Abstract
Total knee arthroplasty (TKA) is one of the most frequent and successful procedures performed in orthopedic surgery. Despite its safety, complications are still present. Infection is one of the more devastating complications in TKA as it places a significant burden on patients, surgeons, and health systems. Surgical site infection in non-contaminated surgery still affects 2–5% of patients. These data highlight the importance of prophylactic measures in preventing infection following TKA. The key point on choosing antibiotic prophylaxis is the spectrum of action and the penetration into the bone and periarticular tissues. Antibiotics should cover the most frequent microorganisms causing postoperative infection. It should achieve a high enough concentration (at least the minimum inhibitory concentration) in the serum and bone and maintain this over time. For standard antibiotic prophylaxis, drug administration should be done during the hour before incision. Cephalosporins are the most widely used antibiotics for periprosthetic joint infection prophylaxis during the last decades in the USA and Europe. They are effective against gram-positive organisms, aerobic gram-negative bacilli, and anaerobes. Despite the great advantages, cefazolin (1–3 g depending on body weight every 2–5 h) is not effective against methicillin-resistant Staphylococcus aureus (MRSA). For this, increased prevalence of MRSA should be taken into account to decide if cefazolin is the best option. However, clindamycin (90 mg every 3–6 h) and vancomycin (15/kg every 6–12 h) are appropriate options when cephalosporins are contraindicated (i.e., allergy) or when risk factors for antibiotic-resistant organism are present.
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References
Bosco JA, Bookman J, Slover J, Edusei E, Levine B. Principles of antibiotic prophylaxis in total joint arthroplasty: current concepts. J Am Acad Orthop Surg. 2015;23:e27–35.
Anderson DJ, Sexton DJ, Kanafani ZA, Auten G, Kaye KS. Severe surgical site infection in community hospitals: epidemiology, key procedures, and the changing prevalence of methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol. 2007;28:1047–53.
Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplast. 2012;27(8 Suppl):61–65.e1.
Prokuski L. Prophylactic antibiotics in orthopaedic surgery. J Am Acad Orthop Surg. 2008;16:283–93.
Illingworth KD, Mihalko WM, Parvizi J, Sculco T, McArthur B, el Bitar Y, et al. 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.
Lamagni T. Epidemiology and burden of prosthetic joint infections. J Antimicrob Chemother. 2014;69(Suppl 1):5–10.
Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect. 2013;14:73–156.
Meehan J, Jamali AA, Nguyen H. Prophylactic antibiotics in hip and knee arthroplasty. J Bone Joint Surg Am. 2009;91:2480–90.
Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70:195–283.
Burke JF. The effective period of preventive antibiotic action in experimental incisions and dermal lesions. Surgery. 1961;50:161–8.
Tachdjian MO, Compere EL. Postoperative wound infections in orthopedic surgery; evaluation of prophylactic antibiotics. J Int Coll Surg. 1957;28(6 Pt 1):797–805.
Fogelberg EV, Zitzmann EK, Stinchfield FE. Prophylactic penicillin in orthopaedic surgery. J Bone Joint Surg Am. 1970;52:95–8.
Peel TN, Cheng AC, Buising KL, Choong PFM. Microbiological aetiology, epidemiology, and clinical profile of prosthetic joint infections: are current antibiotic prophylaxis guidelines effective? Antimicrob Agents Chemother. 2012;56:2386–91.
Ritter MA. Operating room environment. Clin Orthop Relat Res. 1999;369:103–9.
Rao N, Cannella B, Crossett LS, Yates AJ, McGough R. A preoperative decolonization protocol for Staphylococcus aureus prevents orthopaedic infections. Clin Orthop Relat Res. 2008;466:1343–8.
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;97:1449–158.
Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms: a common cause of persistent infections. Science. 1999;284:1318–22.
Costerton JW. Biofilm theory can guide the treatment of device-related orthopaedic infections. Clin Orthop Relat Res. 2005;437:7–11.
Zimmerli W, Moser C. Pathogenesis and treatment concepts of orthopaedic biofilm infections. FEMS Immunol Med Microbiol. 2012;65:158–68.
Septimus EJ, Schweizer ML. Decolonization in prevention of health care-associated infections. Clin Microbiol Rev. 2016;29:201–22.
Voigt J, Mosier M, Darouiche R. Antibiotics and antiseptics for preventing infection in people receiving revision total hip and knee prostheses: a systematic review of randomized controlled trials. BMC Infect Dis. 2016;16:749.
Schulz LT, Fox BC, Polk RE. Can the antibiogram be used to assess microbiologic outcomes after antimicrobial stewardship interventions? A critical review of the literature. Pharmacotherapy. 2012;32:668–76.
Campbell KA, Stein S, Looze C, Bosco JA. Antibiotic stewardship in orthopaedic surgery: principles and practice. J Am Acad Orthop Surg. 2014;22:772–81.
Parvizi J, Gehrke T, Chen AF. Proceedings of the International Consensus on Periprosthetic Joint Infection. Bone Joint J. 2013;95-B(11):1450–2.
Parvizi J, Pawasarat IM, Azzam KA, Joshi A, Hansen EN, Bozic KJ. Periprosthetic joint infection: the economic impact of methicillin-resistant infections. J Arthroplast. 2010;25(6 Suppl):103–7.
Sewick A, Makani A, Wu C, O’Donnell J, Baldwin KD, Lee G-C. Does dual antibiotic prophylaxis better prevent surgical site infections in total joint arthroplasty? Clin Orthop Relat Res. 2012;470:2702–7.
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 Arthroplast. 2010;25:1078–82.
Angthong C, Krajubngern P, Tiyapongpattana W, Pongcharoen B, Pinsornsak P, Tammachote N, et al. Intraosseous concentration and inhibitory effect of different intravenous cefazolin doses used in preoperative prophylaxis of total knee arthroplasty. J Orthop Traumatol. 2015;16:331–4.
Ravi S, Zhu M, Luey C, Young SW. Antibiotic resistance in early periprosthetic joint infection. ANZ J Surg. 2016;86:1014–8.
Eshkenazi AU, Garti A, Tamir L, Hendel D. Serum and synovial vancomycin concentrations following prophylactic administration in knee arthroplasty. Am J Knee Surg. 2001;14:221–3.
Bryson DJ, Morris DLJ, Shivji FS, Rollins KR, Snape S, Ollivere BJ. Antibiotic prophylaxis in orthopaedic surgery: difficult decisions in an era of evolving antibiotic resistance. Bone Joint J. 2016;98-B:1014–9.
Lazzarini L, Novelli A, Marzano N, Timillero L, Fallani S, Viola R, et al. Regional and systemic prophylaxis with teicoplanin in total knee arthroplasty: a tissue penetration study. J Arthroplast. 2003;18:342–6.
Asensio A, Alvarez-Espejo T, Fernandez-Crehuet J, Ramos A, Vaque-Rafart J, Bishopberger C, et al. Trends in yearly prevalence of third-generation cephalosporin and fluoroquinolone resistant Enterobacteriaceae infections and antimicrobial use in Spanish hospitals, Spain, 1999 to 2010. Euro Surveill. 2011;16(40):12–20.
Bannister GC, Auchincloss JM, Johnson DP, Newman JH. The timing of tourniquet application in relation to prophylactic antibiotic administration. J Bone Joint Surg Br. 1988;70:322–4.
Steinberg JP, Braun BI, Hellinger WC, Kusek L, Bozikis MR, Bush AJ, et al. Timing of antimicrobial prophylaxis and the risk of surgical site infections: results from the trial to reduce antimicrobial prophylaxis errors. Ann Surg. 2009;250:10–6.
Soriano A, Bori G, García-Ramiro S, Martinez-Pastor JC, Miana T, Codina C, et al. Timing of antibiotic prophylaxis for primary total knee arthroplasty performed during ischemia. Clin Infect Dis. 2008;46:1009–14.
Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992;326:281–6.
Catanzano A, Phillips M, Dubrovskaya Y, Hutzler L, Bosco J. The standard one gram dose of vancomycin is not adequate prophylaxis for MRSA. Iowa Orthop J. 2014;34:111–7.
Swoboda SM, Merz C, Kostuik J, Trentler B, Lipsett PA. Does intraoperative blood loss affect antibiotic serum and tissue concentrations? Arch Surg. 1996;131:1165–71, discussion 1171–2.
Zelenitsky SA, Ariano RE, Harding GKM, Silverman RE. Antibiotic pharmacodynamics in surgical prophylaxis: an association between intraoperative antibiotic concentrations and efficacy. Antimicrob Agents Chemother. 2002;46:3026–30.
Wymenga AB, Hekster YA, Theeuwes A, Muytjens HL, van Horn JR, Slooff TJ. Antibiotic use after cefuroxime prophylaxis in hip and knee joint replacement. Clin Pharmacol Ther. 1991;50:215–20.
Williams DN, Gustilo RB. The use of preventive antibiotics in orthopaedic surgery. Clin Orthop Relat Res. 1984;190:83–8.
Mauerhan DR, Nelson CL, Smith DL, Fitzgerald RH, Slama TG, Petty RW, et al. Prophylaxis against infection in total joint arthroplasty. One day of cefuroxime compared with three days of cefazolin. J Bone Joint Surg Am. 1994;76:39–45.
Campbell R, Dean B, Nathanson B, Haidar T, Strauss M, Thomas S. Length of stay and hospital costs among high-risk patients with hospital-origin Clostridium difficile-associated diarrhea. J Med Econ. 2013;16:440–8.
Tokarski AT, Karam JA, Zmistowski B, Deirmengian CA, Deirmengian GK. Clostridium difficile is common in patients with postoperative diarrhea after hip and knee arthroplasty. J Arthroplast. 2014;29:1110–3.
Magee G, Strauss ME, Thomas SM, Brown H, Baumer D, Broderick KC. Impact of Clostridium difficile-associated diarrhea on acute care length of stay, hospital costs, and readmission: a multicenter retrospective study of inpatients, 2009–2011. Am J Infect Control. 2015;43:1148–53.
Drozd EM, Inocencio TJ, Braithwaite S, Jagun D, Shah H, Quon NC, et al. Mortality, hospital costs, payments, and readmissions associated with Clostridium difficile infection among Medicare beneficiaries. Infect Dis Clin Pract (Baltim Md). 2015;23:318–23.
Pitt HA, Postier RG, MacGowan AW, Frank LW, Surmak AJ, Sitzman JV, et al. Prophylactic antibiotics in vascular surgery. Topical, systemic, or both? Ann Surg. 1980;192:356–64.
Bode LGM, Kluytmans JAJW, Wertheim HFL, Bogaers D, Vandenbroucke-Grauls CMJE, Roosendaal R, et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med. 2010;362:9–17.
Kalmeijer MD, van Nieuwland-Bollen E, Bogaers-Hofman D, de Baere GA. Nasal carriage of Staphylococcus aureus is a major risk factor for surgical-site infections in orthopedic surgery. Infect Control Hosp Epidemiol. 2000;21:319–23.
Skråmm I, Fossum Moen AE, Årøen A, Bukholm G. Surgical site infections in orthopaedic surgery demonstrate clones similar to those in orthopaedic Staphylococcus aureus nasal carriers. J Bone Joint Surg Am. 2014;96:882–8.
Kim DH, Spencer M, Davidson SM, Li L, Shaw JD, Gulczynski D, et al. Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am. 2010;92:1820–6.
Hadley S, Immerman I, Hutzler L, Slover J, Bosco J. Staphylococcus aureus decolonization protocol decreases surgical site infections for total joint replacement. Arthritis. 2010;2010:924518.
Mulcahy ME, Geoghegan JA, Monk IR, O’Keeffe KM, Walsh EJ, Foster TJ, et al. Nasal colonisation by Staphylococcus aureus depends upon clumping factor B binding to the squamous epithelial cell envelope protein loricrin. PLoS Pathog. 2012;8:e1003092.
Wassenberg MWM, Kluytmans JA, Bosboom RW, Buiting AGM, van Elzakker EPM, Melchers WJG, et al. Rapid diagnostic testing of methicillin-resistant Staphylococcus aureus carriage at different anatomical sites: costs and benefits of less extensive screening regimens. Clin Microbiol Infect. 2011;17:1704–10.
Hacek DM, Robb WJ, Paule SM, Kudrna JC, Stamos VP, Peterson LR. Staphylococcus aureus nasal decolonization in joint replacement surgery reduces infection. Clin Orthop Relat Res. 2008;466:1349–55.
Courville XF, Tomek IM, Kirkland KB, Birhle M, Kantor SR, Finlayson SRG. Cost-effectiveness of preoperative nasal mupirocin treatment in preventing surgical site infection in patients undergoing total hip and knee arthroplasty: a cost-effectiveness analysis. Infect Control Hosp Epidemiol. 2012;33:152–9.
Slover J, Haas JP, Quirno M, Phillips MS, Bosco JA. Cost-effectiveness of a Staphylococcus aureus screening and decolonization program for high-risk orthopedic patients. J Arthroplast. 2011;26:360–5.
Shrestha NK, Shermock KM, Gordon SM, Tuohy MJ, Wilson DA, Cwynar RE, et al. Predictive value and cost-effectiveness analysis of a rapid polymerase chain reaction for preoperative detection of nasal carriage of Staphylococcus aureus. Infect Control Hosp Epidemiol. 2003;24:327–33.
Lauderdale T-LY, Wang J-T, Lee W-S, Huang J-H, McDonald LC, Huang I-W, et al. Carriage rates of methicillin-resistant Staphylococcus aureus (MRSA) depend on anatomic location, the number of sites cultured, culture methods, and the distribution of clonotypes. Eur J Clin Microbiol Infect Dis. 2010;29:1553–9.
Luteijn JM, Hubben GA, Pechlivanoglou P, Bonten MJ, Postma MJ. Diagnostic accuracy of culture-based and PCR-based detection tests for methicillin-resistant Staphylococcus aureus: a meta-analysis. Clin Microbiol Infect. 2011;17:146–54.
Perl TM. Prevention of Staphylococcus aureus infections among surgical patients: beyond traditional perioperative prophylaxis. Surgery. 2003;134(5 Suppl):S10–7.
Kalmeijer MD, Coertjens H, van Nieuwland-Bollen PM, Bogaers-Hofman D, de Baere GJ, Stuurman A, et al. Surgical site infections in orthopedic surgery: the effect of mupirocin nasal ointment in a double-blind, randomized, placebo-controlled study. Clin Infect Dis. 2002;35:353–8.
Poovelikunnel T, Gethin G, Humphreys H. Mupirocin resistance: clinical implications and potential alternatives for the eradication of MRSA. J Antimicrob Chemother. 2015;70:2681–92.
Caffrey AR, Quilliam BJ, LaPlante KL. Risk factors associated with mupirocin resistance in methicillin-resistant Staphylococcus aureus. J Hosp Infect. 2010;76:206–10.
Anderson MJ, David ML, Scholz M, Bull SJ, Morse D, Hulse-Stevens M, et al. Efficacy of skin and nasal povidone-iodine preparation against mupirocin-resistant methicillin-resistant Staphylococcus aureus and S. aureus within the anterior nares. Antimicrob Agents Chemother. 2015;59:2765–73.
McConeghy KW, Mikolich DJ, LaPlante KL. Agents for the decolonization of methicillin-resistant Staphylococcus aureus. Pharmacotherapy. 2009;29:263–80.
Hill RL, Casewell MW. The in-vitro activity of povidone-iodine cream against Staphylococcus aureus and its bioavailability in nasal secretions. J Hosp Infect. 2000;45:198–205.
Kapadia BH, Johnson AJ, Daley JA, Issa K, Mont MA. Pre-admission cutaneous chlorhexidine preparation reduces surgical site infections in total hip arthroplasty. J Arthroplast. 2013;28:490–3.
Immerman I, Ramos NL, Katz GM, Hutzler LH, Phillips MS, Bosco JA. The persistence of Staphylococcus aureus decolonization after mupirocin and topical chlorhexidine: implications for patients requiring multiple or delayed procedures. J Arthroplast. 2012;27:870–6.
Hinarejos P, Guirro P, Puig-Verdie L, Torres-Claramunt R, Leal-Blanquet J, Sanchez-Soler J, et al. Use of antibiotic-loaded cement in total knee arthroplasty. World J Orthop. 2015;6:877–85.
Joseph TN, Chen AL, Di Cesare PE. Use of antibiotic-impregnated cement in total joint arthroplasty. J Am Acad Orthop Surg. 2003;11:38–47.
van Kasteren MEE, Manniën J, Ott A, Kullberg B-J, de Boer AS, Gyssens IC. Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor. Clin Infect Dis. 2007;44:921–7.
Arora M, Chan EK, Gupta S, Diwan AD. Polymethylmethacrylate bone cements and additives: a review of the literature. World J Orthop. 2013;4:67–74.
Penner MJ, Masri BA, Duncan CP. Elution characteristics of vancomycin and tobramycin combined in acrylic bone-cement. J Arthroplast. 1996;11:939–44.
Lautenschlager EP, Jacobs JJ, Marshall GW, Meyer PR. Mechanical properties of bone cements containing large doses of antibiotic powders. J Biomed Mater Res. 1976;10:929–38.
Awad SS, Palacio CH, Subramanian A, Byers PA, Abraham P, Lewis DA, et al. Implementation of a methicillin-resistant Staphylococcus aureus (MRSA) prevention bundle results in decreased MRSA surgical site infections. Am J Surg. 2009;198:607–10.
Mohd Fuad D, Masbah O, Shahril Y, Jamari S, Norhamdan MY, Sahrim SH. Biomechanical properties of bone cement with addition of cefuroxime antibiotic. Med J Malaysia. 2006;61(Suppl A):27–9.
Jiranek WA, Hanssen AD, Greenwald AS. Antibiotic-loaded bone cement for infection prophylaxis in total joint replacement. J Bone Joint Surg Am. 2006;88:2487–500.
Lewis G, Janna S, Bhattaram A. Influence of the method of blending an antibiotic powder with an acrylic bone cement powder on physical, mechanical, and thermal properties of the cured cement. Biomaterials. 2005;26:4317–25.
Bohm E, Zhu N, Gu J, de Guia N, Linton C, Anderson T, et al. Does adding antibiotics to cement reduce the need for early revision in total knee arthroplasty? Clin Orthop Relat Res. 2014;472:162–8.
Gutowski CJ, Zmistowski BM, Clyde CT, Parvizi J. The economics of using prophylactic antibiotic-loaded bone cement in total knee replacement. Bone Joint J. 2014;96-B:65–9.
Campbell KA, Phillips MS, Stachel A, Bosco JA, Mehta SA. Incidence and risk factors for hospital-acquired Clostridium difficile infection among inpatients in an orthopaedic tertiary care hospital. J Hosp Infect. 2013;83:146–9.
Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31:431–55.
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Vaquero-Picado, A., Rodríguez-Merchán, E.C. (2018). Antibiotic Prophylaxis to Prevent Infection in Total Knee Arthroplasty. In: Rodríguez-Merchán, E., Oussedik, S. (eds) The Infected Total Knee Arthroplasty. Springer, Cham. https://doi.org/10.1007/978-3-319-66730-0_5
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