Efficacy of a single dose of cefazolin as a prophylactic antibiotic in primary arthroplasty

doi:10.1016/S0883-5403(03)00201-8

The Journal of Arthroplasty

Volume 18, Issue 6, September 2003, Pages 714-718

https://doi.org/10.1016/S0883-5403(03)00201-8 Get rights and content

Abstract

We analyzed the wound infection rate of 1,367 primary total hip and knee arthroplasties performed between 1991 and 1999. Two hundred and fifteen arthroplasties were performed with 3 doses (3 × 750 mg) of cefuroxime, and 1,152 arthroplasties were performed with a single preoperative dose (1 × 1 g) of cefazolin as antimicrobial prophylaxis. All wound infections that occurred within 2 years of the index surgery were analyzed. The deep wound infection rate of total hip arthroplasty was 1.1% (95% confidence interval [CI], 0%–3.3%) in the cefuroxime group and 1.1% (95% CI, 0%–2.2%) in the cefazolin group (Fisher’s exact test, P = 1.0). The deep wound infection rate of total knee arthroplasty in the cefuroxime group (1.6%; 95% CI, 0%–3.8%) was not significantly different from the cefazolin group (1.0%; 95% CI, 0.3%–1.7%) (Fisher’s exact test, P = .63). We concluded that a single dose (1 g) of cefazolin given at anesthetic induction offered similar protection to 3 doses (3 × 750 mg) of cefuroxime in preventing infection in primary total joint arthroplasty.

Section snippets

Patients and methods

We reviewed all the primary total hip arthroplasties (THAs) and total knee arthroplasties (TKAs) performed in our hospital from January 1991 to December 1999. In January 1991, we launched a surgical wound infection surveillance program to monitor all orthopedic surgeries, including total joint arthroplasty. A designated registered nurse from the hospital infection control unit regularly assessed all patients who underwent orthopedic procedures in the absence of the surgical team to record and

Results

From January 1991 to December 1999, we performed a total of 1,377 primary THAs and primary TKAs in 897 patients. Four patients were excluded because they were allergic to penicillins or cephalosporins, and 6 additional patients were excluded because they required steroid treatment for inflammatory arthritis. Therefore, 1,367 arthroplasties in 887 patients were available for review. Of these 1,367 arthroplasties, 215 were in the cefuroxime group and 1,152 were in the cefazolin group. The

Discussion

Cefazolin is a broad-spectrum, first-generation cephalosporin. It is currently the most popular antimicrobial prophylaxis in a wide range of “clean” surgeries, including cardiac and vascular surgery [8] as well as orthopedic procedures 4, 9, 10, 11, 12, 13. Although the pharmacokinetics aspects 7, 9, 14, 15, 16, 17, 18 and the efficacy of cefazolin in bringing down the infection rate of arthroplasty to around 1% were well studied and documented 5, 9, 10, 11, 12, 13, there is still no consensus

Acknowledgements

We would like to thank Dr. Jennifer S.K. Chan, Department of Statistics & Actuarial Science, The University of Hong Kong, for providing valuable statistical advice on the study.

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Cited by (48)

Perioperative Antibiotic Prophylaxis: Single and 24-Hour Antibiotic Dosages are Equally Effective at Preventing Periprosthetic Joint Infection in Total Joint Arthroplasty
2021, Journal of Arthroplasty
Perioperative antibiotic prophylaxis is used to prevent surgical site infection and periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). Secondary to a national shortage of cefazolin, patients at our institution began receiving a single preoperative prophylactic antibiotic dose for primary TJA and no 24-hour postoperative antibiotic prophylaxis. The purpose of the study was to compare the efficacy of single-dose antibiotic use versus 24-hour dosing of prophylactic antibiotics in the prevention of acute PJI and short-term complications after primary TJA.
A retrospective review of 3317 patients undergoing primary TJA performed from January 2015 to December 2019 identified 554 patients who received a single dose of preoperative antibiotic prophylaxis during the antibiotic shortage and 2763 patients who received post-TJA 24-hour antibiotic prophylaxis before the shortage. Patient records were evaluated for acute PJI, superficial infection, 90-day reoperation, and 90-day complications.
There were no significant differences in patient characteristics between single-dose and 24-hour antibiotic groups. Similarly, there were no significant differences in rates of acute PJI (0.7% vs 0.2%; P = .301), superficial infection (2.4% vs 1.4%; P = .221), 90-day reoperation (2.1% vs 1.1%; P = .155), and 90-day complications (9.9% vs 7.9%; P = .169) between single and 24-hour antibiotic dose. Post hoc power analysis demonstrated adequate sample size, beta = 93%.
Single-dose prophylactic antibiotics did not lead to an increased risk of acute PJI or short-term complications after TJA. Our study suggests that administration of a single antibiotic dose may be safely considered in patients undergoing routine primary TJA.
The AAHKS Clinical Research Award: Extended Oral Antibiotics Prevent Periprosthetic Joint Infection in High-Risk Cases: 3855 Patients With 1-Year Follow-Up
2021, Journal of Arthroplasty
Citation Excerpt :
These findings support the efficacy and safety of using an extended antibiotic protocol for high-risk patients after TJA. Data regarding the optimal duration of antibiotic prophylaxis after surgery have been conflicting, with low-level evidence suggesting that a single dose of antibiotics is as effective as multiple doses [42–50]. However, 2017 CDC guidelines recommended against the continuation of antibiotics postoperatively (after incision closure) after TJA [51]; this is concerning because the guidelines are based on only 6 orthopedic studies [47,52–56], 5 of which were published before 1991 and only 2 of which were TJA related.
Surgical and host factors predispose patients to periprosthetic joint infection (PJI) after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). While surgical factors are modifiable, host factors can be challenging, and there are limited data demonstrating that preoperative patient optimization decreases risk of PJI. The goal of this study was to evaluate whether extended oral antibiotic prophylaxis reduces the one-year infection rate in high-risk patients.
A total of 3855 consecutive primary THAs and TKAs performed between 2011 and 2019 at a suburban academic hospital with modern perioperative and infection-prevention protocols were retrospectively reviewed. Beginning in January 2015, a 7-day oral antibiotic prophylaxis protocol was implemented after discharge for patients at high risk for PJI. The percentage of high-risk patients diagnosed with PJI within 1 year was compared between groups that did and did not receive extended antibiotic prophylaxis. Univariate and logistic regression analyses were performed, with P ≤ .05 denoting statistical significance.
Overall 1-year infection rates were 2.26% and 0.85% after THA and TKA, respectively. High-risk patients with extended antibiotic prophylaxis had a significantly lower rate of PJI than high-risk patients without extended antibiotic prophylaxis (0.89% vs 2.64%, respectively; P < .001). There was no difference in the infection rate between high-risk patients who received antibiotics and low-risk patients (0.89% vs 1.29%, respectively; P = .348) with numbers available.
Extended postoperative oral antibiotic prophylaxis for 7 days led to a statistically significant and clinically meaningful reduction in 1-year infection rates of patients at high risk for infection. In fact, the PJI rate in high-risk patients who received antibiotics was less than the rate seen in low-risk patients. Thus, extended oral antibiotic prophylaxis may be a simple measure to effectively counteract poor host factors. Moreover, the findings of this study may mitigate the incentive to select healthier patients in outcome-based reimbursement models. Further study with a multicenter randomized control trial is needed to further validate this protocol.
Therapeutic level III.
Characteristics of Antibiotic Prophylaxis and Risk of Surgical Site Infections in Primary Total Hip and Knee Arthroplasty
2020, Journal of Arthroplasty
Despite numerous antibiotic prophylaxis options for total hip arthroplasty (THA) and total knee arthroplasty (TKA), an assessment of practice patterns and comparative effectiveness is lacking. We aimed to characterize antibiotic utilization patterns and associations with infection risk and hypothesized differences in infection risk based on regimen.
A retrospective cohort study was performed using data from 436,724 THA and 862,918 TKA (Premier Healthcare Database; 2006-2016). Main exposures were antibiotic type and duration: day of surgery only (day 0) or through postoperative day 1 (day 1). The primary outcome was surgical site infection (SSI) <30 days postoperation. Mixed-effect models measured associations between prophylaxis regimen and SSI as odds ratios (ORs) with 95% confidence intervals (CIs).
SSI prevalence was 0.21% (n = 914) for THA and 0.22% (n = 1914) for TKA. Among THA procedures, the most commonly used antibiotics were cefazolin (74.1%), vancomycin (8.4%), “other” antibiotic combinations (7.1%), vancomycin + cefazolin (5.1%), and clindamycin (3.3%). Here, 51.8% received prophylaxis on day 0 only, whereas 48.2% received prophylaxis through day 1. Similar patterns existed for TKA. Relative to cefazolin, higher SSI odds were seen with vancomycin (OR = 1.36; CI 1.09-1.71) in THA and with vancomycin (OR = 1.29; CI = 1.10-1.52), vancomycin + cefazolin (OR = 1.35; CI = 1.12-1.64), clindamycin (OR = 1.38; CI = 1.11-1.71), and “other” antibiotic combinations (OR = 1.28; CI = 1.07-1.53) in TKA. Prophylaxis duration did not alter SSI odds. Results were corroborated in sensitivity analyses.
Antibiotic prophylaxis regimens other than cefazolin were associated with increased SSI risk among THA/TKA patients. These findings emphasize a modifiable intervention to mitigate infection risk.
Dual prophylaxis with teicoplanin and cefazolin in the prevention of prosthetic joint infection
2019, Enfermedades Infecciosas y Microbiologia Clinica
Existe un creciente aumento de las infecciones de prótesis articular (IPA) por bacterias resistentes a las cefalosporinas utilizadas en la profilaxis quirúrgica. La sustitución de estas por glucopéptidos no ha demostrado mejorar los resultados pero sí su asociación.
Estudio comparativo de la asociación de teicoplanina y cefazolina antes de la cirugía de artroplastia frente a cefazolina sola de un grupo control previo.
En el periodo control hubo 16 IPA de 585 cirugías, mientras que en el grupo de intervención fueron 6 de 579 (incidencia 2,7% vs. 1,03%; RR 0,4, p = 0,04). En el grupo control, 11 de las infecciones fueron causadas por bacterias grampositivas frente a 4 en el de intervención (1,8% vs. 0,7%, p = 0,08).
La adición de teicoplanina a cefazolina en la profilaxis de la cirugía de artroplastia se asoció a una reducción de la incidencia de IPA, a expensas de un descenso de las causadas por grampositivos.
There is a growing increase in prosthetic joint infection (PJI) incidence due to cephalosporin-resistant bacteria, used in surgical prophylaxis. The replacement of these with glycopeptides has not been shown to improve the results, but they have been shown to improve with their combination.
Comparative study of combination of teicoplanin and cefazolin before arthroplasty surgery against cefazolin alone from a previous control group.
During the control period, there were 16 PJIs from 585 surgeries, while in the intervention group there were 6 from 579 (incidence 2.7% vs. 1.03%, RR 0.4, P=.04). In control group, 11 of the infections were caused by Gram-positive bacteria versus 4 in the intervention group (1.8% vs. 0.7%, P=.08).
The addition of teicoplanin to cefazolin in the prophylaxis of arthroplasty surgery was associated with a reduction in the incidence of PJI, thanks to a decrease in infections caused by Gram-positive bacteria.
Formulation development and characterization of cefazolin nanoparticles-loaded cross-linked films of sodium alginate and pectin as wound dressings
2019, International Journal of Biological Macromolecules
Citation Excerpt :
Cefazolin is mainly used for topical bacterial infections according to FDA with great scope for soft tissue infections preoperatively and postoperatively. It is the most prescribed drug among the patients undergoing orthopaedic surgical procedures because of the increased risk of exposure to Staphylococcus aureus especially in knee arthroplasty [7]. But the drug accounts for its repeated administration due to its shorter half-life (1−2h) as it gets rapidly eliminated from the body thus accounting for bacterial resistance.
The present study focuses on the preparation of nanoparticles-loaded ionic cross-linked films for the topical delivery of cefazolin. The aim of the study was to prepare a dosage form which can provide local effect of cefazolin along with sustained delivery at the site of application. Cefazolin was loaded into chitosan nanoparticles to mask the burst release of the drug and they were optimized based on particle size, PDI, % EE and zeta potential. Finally, the prepared nanoparticles were loaded into the films comprising of sodium alginate and pectin which were then subjected to cross-linking via calcium chloride to improve the mechanical strength of the hydrogel films upon exposure to wound fluid. The films were assessed for physical and mechanical properties, swelling behavior, water transmission rate, mucoadhesion, FTIR, DSC, percent inhibition assay and in vitro release profile. Optimized formulation with Cefazolin nanoparticles in the size range of 227 nm and 0.5% CL films showed significantly better results (p < 0.05) as compared to the films with increased cross-linker concentration. Therefore, 0.5% CL films were considered more suitable for the treatment of infections when applied as wound dressing.
Hip and Knee Section, Prevention, Antimicrobials (Systemic): Proceedings of International Consensus on Orthopedic Infections
2019, Journal of Arthroplasty

View all citing articles on Scopus

¹: No benefits or funds were received in support of this study.

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Efficacy of a single dose of cefazolin as a prophylactic antibiotic in primary arthroplasty1

Abstract

Section snippets

Patients and methods

Results

Discussion

Acknowledgements

Surg Clin North Am

Lancet

Lancet

J Arthroplasty

J Thorac Cardiovasc Surg

J Arthroplasty

Cost of treating an infected total knee replacement

Clin Orthop

The use of prophylactic antimicrobial agents during and after hip arthroplasty

Clin Orthop

Effect of intraoperative blood loss on the serum level of cefazolin in patients managed with total hip arthroplasty. A prospective, controlled study

J Bone Joint Surg Am

Cefazolin versus cefamandole for prophylaxis during total joint arthroplasty

Clin Orthop

Antimicrobial prophylaxis for arthroplastya comparative study of cefonicid and cefazolin

Orthopedics

Short-term preventive antibiotics

Clin Orthop

Comparative multicenter trial of teicoplanin versus cefazolin for antimicrobial prophylaxis in prosthetic joint implant surgery

Eur J Clin Microbiol Infect Dis

The use of preventive antibiotics in orthopaedic surgery

Clin Orthop

The penetration characteristics of cefazolin, cephalothin, and cephradine into bone in patients undergoing total hip replacement

J Bone Joint Surg Am

Penetration of cephalosporins into bone

Infection

Penetration of moxalactam and cefazolin into bone following simultaneous bolus or infusion

Clin Orthop

Cefazolin concentrations in bone and synovial fluid

J Bone Joint Surg Am

Bone and serum concentrations of five cephalosporin drugsrelevance to prophylaxis and treatment in orthopedic surgery

Clin Orthop

The effective period of preventative antibiotic action in experimental incisions and dermal lesions

Surgery

Prophylactic penicillin in orthopaedic surgery

J Bone Joint Surg Am

Efficacy of a single dose of cefazolin as a prophylactic antibiotic in primary arthroplasty¹