Antimicrobial (antibiotic) prophylaxis in joint replacement surgery

Joint replacement without prophylactic antibiotics results in an unacceptably high incidence of infection:

• rate of deep infection after total hip replacement is 0.3-2% (1,2)
  • a Canadian study (2) revealed that the cumulative infection rate after the index total hip arthroplasties rose from 0.8% at 2 years to 1.4% at 20 years; 9.6% of the index operations required further surgery. When infections attributed to these secondary procedures were included, the infection rate rose from 0.9% at 2 years to 2% at 20 years
    
    
• the rate of infection after knee replacement is about twice that of following hip replacement
  
  
• factors that increase the risk of infection include co-morbid disease (e.g. diabetes mellitus, malignancy), longer duration of surgery, previous arthroplasty involving the same joint
  
  
• incidence of infection is highest in the first 6 months following surgery although up to 50% of all prosthetic joint infections present more than 2 years after the operation (4)
  
  
• following joint replacement, the organisms responsible for infection are often bacteria with low virulence in the absence of implanted material e.g. coagulase-negative staphylococci (see menu item). Also infection with Staphylococcal aureus is common, including an increasing number of infections with meticillin-resistant Staphylococcus aureus (MRSA) (1)

Preventive measures include:

• general measures (see menu item 'prevention of infection in orthopaedics')
• intravenous antibiotics given 30-60 minutes before skin incicision, and continued for at most 24 hours (6). Traditionally, a first- or second-generation cephalosporin (e.g. cefuroximine) or, alternatively, a penicillinase-resistant penicillin (e.g. flucloxacillin) have been used as antimicrobial prophylaxis for orthopaedic implant surgery. However, the precise regimen should be based on local information about pathogens in orthopaedic surgical site infections and their susceptibility to antibiotics

Reference:

• (1) NINSS partnership. Surveillance of surgical site infection in English hospitals 1997-99. London: Public Health Laboratory Service, 2000.
• (2) Hamilton H, Jamieson J.Deep infection in total hip arthroplasty. Can J Surg. 2008 Apr;51(2):111-7.
• (3) Ahnfelt L et al (1990). Prognosis of total hip replacement. A Swedish multicentre study of 4664 revisions. Acta Orthop Scand, 61 (suppl 238), 1-269.
• (4) Berbari EF et al (1998). Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis, 27, 1247-54.
• (5) Steckelberg JM, Osmon DR. Prosthetic joint infections. In: Bisno AL, Waldvogel FA (Eds). Infections associated with indwelling medical devices. Second Edition. Washington: American Society for Microbiology, 1994.
• (6) Drug and Therapeutics Bulletin (2001), 39 (6), 43-6.