Preoperative optimization, perioperative antibiotics may prevent infection after TJR
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Preoperative optimization of patients and perioperative antibiotic use may prevent infection after total joint replacement, according to a presenter here.
Surgeons should maintain and manage a patient’s glycemic control in the perioperative period to reduce a patient’s risk of infection, regardless of whether they have diabetes or not, according to Bryan D. Springer, MD. Although hemoglobin A1c is most commonly used as a marker of glucose control, Springer noted it takes 3 months to change hemoglobin A1c, whereas it takes 2 to 3 weeks to change serum fructosamine.
“If I have a patient that has a hemoglobin A1c above 8% and we do not want to delay their surgery 3 months, we’ll put them on a strict regimen for 4 to 6 weeks and then we’ll check a serum fructosamine,” Springer said during his presentation at the Current Concepts in Joint Replacement Winter Meeting. “If it’s less than 293 [µmol/mL], oftentimes we will proceed with surgery.”
Among patients who are obese, Springer noted a reasonable attempt should be made to optimize the patient’s weight. However, if the patient’s weight cannot be optimized, he said surgeons should “factor in the overall assessment of the patient’s health and decide whether or not to proceed on an individual patient on that basis.”
Malnutrition can be identified by a serum albumin level less than 3.5 g/dL, and patients who smoke should quit smoking around 4 to 8 weeks prior to surgery to start to normalize metabolic and immune function, according to Springer. Since vitamin D plays an important role in immune system modulation, Springer noted patients with vitamin D levels less than 10 ng/mL should be sent to an endocrinologist for optimization. He added surgeons have two pathways to screen for MRSA and methicillin-susceptible Staphylococcus aureus.
“Universal screening. So, test everybody, selectively decolonize those that are positive. The benefit of that is you identify who’s positive, you can give them vancomycin,” Springer said. “Logistically, it’s easier just to universally decolonize everybody and just selectively give vancomycin plus Ancef (cefazolin, GlaxoSmithKline) to the high-risk patients.”
For perioperative antibiotics, Springer noted cephalosporin remains the antibiotic of choice due to is cost effectiveness, rapid tissue and bone penetration and gram positive and gram negative coverage. He added routine use of vancomycin remains controversial and does not provide gram negative coverage, so should be reserved for patients who are MRSA positive or those with cephalosporin allergies.
“Penicillin allergic patients are rare, and I think it is important you either screen for them with allergy testing, test dosing or develop an algorithm,” Springer said.
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Springer BD. Preventing infection in 2021: What to do...what not to do. Presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 8-11, 2021; Orlando (hybrid meeting).
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