Where Are We Now?
Deep prosthetic joint infections (PJI) following total joint arthroplasty (TJA) can be catastrophic. Timely administration of intravenous antibiotics prior to surgical incision is one of the most effective strategies to prevention of postoperative infections [6]. Currently, first- or second-generation cephalosporins are recommended for prophylaxis prior to routine THA and TKA [1]. However, in recent years, changes in patient demographics and increasing prevalence of resistant organisms in patients undergoing lower-extremity arthroplasty have raised the question of whether current recommendations are adequate. Combination therapies including the routine addition of vancomycin to the prophylactic antimicrobial regimen have shown only comparable efficacy to monotherapy in some studies, while increasing the risk of acute kidney injury in others [3, 8]. Furthermore, decolonization protocols have also been shown to be variable in terms of compliance and efficacy [10]. Therefore, the question remains: What is the correct approach to antibiotic prophylaxis prior to hip or knee replacement?
In this article, Tan et al. present an interesting study on the use of vancomycin alone for prophylaxis in patients with penicillin allergies undergoing TJA. The authors found that administration of vancomycin alone did not increase the rate of deep surgical site infections, but decreased the risk for infections with Gram-positive organisms and antibiotic resistant organisms.
Where Do We Need To Go?
This work adds valuable information, but a number of questions remain. It would be important to validate these findings in other centers, and in prospective studies that permit tighter standardization of clinical practices. Of course, the endpoint we are most interested in—deep infection—requires much larger (and almost certainly multicenter) studies.
The allure of widespread utilization of vancomycin as an effective agent to prevent infections with resistant organisms must be tempered by the potential risks, including renal toxicity, ototoxicity, and antimicrobial resistance. However, this is a common clinical scenario that not only affects arthroplasty surgeons, but all orthopaedic surgeons. Even though cross-reactivity and true anaphylaxis resulting from cephalosporin administration is only approximately 10% [2], most surgeons opt for antibiotic alternatives rather than “test-dosing” the patient under anesthesia to determine the presence or absence of true allergy. Vancomycin and clindamycin are commonly used alternatives in these situations, but concerns remain with regards to the efficacy of clindamycin and coverage of vancomycin as stand-alone agents [9]. Other studies have shown an increased risk of infections when only vancomycin is administered for routine prophylaxis [7]. Consequently, larger, prospective studies taking into account host factors, local antibiograms, and clinical practices such as decolonization protocols will be needed to definitively define the indications and efficacy for various antibiotic prophylactic protocols surrounding TJA.
How Do We Get There?
Many factors contribute to the risk of surgical site infections, and so to study the impact of antibiotics on infection properly, a multidisciplinary approach is called for. First, standardization of definitions and clinical practices will allow us to collaborate to find an answer to this problem without introducing confounding variables and bias. Today, there are established criteria for the work-up and diagnosis for infected TJA as well as clinical practice guidelines for the management of the infected TJA [5]. Second, a creation and contribution of surgical site infection and PJI data to various local and national registries will allow surveillance at a population level and the development of protocols based on specific antibiograms. Finally, and perhaps most challenging, is the need to define the “optimized” candidate for joint arthroplasty. Conditions such as diabetes, chronic kidney disease, obesity, and malnutrition have been shown to place patients at increased risk for development of infections postoperatively [4]. We need more studies that specifically ascertain at what point we should consider those sorts of conditions “well enough” managed that it is clinically reasonable to proceed with elective arthroplasty. Because of the increased risk, those studies also should help us to determine whether these higher-risk patients should be treated with different antibiotic approaches than low-risk patients?
Identifying the correct antibiotic prophylaxis protocols can have profound and wide-reaching impact. The cost to prevent a single patient’s infection must be counterbalanced against the risks in that patient of adverse effects, but also against societal costs, such as the development of antibiotic-resistant organisms. Orthopaedic surgeons, will be at the forefront of this dilemma and must play a part in practicing good, evidence-based, antibiotic stewardship.
References
American Academy of Orthopaedic Surgeons. Recommendations for the use of intravenous antibiotic prophylaxis information statement. Available at: http://www.aaos.org/about/papers/advistmt/1027.asp. Accessed September 12, 2015.
Audicana M, Bernaola G, Urrutia I, Echechipia S, Gastaminza G, Muñoz D, Fernández E, Fernández de Corres L. Allergic reactions to betalactams: Studies in a group of patients allergic to penicillin and evaluation of cross-reactivity with cephalosporin. Allergy. 1994;49:108–113.
Courtney PM, Melnic CM, Zimmer Z, Anari J, Lee GC. Addition of vancomycin to cefazolin prophylaxis is associated with acute kidney injury after primary joint arthroplasty. Clin Orthop Relat Res. 2015;473:2197–2203.
Eka A, Chen AF. Patient-related medical risk factors for periprosthetic joint infection of the hip and knee. Ann Transl Med. 2015;3:233.
Frank RM, Cross MB, Della Valle CJ. Periprosthetic joint infection: Modern aspects of prevention, diagnosis, and treatment. J Knee Surg. 2015;28:105–112.
Illingworth KD, Mihalko WM, Parvizi J, Sculco T, McArthur B, el Bitar Y, Saleh KJ. How to minimize infection and thereby maximize patient outcomes in total joint arthroplasty: A multicenter approach: AAOS exhibit selection. J Bone Joint Surg Am. 2013;95:e50.
Ponce B, Raines BT, Reed RD, Vick C, Richman J, Hawn M. Surgical site infection after arthroplasty: Comparative effectiveness of prophylactic antibiotics: do surgical care improvement project guidelines need to be updated? J Bone Joint Surg Am. 2014;96:970–977.
Sewick A, Makani A, Wu C, O’Donnell J, Baldwin KD, Lee GC. Does dual antibiotic prophylaxis better prevent surgical site infections in total joint arthroplasty? Clin Orthop Relat Res. 2012;470:2702–2707.
Tyllianakis ME, Karageorgos AC, Marangos MN, Saridis AG, Lambiris EE. Antibiotic prophylaxis in primary hip and knee arthroplasty: Comparison between cefuroxime and two specific antistaphylococcal agents. J Arthroplasty. 2010;25:1078–1082.
Weiser MC, Moucha CS. The current state of screening and decolonization for the prevention of staphylococcus aureus surgical site infection after total hip and knee arthroplasty. J Bone Joint Surg Am. 2015;97:1449–1458.
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This CORR Insights® is a commentary on the article “Is Vancomycin-only Prophylaxis for Patients With Penicillin Allergy Associated With Increased Risk of Infection After Arthroplasty?” by Tan and colleagues available at: DOI: 10.1007/s11999-015-4672-4.
The author certifies that he, or any member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.
The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR ® or The Association of Bone and Joint Surgeons®.
This CORR Insights® comment refers to the article available at DOI: 10.1007/s11999-015-4672-4.
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Lee, GC. CORR Insights®: Is Vancomycin-only Prophylaxis for Patients With Penicillin Allergy Associated With Increased Risk of Infection After Arthroplasty?. Clin Orthop Relat Res 474, 1607–1609 (2016). https://doi.org/10.1007/s11999-016-4690-x
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DOI: https://doi.org/10.1007/s11999-016-4690-x