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Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection

Javad Parvizi MD, FRCS
Thorsten Gehrke MD


Title:
Perioperative Antibiotics

Liaisons:
Erik Hansen MD

Leaders:
Katherine Belden MD, Randi Silibovsky MD (US), Markus Vogt MD (International)

Delegates:
William Arnold MD, PhD, Goran Bicanic MD, PhD, Stefano Bini MD, Fabio Catani MD, Jiying Chen MD, PhD, Mohammad Ghazavi MD, FRCSC, Karine M. Godefroy MD, Paul Holham MD, Hamid Hosseinzadeh MD, Kang II Kim MD, PhD, Klaus Kirketerp-Møller MD, Lars Lidgren MD PhD, Jian Hao Lin MD, Jess H Lonner MD, Christopher C Moore MD, Panayiotis Papagelopoulos MD, Lazaros Poultsides MD MSc PhD, R Lor Randall MD, Brian Roslund PharmD, Khalid Saleh MD MSC FRCSC MHCM, Julia V Salmon MD, Edward Schwarz PhD, Jose Stuyck MD, Annette W Dahl MD, Koji Yamada MD

Vol 1, Num S1, September 2014

 

   

Question 1: What is the optimal timing of the preoperative dose of antibiotics?

Consensus: The preoperative dose of antibiotics should be administered within one hour of surgical incision; this can be extended to two hours for vancomycin and fluoroquinolones. Furthermore, surveillance measures are critical in ensuring clinician compliance with this objective.

Delegate Vote: Agree: 97%, Disagree: 2%, Abstain: 1% (Strong Consensus)


Question 2: Is there an optimal antibiotic that should be administered for routine perioperative surgical prophylaxis?

Consensus: A first or second generation cephalosporin (cefazolin or cefuroxime) should be administered for routine perioperative surgical prophylaxis. Isoxazolyl penicillin is used as an appropriate alternative.

Delegate Vote: Agree: 89%, Disagree: 8%, Abstain: 3% (Strong Consensus)


Question 3: What is the choice of antibiotic in patients who have pre-existing prostheses such as heart valves?

Consensus: The choice of antibiotics for patients with pre-existing prostheses such as heart valves is the same as that for routine elective arthroplasty.

Delegate Vote: Agree: 94%, Disagree: 3%, Abstain: 3% (Strong Consensus)


Question 4: What alternatives are available for routine prophylaxis when cephalosporins are not an option?

Consensus: Curently teicoplanin and vancomycin are reasonable alternatives when routine antibiotic prophylaxis cannot be administered.

Delegate Vote: Agree: 73%, Disagree: 22%, Abstain: 5% (Strong Consensus)


Question 5A: What antibiotic should be administered in a patient with a known anaphylactic penicillin allergy?

Consensus: In a patient with a known anaphylactic reaction to penicillin, vancomycin or clindamycin should be administered as prophylaxis. Teicoplanin is an option in countries where it is available.

Delegate Vote: Agree: 88%, Disagree: 10%, Abstain: 2% (Strong Consensus)


Question 5B: What antibiotic should be administered in a patient with a known non-anaphylactic penicillin allergy?

Consensus: In a patient with a reported non-anaphylactic reaction to penicillin, a second-generation cephalosporin can be used safely as there is limited cross-reactivity. Penicillin skin testing may be helpful in certain situations to clarify whether the patient has a true penicillin allergy.

Delegate Vote: Agree: 87%, Disagree: 9%, Abstain: 4% (Strong Consensus)


Question 6: What are the indications for administration of vancomycin?

Consensus: Vancomycin should be considered for patients who are current MRSA carriers or have anaphylactic allergy to penicillins.
Consideration should be given to screening high risk patients such as:
- Patients in regions with a high prevalence of MRSA.
- Institutionalized patients (nursing home residents, dialysis-dependent patients, and those who have been in the intensive care unit).
- Healthcare workers.

Delegate Vote: Agree: 93%, Disagree: 7%, Abstain: 0% (Strong Consensus)


Question 7: Is there evidence to support the routine use of vancomycin for preoperative prophylaxis?

Consensus: No. Routine use of vancomycin for preoperative prophylaxis is not recommended.

Delegate Vote: Agree: 93%, Disagree: 6%, Abstain: 1% (Strong Consensus)


Question 8: Is there a role for routine prophylactic use of dual antibiotics (cephalosporins and aminoglycosides or cephalosporins and vancomycin)?

Consensus: Routine prophylactic use of dual antibiotics is not recommended.

Delegate Vote: Agree: 85%, Disagree: 14%, Abstain: 1% (Strong Consensus)


Question 9: What should be the antibiotic of choice for patients with abnormal urinary screening and/or an indwelling urinary catheter?

Consensus: The presence of urinary tract symptoms should trigger urinary screening prior to TJA. Asymptomatic patients with bacteriuria may safely undergo TJA provided that routine prophylactic antibiotics are administered. Patients with acute urinary tract infections (UTI) need to be treated prior to elective arthroplasty.

Delegate Vote: Agree: 82%, Disagree: 12%, Abstain: 6% (Strong Consensus)


Question 10: Should the preoperative antibiotic choice be different in patients who have previously been treated for another joint infection?

Consensus: The type of preoperative antibiotic administered to a patient with prior septic arthritis or PJI should cover the previous infecting organism of the same joint. In these patients, we recommend the use of antibiotic-impregnated cement, if a cemented component is utilized.

Delegate Vote: Agree: 84%, Disagree: 10%, Abstain: 6% (Strong Consensus)


Question 11: Should postoperative antibiotics be continued while a urinary catheter or surgical drain remains in place?

Consensus: No. There is no evidence to support the support the continued use of postoperative antibiotics when urinary catheter or surgical drains are in place. Urinary catheters and surgical drains should be removed as soon as safely possible.

Delegate Vote: Agree: 90%, Disagree: 7%, Abstain: 3% (Strong Consensus)


Question 12: What is the evidence for the optimal duration of postoperative antibiotics in decreasing SSI or PJI?

Consensus: Postoperative antibiotics should not be administered for greater than 24 hours after surgery.

Delegate Vote: Agree: 87%, Disagree: 10%, Abstain: 3% (Strong Consensus)


Question 13: Until culture results are finalized, what antibiotic should be administered to a patient with a presumed infection?

Consensus: In a patient with a presumed infection when culture results are pending, empiric antibiotic coverage should depend on the local microbiological epidemiology. Culture data should assist in the tailoring of antibiotic regimens.

Delegate Vote: Agree: 96%, Disagree: 1%, Abstain: 3% (Strong Consensus)


Question 14: What is the appropriate preoperative antibiotic for a second-stage procedure?

Consensus: The appropriate preoperative antibiotic for the second stage should include coverage of the prior organism(s). Cemented arthroplasty components should be inserted with antibiotic-laden bone cement.

Delegate Vote: Agree: 66%, Disagree: 31%, Abstain: 3% (Strong Consensus)


Question 15: For surgeries of longer duration, when should an additional dose of antibiotic be administered intraoperatively?

Consensus: An additional dose of antibiotic should be administered intraoperatively after two half-lives of the prophylactic agent. The general guidelines for frequency of intraoperative antibiotic administration are provided. We recommend that re-dosing of antibiotics be considered in cases of large blood volume loss (>2000 cc) and fluid resuscitation (>2000cc). As these are independent variables, re-dosing should be considered as soon as the first of these parameters are met.

Delegate Vote: Agree: 94%, Disagree: 5%, Abstain: 1% (Strong Consensus)


Question 16: Should preoperative antibiotic doses be weight-adjusted?

Consensus: Preoperative antibiotics have different pharmacokinetics based on patient weight and should be weight-adjusted.

Delegate Vote: Agree: 95%, Disagree: 4%, Abstain: 1% (Strong Consensus)


Question 17A: What type of perioperative antibiotic prophylaxis is recommended for current MRSA carriers?

Consensus: For current MRSA carriers, vancomycin or teicoplanin is the recommended perioperative antibiotic prophylaxis.

Delegate Vote: Agree: 86%, Disagree: 12%, Abstain: 2%(Strong Consensus)


Question 17B: Should patients with prior history of MRSA be re-screened? What should the choice of perioperative prophylactic antibiotics be in these patients?

Consensus: Patients with prior history of MRSA should be re-screened preoperatively. If patients are found to be negative for MRSA, we recommend routine perioperative antibiotic prophylaxis.

Delegate Vote: Agree: 76%, Disagree: 23%, Abstain: 1% (Strong Consensus)


Question 18: What is the recommended prophylaxis in patients undergoing major orthopaedic reconstructions for either tumor or non-neoplastic conditions using megaprosthesis?

Consensus: Until the emergence of further evidence, we recommend the use of routine antibiotic prophylaxis for patients undergoing major reconstruction.

Delegate Vote: Agree: 93%, Disagree: 6%, Abstain: 1% (Strong Consensus)


Question 19: Should antibiotic prophylaxis be different in patients who have reconstruction by bulk allograft?

Consensus: We recommend the use of routine antibiotic prophylaxis in patients who have reconstruction by bulk allograft.

Delegate Vote: Agree: 93%, Disagree: 5%, Abstain: 2% (Strong Consensus)


Question 20: Do patients with poorly controlled diabetes, immunosuppression, or autoimmune disease require a different perioperative antibiotic prophylaxis?

Consensus: No. Routine antibiotic prophylaxis is recommended in these patients.

Delegate Vote: Agree: 90%, Disagree: 9%, Abstain: 1% (Strong Consensus)


Question 21A: Should preoperative antibiotics be different for primary and revision TJA?

Consensus: No. Perioperative antibiotic prophylaxis should be the same for primary and uninfected revision arthroplasty.

Delegate Vote: Agree: 89%, Disagree: 10%, Abstain: 1% (Strong Consensus)


Question 21B: Should preoperative antibiotics be different for hips and knees?

Consensus: Perioperative antibiotic prophylaxis should be the same for hips and knees.

Delegate Vote: Agree: 99%, Disagree: 1%, Abstain: 0% (Strong Consensus)


Question 22: What is the best antibiotic prophylaxis to choose in patients with colonization by carbapenem resistant enterobacteriaceae or multi-drug resistant (MDR)-Acinetobacter spp?

Consensus: There is insufficient data to recommend expanded antibiotic prophylaxis in patients known to be colonized or recently infected with MDR pathogens.

Delegate Vote: Agree: 76%, Disagree: 8%, Abstain: 16% (Strong Consensus)


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    Table 1: Recommended dosing of preoperative antibiotics by weight
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