in resistance to the antibiotic involved.
Some studies show that a day's course is as effective as a seven-day one. A shorter antibiotic course
decreases the costs, reduces side-effects and minimizes the development of resistance. An optimal
duration of antibiotic treatment has not been defined yet, and is still a hot issue for discussion. Many
authors recommend one pre-operative antibiotic dose and, according to the kind of antibiotic, agree to
its 24-hour administration in order to lower the toxic effect of antibiotic and to prevent selection of
resistant microorganisms. The choice of suitable antibiotics for prophylactic treatment should be based
on the range of agents causing joint replacement infections and the pharmacological properties of the
drug. This should have minimal toxicity, should be well tolerated by the patient and, from the
epidemiological point of view, should have a low risk of inducing resistance because of frequent use.
Naturally, it is not possible to include all antibiotics against all causative agents and therefore attention
should be paid, in the first place, to Gram-positive bacteria, i.e. e., staphylococci and streptococci, which
are the most common causes of infectious complications associated with joint replacement. Because of
difficulties related to the right choice of antibiotic, it is recommended to keep a record of complications
in each patient in order to provide feedback and to facilitate the establishment of reliable antibioticbased prevention. The prevention of infection in orthopedics is a comprehensive issue. It cannot be
expected that prophylactic antibiotic treatment will compensate for mistakes made in operative
protocols, for inadequate operative techniques, for shortcomings in operating theatre equipment or
insufficient preparation of patients.
Endothelin-1 is secreted after total knee arthroplasty regardless of the use of a
tourniquet.
Matziolis G. Drahn T. Schroder JH. Krocker D. Tuischer J. Perka C.
Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) Journal of
Orthopaedic Research. 23(2):392-6, 2005 Mar. UI: 15734253
Early infections and wound healing disorders after implantation of a total knee replacement occur
regardless of the intraoperative use of a tourniquet. The biochemical regulatory processes responsible
for the disturbances in microcirculation and thus the potential therapeutic options have yet to be
elucidated. The hypothesis of the present paper was that endothelin-1 (ET-1), a mediator of
microcirculation disturbances in parenchymatous organs, also is released after major operations on
peripheral joints. The concentration of ET-1 in the plasma was determined preoperatively and at 10
postoperative time points (5 min-48 h) with (group A, n=10) and without the use of a tourniquet (group
B, n=10). The ET-1 concentration achieved its maximum 6h after opening the tourniquet, which
corresponded to 3.3 times the preoperative value. Without a tourniquet, the concentration maximum
(2.9 times the baseline value) was achieved already 1.5 h after the end of the operation. However, the
total amount of ET-1 secreted over 24 h was identical in both groups (p>0.5). We conclude that the
tissue hypoxia resulting from the use of a tourniquet modulates ET-1 secretion, but that traumatization
during the operation has a much stronger influence on the total amount secreted. ET-1 antagonists thus
should be discussed for the drug prophylaxis of wound healing disorders, regardless of the use of a
tourniquet.
Antibiotic prophylaxis and tourniquet application in podiatric surgery.
Deacon JS, Wertheimer SJ, Washington JA
AMED (Allied and Complementary Medicine) Journal of Foot and Ankle Surgery 1996 Jul-Aug;35(4):3449. AN: 9146996
The use of prophylactic antibiosis in podiatric surgery is common, especially in patients undergoing
endoprosthetic procedures, major arthrodeses, lengthy procedures, or in immuncompromised patients.
The goal of prophylaxis is to prevent infection. For this to occur, there must be an adequate
concentration of the antimicrobial agent in the tissue at the time of the incision. Historically, prophylaxis
has consisted of intravenous administration of 1 gm. of cefazolin, 30 to 60 minutes prior to surgery.
Cefazolin concentrations in the medial eminence of the first metatarsal were measured in patients
undergoing bunionectomy procedures where pneumatic ankle tourniquets were used for hemostasis.
The goal of this study was to determine if the current standards of prophylactic antibiotic administration
provide adequate bone levels of cefazolin to effectively inhibit potential infection-causing pathogens.
Timing of antibiotic prophylaxis for primary total knee arthroplasty performed
during ischemia.
Soriano A. Bori G. Garcia-Ramiro S. Martinez-Pastor JC. Miana T. Codina C. Macule F. Basora M. Martinez
JA. Riba J. Suso S. Mensa J. Clinical Infectious Diseases 2008;46:1009–1014 © 2008 by the Infectious
Diseases Society of America. All rights reserved. 1058-4838/2008/4607-0008$15.00 DOI:
10.1086/529145 http://www.journals.uchicago.edu/doi/abs/10.1086/529145
There is no clinical trial analyzing the best moment to infuse an antibiotic during knee arthroplasty
performed during ischemia. We designed a single-center, randomized, double-blind, placebo-controlled
trial to evaluate whether antibiotic therapy should be administered before tourniquet inflation or just
before tourniquet deflation. MATERIAL AND METHODS: Patients who underwent a primary knee
arthroplasty were randomized to receive (1) 1.5 g of cefuroxime 10-30 min before inflation of the
tourniquet and placebo 10 min before release of the tourniquet (standard arm) or (2) placebo 10-30 min
before inflation of the tourniquet and 1.5 g of cefuroxime 10 min before release of the tourniquet
(experimental arm). In both arms, a postoperative dose of 1.5 g of cefuroxime was given 6 h after the
surgical procedure. The main variables associated with the rate of deep-tissue infection after 3 and 12
months of follow-up were gathered. Continuous variables were compared using Student's t test, and
categorical variables were compared using the chi(2) test or Fisher's exact test. RESULTS: From
September 2004 through December 2005, a total of 908 patients were randomized, 442 and 466 of
whom were allocated to the standard and experimental arms, respectively. There were no differences
between treatment arms in terms of age, sex, comorbidity, American Society of Anaesthesiologists
score, duration of surgery, need of blood transfusion, or fourth-day hematocrit. The rates of deep-tissue
infection among the standard and experimental groups were 3.4% and 1.9%, respectively, at 3 months
of follow-up (P = .21) and 3.6% and 2.6%, respectively, at 12 months of follow-up (P = .44).
CONCLUSION: The administration of prophylactic antibiotics just before tourniquet release was not
inferior to standard antibiotic prophylaxis.
Timing and dosage of antibiotic administration should optimize the efficacy of
the therapy.
June 2004 American Academy of Orthopaedic Surgeons. Information Statement 1027.
http://www.aaos.org/about/papers/advistmt/1027.asp
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
Prophylactic Antibiotics in Orthopaedic Surgery
Laura Prokuski, MD. Associate Professor. University of Wisconsin. Department of Orthopedics and
Rehabilitation. Madison, WI
http://www.ohiokepro.com/providers/hospital/telemats/02.09.2007.Prophylactic_Antibiotics_in_Ortho
pedic_Surgery.pdf
*page 25 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
Antibiotic Prophylaxis for Inpatient and Outpatient Surgery
Bratzler and the Surgical infection Prevention Guidelines Writers Workgroup. Antimicrobial prophylaxis
for surgery: an advisory statement from the National Surgical infection Prevention Project. CID.
2004;38:1706-15. American Society of health-system pharmacist’s therapeutic guidelines on
antimicrobial prophylaxis in surgery. AJHP. 1999;56:1839-88. Society of Thoracic Surgeons guideline on
Antibiotic Prophylaxis in Cardiac Surgery. Available at www.sts.org. American College of Obstetricians
and Gynecologists (ACOG) Committee on Practice Bulletins. ACOG Practice Bulletin No. 74 Antibiotic
prophylaxis for gynecologic procedures. Obstet Gynecol July 2006; 108(1):225-34. ACC/AHA 2006
Guidelines for Management of Patient with Valvular Heart Disease. Circ.2006; 114:e84-231.
http://74.125.155.132/search?q=cache:zmx3f86omJkJ:www.sarasotaanesthesia.com/documents/Antibi
oticSurgicalProphylaxisProtocolSMH200901Update4_000.doc+tourniquet+usage+in+relation+to+prophylactic+antibiotic+to+prevent+surgical+sit
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Timing: Most antibiotics for surgical prophylaxis must be initiated within 60 minutes of the first incision.
Antibiotic prophylaxis with vancomycin and ciprofloxacin should be initiated 60-120 minutes before the
first incision is made, since vancomycin is infused at a rate of 1 gram per hour. When a proximal
tourniquet is used, recommended guidelines state the entire infusion should be completed prior to
inflation of the tourniquet. Vancomycin and Ciprofloxacin to be initiated in pre-op at the discretion of
the room.
Prophylactic antibiotics for joint arthroplasty: Which one and for how long?
By Javad Parvizi, MD, FRCS; Valentin Antoci Jr., PhD
ORTHOPEDICS TODAY 2008; 28:26
http://www.orthosupersite.com/view.asp?rID=31033
Administration of antibiotics at the time of anaesthesia allows time for achieving microbicidal
concentrations in tissues. Marculescu and colleagues suggested vancomycin should be administered
within 2 hours presurgery due to the longer infusion time. To support such timing, Johnson and
colleagues showed levels above the minimum inhibitory concentration (MIC) within 10 minutes of
infusing 1.5 g of cefuroxime, with bone concentrations of antibiotics surpassing 60 times the MIC.
Interestingly, the antibiotic level was minimally affected by use of a tourniquet.
Prevention and treatment of surgical site infection: summary of NICE guidance
David Leaper, visiting professor1, Shona Burman-Roy, systematic reviewer 2, Ana Palanca, research assistant 2,
Katherine Cullen, health economist2, Danielle Worster, information scientist 2, Eva Gautam-Aitken, project
manager2, Martin Whittle, clinical codirector2, On behalf of the Guideline Development Group
1
Department of Wound Healing, Cardiff University, Cardiff, 2 National Collaborating Centre for Women’s and
Children’s Health, London W1T 2QA
Published 28 October 2008, doi:10.1136/bmj.a1924
BMJ 2008;337:a1924
http://www.sld.cu/uvs/cirured/temas.php?idv=23051
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Give antibiotic treatment (in addition to prophylaxis) to patients having surgery on a dirty or
infected wound.
Consider giving a single intravenous dose of antibiotic prophylaxis on starting anaesthesia, or
earlier for operations in which a tourniquet is used. Repeat the dose if the operation is longer
than the half life of the antibiotic given.
Do not use antibiotic prophylaxis routinely for clean, non-prosthetic uncomplicated surgery.