Antimicrobial Stewardship in Total Joint Arthroplasty: Outcomes of a Collaborative Program Implementation

Abstract

Introduction: Antimicrobial stewardship has been cited as a crucial component of orthopaedic surgical care; however, limited high-quality data exist to guide antibiotic use across the total joint arthroplasty continuum. Antimicrobial stewardship program (ASP) implementation and evaluation is needed in this space. Methods: We pursued a prospective, sequential cohort study of an interprofessional ASP for total joint arthroplasty (TJA) formed in late 2017 at the study institution. Twelve total evidence-based recommendations for protocol change were issued, with 11 accepted and implemented across three project phases spanning March 2018 to December 2019. The primary study outcome was the rate of optimal preoperative intravenous antibiotic selection as assessed for Baseline versus Postintervention time periods. Secondary outcomes included individual antibiotic utilization rates. Descriptive statistics were pursued for institutional surgical site infection (SSI) and postoperative acute kidney injury (AKI) rates across the affected time frame. A cost-benefit analysis of the ASP was estimated from the institutional perspective. Results: The rate of optimal preoperative antibiotic selection increased from 64.9% in the Baseline Period (February 2018, n = 57) to 95.4% in the Postimplementation period (June 2018 to December 2019, n = 1,220) (P , 0.001). The rates of second-line preoperative antibiotics and total perioperative antibiotic exposures decreased. Total SSI and AKI rates in primary elective TJA seemed to decrease from calendar year 2018 to 2019 (deep SSI 1.00% to 0.22%, superficial SSI 0.66% to 0.00%, and AKI 1.97% to 1.03%). The institution realized an estimated $197,050 cost savings per 1000 TJA procedures. Discussion: A comprehensive ASP for TJA was associated with an increased use of optimal preoperative antibiotic selection, decreased total antibiotic exposures, and cost savings, without apparent detriment to SSI or AKI rates.

Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews

“…Pharmacists attached to various surgical services have provided consultation to anesthesiologists at the service and individual patient levels regarding local anesthetic systemic toxicity (LAST) and enhanced recovery analgesic/anesthetic pathways (in light of the recent move toward increased local anesthetic use to reduce opioid exposure) as well as evolving surgical techniques. Collaboration with surgeons has often focused on risk assessments and treatment recommendations for preoperative and pharmacokinetic-based antimicrobial optimization [ 157 ], VTE and PONV prophylaxis [ 144 , 147 ], postoperative pain management, POI mitigation, and electrolyte replacement and nutrition support, including glycemic control [ 158 ]. In one 20-month pre-/post-study in which clinical pharmacists were directly involved, pre-implementation colonic SSIs were reduced from 10% to 2%, VTE rate decreased from 0.6% to 0%, and postoperative readmission rate decreased from 4.8% to 1.3% [ 111 ].…”

Performance and Hypothetical Impact on Joint Infection Management of the BioFire Joint Infection Panel: a Retrospective Analysis

“…Therefore, as is evident for other syndromic testing strategies using multiplex molecular assays, introduction of the BJA demands strict structuring of the whole diagnostic process. To this end, dedicated antimicrobial stewardship programs for bone and joint infection are of great value ( 27 – 30 ).…”