Extended antibiotics in orthopedic surgery may add to costs, but not stem infection
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Only when quality evidence dictates it, should orthopedic surgeons change how they use antibiotics for prophylaxis and treatment after surgery, symposium participants said at the Musculoskeletal Infection Society Annual Meeting.
At the meeting, which was held virtually, three presenters said the rationale for surgeons to make such a change in practice for total joint arthroplasty and trauma surgery may be to improve the safety of their patients and mitigate any complications of antibiotic therapy, but extended use of antibiotics may increase the cost of surgical care.
Symposium moderator Thorsten M. Seyler, MD, PhD, an orthopedic surgeon at Duke University School of Medicine in Durham, North Carolina, reviewed the latest clinical guidelines and evidence in the literature for the use of extended antibiotics in patients undergoing primary total hip arthroplasty and total knee arthroplasty.
There is no evidence to support the use of oral antibiotics in primary THA and TKA beyond a single initial dose given within 1 hour before the surgical incision, a practice supported by recommendations from the WHO in 2018 and CDC in 2017, he said.
“The available evidence suggests that a single dose of perioperative antibiotics is sufficient. There is no acceptable evidence available that support[s] longer courses, and I mean with longer courses, past discharge.”
Seyler reviewed results from studies that examined the effect of single vs. multiple doses of antibiotics and of short-term vs. extended antibiotic dosing in primary THA and TKA, including the much-cited study by R. Michael Meneghini, MD, and colleagues published in the Journal of Bone and Joint Surgery in 2018 and presented at the American Association of Hip and Knee Surgeons Annual Meeting.
He said the study had weaknesses, which do not justify applying its findings to current orthopedic practice. Seyler said, for example, the cohort was small and the researchers were not clear about who received antibiotics longer than 7 days or by IV administration.
“Practice changer? My vote, based on this study, do not do it. There is simply not enough evidence to go 7 days and give a patient oral antibiotics when you go ahead and discharge them from the hospital,” Seyler said.
Antibiotics may delay reinfection
There is a paucity of studies that address extended antibiotic use for one-stage THA and TKA, according to Jessica L. Seidelman, MD, MPH, an infectious disease physician at Duke University School of Medicine. Therefore, her presentation focused on antibiotic use for two-stage THA and TKA, which she said has reported success rates of 73% to 98% in studies published between 1995 and 2019.
“I think we still don’t have clear evidence that oral antibiotics decrease absolute risk of reinfection following one- or two-stage arthroplasty,” Seidelman said.
She discussed a recent randomized controlled trial conducted at seven centers that used per protocol analysis to compare 63 patients treated with antibiotics for 3 months to 70 controls who did not receive oral antibiotics postoperatively following two-stage arthroplasty for hip and knee prosthetic joint infection.
At a mean follow-up of about 3 years, nine infections recurred in the antibiotics group vs. 20 infections in the control group, Seidelman said.
The Kaplan-Meier graph of the results showed “there was a significant difference in infection-free survival in the group receiving oral antibiotics compared to those who did not,” she said, but noted about one-fifth of the reinfections in the treatment group occurred within the first 90 days or reimplantation.
“Oral antibiotics may still just be delaying the onset of reinfection. I think what we still do know is that oral antibiotics have significant side effects and do provide additional cost to patients,” Seidelman said.
Extended antibiotics, surgical site infection
Gregory J. Della Rocca, MD, PhD, FAAOS, FACS, an orthopedic surgeon at the University of Missouri, in Columbia, Missouri, discussed results of an international trauma trial — called the Flow study — that included 2,400 patients with extremity fractures.
“There was an association between extended antibiotic prophylaxis in surgical site infection and it differed by level of wound contamination,” Della Rocca said.
Patients received either greater than 72 hours of antibiotics or less than or equal to 72 hours of antibiotics postoperatively, and the primary outcomes was a surgical site infection within 12 months of surgery, he said.
“What we found was 12% of these had these surgical site infections,” Della Rocca said.
“Unadjusted logistic regression results demonstrated no association between surgical site infection and antibiotic duration. So, longer antibiotics did not seem to have any effect on surgical site infection,” he said.
However, Della Rocca, who was a study investigator, said the effect of the antibiotics differs based on the extent of the wound contamination. Investigators looked at the effect of antibiotics in fracture wounds in patients whose fractures had mild contamination or no to minimal contamination; moderate contamination with surface contamination that could readily be removed; and severe contamination, which encompassed fractures with “massive contamination with high risk due to environmental contamination.”
With mild contamination, they found “the odds ratio of developing surgical site infection was higher than that with moderate and also severely contaminated ones, also demonstrating a higher likelihood of surgical site infection with prolonged antibiotic administration,” he said.
Reference:
Inabathula A, et al. J Bone Joint Surg Am. 2018;doi:10.2106/JBJS.17.01485.
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