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Risk of surgical site infection after lower limb implant removal not reduced with cefazolin
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A single preoperative dose of IV cefazolin did not reduce the risk of surgical site infection within 30 days following removal of orthopedic implants used for treatment of fractures below the knee compared with saline, according to results published in JAMA.
Tim Schepers , MD, PhD, and colleagues randomly assigned 500 patients with previous surgical treatment for fractures below the knee and who were undergoing removal of orthopedic implants to receive either a single preoperative IV dose of cefazolin or sodium chloride. The primary outcome measure was surgical site infection (SSI) within 30 days as measured by the criteria from the CDC, while secondary outcome measures included functional outcome, health-related quality of life and patient satisfaction.
Overall, 470 patients completed the study. Of these, 228 were in the cefazolin group and 242 were in the saline group. Results showed 14% of patients overall developed an SSI. In the cefazolin group, 13.2% of patients developed an SSI vs. 14.9% in the saline group. Researchers noted no significant differences in any of the secondary outcome measures postoperatively between groups.
“In this multicenter randomized clinical trial (including 470 patients) patients undergoing surgery for removal of orthopedic implants, used for treatment of fractures below the knee (eg, foot, ankle and lower leg), a single dose of intravenous cefazolin prophylaxis compared with saline did not appear to reduce the risk of surgical site infection within 30 days following implant removal,” Schepers told Healio.com/Orthopedics. “The rates of postoperative wound complications were high (13.2% vs. 14.9%), and future research should focus on the cause of these high rates and on strategies to lower these numbers.” – by Casey Tingle
Disclosure: Funding was received from ZonMW, the Netherlands organization for health research and development grant.
Perspective
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Andrew R. Hsu, MD
Is it better to be safe than sorry with preoperative antibiotics for lower extremity hardware removals or are we over-treating patients? That is the core question that a recent multicenter, randomized clinical trial done in the Netherlands set out to answer. Results showed a single dose of preoperative IV cefazolin had no significant effect on the 30-day rate of postoperative SSI after lower extremity hardware removal compared to saline (13.2% cefazolin vs. 14.9% saline). Among the 470 patients in the study, superficial infections treated with local wound care with or without oral antibiotics were similar between groups, but seven of the eight total deep infections that required readmission and IV antibiotics with or without surgical debridement occurred in the saline group (0.4% cefazolin vs. 2.9% saline).
The results of this well-done study are interesting and an important addition to the literature, but in isolation they are unlikely to change my practice patterns. I believe that preoperative IV antibiotics with the addition of intraoperative local antibiotics (ie, vancomycin powder in high-risk patients) are still valuable to help reduce the rates of superficial and deep SSIs after any lower extremity surgery. SSIs can be devastating complications, and, in my mind, further research is needed before we should consider stopping the use of preoperative antibiotics for lower extremity hardware removal.
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