Extended Oral Antibiotic Prophylaxis in High-Risk Patients Substantially Reduces Primary Total Hip and Knee Arthroplasty 90-Day Infection Rate

Abstract

Background: Total joint arthroplasty (TJA) episodic payment models shift risk and cost of periprosthetic joint infection (PJI) to surgeons and hospitals, causing some to avoid treating high-risk patients. Furthermore, there are little data to support optimization of host factors preoperatively to decrease PJI, and recent literature supports using extended antibiotic prophylaxis following reimplantation TJA. The purpose of this study was to evaluate whether extended oral antibiotic prophylaxis minimized PJI after primary TJA in high-risk patients. Methods: A retrospective cohort study was performed of 2,181 primary total knee arthroplasties (TKAs) and primary total hip arthroplasties (THAs) carried out from 2011 through 2016 at a suburban academic hospital with modern perioperative and infection-prevention protocols. Beginning in January 2015, extended oral antibiotic prophylaxis for 7 days after discharge was implemented for patients at high risk for PJI. The percentages of patients diagnosed with PJI within 90 days were identified and compared between groups that did and did not receive extended oral antibiotic prophylaxis, with p ≤ 0.05 indicating significance. Results: The 90-day infection rates were 1.0% and 2.2% after the TKAs and THAs, respectively. High-risk patients without extended antibiotic prophylaxis were 4.9 (p = 0.009) and 4.0 (p = 0.037) times more likely to develop PJI after TKA and THA, respectively, than high-risk patients with extended antibiotic prophylaxis. Conclusions: Extended postoperative antibiotic prophylaxis led to a statistically significant and clinically meaningful reduction in the 90-day infection rate of selected patients at high risk for infection. We encourage further study and deliberation prior to adoption of a protocol involving extended oral antibiotic prophylaxis after high-risk TJA, with the benefits weighed appropriately against potential adverse consequences such as increasing the development of antimicrobial resistance. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Investigation of synovial fluid induced Staphylococcus aureus aggregate development and its impact on surface attachment and biofilm formation

“…We have previously reported that bacterial aggregates are present during periprosthetic joint infection [11]. Nearly 50% of S. aureus PJI infections exhibit antibiotic tolerance, and the development of S. aureus aggregates enhances tolerance towards antibiotics and the host immune system [6,12,23,24,[39][40][41]. Herein, we utilized a novel method for precise quantification of synovial fluid induced aggregation using flow cytometry (Figs 1-3).…”

New developments and future challenges in prevention, diagnosis, and treatment of prosthetic joint infection

“…Inabathula et al 59 published a retrospective cohort study comparing an extended oral antibiotic protocol for 7 days to standard perioperative antibiotic administration following elective TJA in groups of patients with high‐risk comorbidities. They found significantly reduced rates of PJI using this protocol with a 1% infection rate in the extended antibiotic group vs 2.2% in the perioperative administered group alone 59 . While this is promising data, others have been critical of the methodology, and the potential global health impact of widespread adoption of these protocols need to be balanced with maintaining appropriate antibiotic stewardship 60 …”

Contemporary Strategies to Prevent Infection in Hip and Knee Arthroplasty

“…In a retrospective cohort study examining 2181 arthroplasties, Inabathula et al [33] investigated whether extended oral antibiotic prophylaxis reduced PJI in high-risk patients. Classification as high risk was determined at a coordinated care conference based on factors including BMI > 35, diabetes, smoking, chronic renal failure, autoimmune disease and colonization with MRSA.…”