Extended oral antibiotic prophylaxis may not reduce risk of PJI after TJA
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Key takeaways:
- Extended oral antibiotic prophylaxis did not reduce infection rates after hip or knee arthroplasty.
- Infection rates were similar between patients with vs. without prophylaxis at 90 days and 1 year.
Published results showed extended oral antibiotic prophylaxis was not associated with a reduced risk of periprosthetic joint infection at 90 days or 1 year among patients who underwent total hip or total knee arthroplasty.
Researchers from Vanderbilt University Medical Center performed a retrospective cohort study of 4,576 patients (mean age, 64 years) who underwent primary THA (n = 1,967) or TKA (n = 2,609) between Jan. 1, 2018, and Dec. 27, 2022.
Among the cohort, 1,769 patients received extended oral antibiotic prophylaxis consisting of 500 mg of cefadroxil twice daily for 10 days, while 2,807 received no extended oral antibiotic prophylaxis. The primary outcome measure was PJI at 90-day and 1-year follow-ups.
At 90 days, PJI rates were 1% and 0.8% for patients who received extended oral antibiotic prophylaxis vs. those who did not, respectively. Researchers deemed this difference insignificant. Similarly, rates of PJI were 1% for both cohorts at 1 year.
After subgroup analysis, researchers found no significant differences in PJI rates for high-risk patients who received extended oral antibiotic prophylaxis (0.8%, n = 254) vs. those who did not (2.3%, n = 396). Among patients who developed PJI at 90 days, researchers found no differences in incidence of Clostridium difficile infection or antibiotic resistance.
“While we did not identify increased antibiotic resistance or Clostridium difficile infection, we cannot recommend wide-spread adoption of extended oral antibiotic prophylaxis, and clarification regarding the role of extended oral antibiotics, even in high-risk patients, is needed,” the researchers wrote in the study.
Perspective
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The recent interest in extended oral antibiotic prophylaxis after total joint arthroplasty comes following the award-winning study by Michael M. Kheir, MD, and colleagues in 2021. From 2010 to 2022, utilization of extended oral antibiotics increased by 366% and 298% following primary and revision THA, respectively. Despite this enthusiasm, the use of extended oral antibiotic prophylaxis remains contentious within the arthroplasty community, with some surgeons challenging the efficacy of extended oral antibiotic prophylaxis in infection prevention and others suggesting increased antibiotic use puts patients at risk by selecting for potentially dangerous, antibiotic-resistant organisms. Proponents of this preventive measure qualify extended oral antibiotic prophylaxis should be limited to “high-risk” populations, such as patients with BMI greater than 35 kg/m2, diabetes, active smoking and antirheumatic medication use. This assertion has been, once again, challenged by Jade B. Flynn, PharmD, BCPS, and colleagues in their single-center, retrospective cohort study of 4,576 primary TJAs.
Given the substantial heterogeneity, underpowered analyses and lack of randomized studies in modern literature, it is clear that no concrete recommendations can be made and the standard of care remains unchanged. In addition to higher-quality studies, it is my opinion that future research should ideally account for newfound interactions between the infecting microorganisms and the host genetic makeup, as well as host microbiome, as our concept of what constitutes a “high-risk” cohort needs to be better defined beyond simply medical comorbidities. It is plausible that extended oral antibiotic prophylaxis should be reserved for a stringent subset of patients wherein the benefits of extended oral antibiotic prophylaxis outweigh the risks to the patient and the society at large.
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