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Antibiotic Prophylaxis for Elective Hip and Knee Prosthetic Joint

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Antibiotic Prophylaxis for Elective Hip and Knee Prosthetic Joint Powered By Docstoc
					Antibiotic Prophylaxis for Joint
         Replacement
   Do the benefits outweigh the risks?

         Vincent C. Schooler, MD
            January 29, 2003
                   Clinical Case

•   54 yo WM with HTN, osteoarthritis, morbid
    obesity, hx. of CVA and MI

•   Chronic knee pain

•   Elective bilateral knee replacement
Case cont.

•   Cefazolin 1g IV Q 8 hours with first dose within 2
    hours of surgery
•   18 g total given over the next 10 days due to LLE erythema
•   Abx. changed to Cephalexin

•   Fever QD

•   Hosp. course complicated by ATN, acute CVA
                Clinical Questions

•   Evidence for Prophylaxis?

•   Recommended Antibiotic and Dosing Interval?

•   When to start?

•   When to stop?

•   Risks of Prophylaxis?
                                          Evidence
•    44 % Reduction of postop infection after hip fx. repair
•    239 pts in RCT*
       • 124 pts.: 2 doses of cephalosporin
      • 115 pts.: placebo
•    First dose at induction of anesthesia and second dose 12 hours later
      Infection Type                          Antibiotic                            Placebo
                                              (p < 0.05)                           (p < 0.05)
            Major                                 1                                    5
    (Positive Cx, purulence)
            Minor                                    4                                   11
(Erythema, edema,warmth)

* Bodoky et al. Antibiotic Prophylaxis with Two Doses of Cephalosporin in Patients Managed with Internal
    Fixation for a Fracture of the Hip. Journal of Bone and Joint Surg Am; 1993 Jan; 75(1):61-65.
Evidence cont.
•   RCT* comparing 4 doses of cefazolin vs. 1 dose vs. 3 doses of
    placebo

•   387 patients undergoing hip surgery

•   Infection Rates: 1.6% (4 Abx. doses) vs. 2.4 % (1 Abx. dose)
    vs. 3.7% (placebo)

•   Low placebo infection rate and small sample size → results not valid

* Buckley et al. Perioperative Cefazolin Prophylaxis in Hip Fracture Surgery. Canadian Journal of
    Surgery. Apr. 1990; 33(2):122-7.
                   Antibiotic Prophylaxis*

•   First-generation cephalosporin (or Vancomycin)

•   Joint Arthroplasty → Cefazolin 1g or Vanco. 1g

•   ORIF → Cefazolin 1g IV preop. & Q 8 hrs X 3 doses


* Merli and Weitz. Medical Management of the Surgical Patient. Second Edition, 1998.
                      Timing of Prophylaxis
• 2847 pts. in cohort study*
• 56% received cefazolin
    •   369 pts. early abx. (2-24 hrs. before incision)
    •   1708 pts. preop abx. (0-2 hrs. before incision)
    •   282 pts. periop abx. (0-3 hrs. after incision)
    •   488 pts. postop abx. (> 3 hrs. after incision)

•   Elective surgical procedures
    •   6% Total Knee Replacement
    •   5% Total Hip Replacement
Timing Cont.


     Timing              Patients          Infections (%)   RR (95% CI)
      Early                369                14 (3.8)      6.7 (2.9-14.7)
     Preop                1708                10 (0.6)            1.0
     Periop                282                 4 (1.4)       2.4 (0.9-7.9)
     Postop                488                16 (3.3)      5.8 (2.6-12.3)
      Total               2847                44 (1.5)           ------



* Classen et al. NEJM 1992; 326:281-286.
Duration of Prophylaxis

Optimal number of doses is controversial

•   RCT compared 24 hr vs. 6 days of cephalosporin prior to hip
    fx. repair*

•   No significant difference in infection rates

•   Stop Abx. within 3 days postop




* Hedstrom et al. Acta Orthop Scand. 1987. Aug; 58 (4):361-364.
                         Risks

•   Allergic reactions

•   Drug Fever

•   C. Diff colitis
Risks cont.

•   COST
    •   Survey of 466 procedures for 4 years *

    •   24 hrs vs. 48 hrs = 7.7 million dollars saved/100K pts

    •   24 hrs vs. 7 days = 30 million dollars saved/100K pts




    * Heydemann et al. Short-term Preventive Antibiotics. Clinical Orthop. 1986, Apr; (205):184-187.
                         Conclusions

•   All patients should be given prophylactic antibiotics within 2
    hours of orthopedic surgery

•   1st generation cephalosporin drug of choice

•   Continue antibiotics for 24 hours maximum postoperatively

•   Minimizing duration to decrease side effects and cost savings

•   Better evidence needed to optimize duration

				
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