Prolonged antibiotics in orthopedic surgery may increase costs, but stem infection not

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August 09, 2020

3 minutes to read

Source / Disclosures

Source: Seyler T, et al. Symposium: Prolonged use of antibiotics for prophylaxis and treatment after orthopedic surgery. Presented at the annual meeting of the Musculoskeletal Infection Society; August 7-8, 2020 (virtual meeting).

Disclosures:
Della Rocca reports that he is a member of the board or committee of the American Academy of Orthopedic Surgeons, the American College of Surgeons, the American Orthopedic Association; is on the Editorial Board or on the Board of Directors of AOTrauma, Geriatric Orthopedic Surgery and Rehabilitation, and the Journal of Orthopedic Trauma; receives shares or stock options from Mergenet and The Orthopedic Implant Company; is a member of the board or committee of the Orthopedic Trauma Association; and receives intellectual property royalties from Wright Medical Technology. Seyler reports that he is receiving research support from the Foundation for Orthopedic Research and Education and the AAHKS for a single-dose versus multiple-dose trial of antibiotics. Seidelman does not report any relevant financial disclosure.

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It is only when good evidence demands it that orthopedic surgeons should change the way they use antibiotics for prophylaxis and treatment after surgery, symposium attendees said at the Musculoskeletal annual meeting. Infection Society.

At the meeting, which was held virtually, three presenters said that the rationale for surgeons to make such a change in the practice of total joint arthroplasty and trauma surgery may be to improve safety. their patients and alleviate the complications of antibiotic therapy, but prolonged use of antibiotics can increase the cost of surgical care.

Conference moderator Thorsten Mr. Seyler, MD, Doctorate, an orthopedic surgeon from Duke University School of Medicine in Durham, North Carolina, reviewed the latest clinical guidelines and evidence in the literature regarding the use of prolonged antibiotics in patients undergoing total hip replacement surgery and knee.

Thorsten M. Seyler

Thorsten Mr. Seyler

There is no evidence to support the use of oral antibiotics in primary THA and PTG beyond a single initial dose administered within one hour of surgical incision, a practice supported by the recommendations of 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 supports[s] longer courses, and I mean with longer courses, a past outing. “

Seyler reviewed the results of studies that examined the effect of single or multiple doses of antibiotics and short-term or prolonged doses of antibiotics in primary THA and PTG, 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 results to current orthopedic practice. Seyler said, for example, that the cohort was small and researchers were unclear who received antibiotics for more than 7 days or intravenously.

“Change of practice? My vote, based on this study, does not. There just isn’t enough evidence to go 7 days and give a patient oral antibiotics when you go ahead and leave the hospital, ”Seyler said.

Antibiotics can delay reinfection

There are few studies examining the prolonged use of antibiotics for one-stage THA and PTG, according to Jessica THE. Seidelman, MD, MPH, infectious disease physician at Duke University School of Medicine. Therefore, her presentation focused on the use of antibiotics for two-step PTH and PTG, which she said 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 the absolute risk of re-infection after one- or two-step arthroplasty,” Seidelman said.

She discussed a recent randomized controlled trial conducted at seven centers that used protocol analysis to compare 63 patients treated with antibiotics for 3 months to 70 controls who did not receive oral antibiotics after joint replacement. two-step treatment for hip and knee infection.

Jessica L. Seidelman

Jessica THE. Seidelman

At an average follow-up of about 3 years, nine infections recurred in the antibiotics group versus 20 infections in the control group, Seidelman said.

The Kaplan-Meier plot of the results showed “that 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 a fifth of re-infections in the treatment group. occurred within the first 90 days or reimplantation.

“Oral antibiotics can further delay the onset of reinfection. I think what we still know is that oral antibiotics have significant side effects and result in additional costs for patients, ”Seidelman said.

Prolonged antibiotics, surgical site infection

Gregory J. Della Rocca, MD, PhD, FAAOS, FACS, an orthopedic surgeon at the University of Missouri, Columbia, Missouri, discussed the results of an international trauma trial – called the Flow Study – which included 2,400 patients with extremity fractures.

“There was an association between prolonged antibiotic prophylaxis in surgical site infection and it differed depending on the level of contamination of the wound,” said Della Rocca.

Patients received more than 72 hours of antibiotics or less than 72 hours of antibiotics after the operation, and the main results were infection of the surgical site within 12 months of surgery, he said.

“What we found was that 12% of them had these surgical site infections,” said Della Rocca.

“The unadjusted logistic regression results showed no association between surgical site infection and antibiotic duration. Thus, longer antibiotics did not seem to have an effect on the surgical site infection, ”he said.

However, Della Rocca, who was a study researcher, said the effect of antibiotics differs depending on the extent of the contamination of the wound. Investigators looked at the effect of antibiotics on fracture wounds in patients whose fractures had little or no to minimal contamination; moderate contamination with surface contamination that could be easily removed; and severe contamination, which included fractures with “high risk massive contamination due to environmental contamination”.

With light contamination, they found that “the odds ratio of developing surgical site infection was higher than that of moderate and also severely contaminated infections, also demonstrating a higher probability of surgical site infection with prolonged administration. antibiotics, ”he said.

Reference:

Inabathula A, et al. J Bone Joint Surg Am. 2018; doi: 10.2106 / JBJS.17.01485.


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