Prevention of prosthetic joint and other types of orthopedic hardware infection

INTRODUCTION — Effective management of prosthetic joint infection (PJI) and other types of orthopedic hardware infection requires surgery and prolonged antimicrobial therapy; treatment failure is common. Given the challenges associated with treating these infections, prevention of infection is clearly desirable.

Most literature pertaining to the prevention of orthopedic hardware infection is derived from studies of patients with joint arthroplasties. Data regarding other types of orthopedic devices are limited; however, in general, similar principles of prevention may apply.

Guidelines addressing prevention strategies include the United States Centers for Disease Control and Prevention guideline for prevention of surgical site infection [1], the National Surgical Infection Prevention Project [2,3], guidelines from the Medical Letter (table 1) [4], guidelines from the American Society of Health-System Pharmacists [5], and an Advisory Statement from the American Academy of Orthopaedic Surgeons [6].

The prevention of orthopedic hardware infection is reviewed here. General principles for prevention of surgical site infection are discussed separately. (See "Overview of control measures for prevention of surgical site infection in adults".)

The epidemiology, clinical manifestations, diagnosis, and treatment of orthopedic hardware infections are discussed separately. (See "Prosthetic joint infection: Epidemiology, microbiology, clinical manifestations, and diagnosis" and "Prosthetic joint infection: Treatment".)

PRIOR TO HARDWARE PLACEMENT

Staphylococcus aureus decolonization — A detailed discussion of Staphylococcus aureus decolonization prior to orthopedic surgery is discussed separately. (See "Overview of control measures for prevention of surgical site infection in adults", section on 'S. aureus decolonization'.)

Other preventive measures — Other preventive measures prior to hardware placement include:

●There is no role for routine diagnosis or treatment of asymptomatic bacteriuria among patients undergoing joint arthroplasty or other orthopedic hardware placement [7-10]. This aspect is discussed further separately. (See "Asymptomatic bacteriuria in adults", section on 'Joint arthroplasty'.)

●A dental evaluation should be undertaken to assess and manage for the presence of gingivitis, occult dental abscess, or decay.

●Patients should be instructed not to shave their lower limbs prior to knee or hip replacement. If needed, hair removal may be performed with clippers immediately prior to surgery [11]. (See "Overview of control measures for prevention of surgical site infection in adults", section on 'Hair removal'.)

●When feasible, certain immunosuppressive therapy should be tapered to the lowest dose possible or discontinued. Expert guidelines are available that provide information about management of specific immunosuppressive agents in patients with rheumatologic conditions undergoing elective hip or knee replacement [12].

●Comorbidities should be optimized, including diabetes mellitus and peripheral edema. (See "Perioperative management of blood glucose in adults with diabetes mellitus".)

Other aspects of the prevention of surgical infections are discussed separately. (See "Overview of control measures for prevention of surgical site infection in adults".)

DURING HARDWARE PLACEMENT

Surgical approach — Surgical issues related to hip and knee arthroplasty are discussed separately. (See "Total hip arthroplasty" and "Total knee arthroplasty".)

Antimicrobial prophylaxis — Orthopedic hardware infections are commonly due to S. aureus or coagulase-negative staphylococci, so preoperative prophylaxis focuses on these organisms.

●No known MRSA colonization – Surgical antimicrobial prophylaxis with cefazolin is warranted for patients with no known MRSA colonization who are undergoing joint replacement or placement of other orthopedic hardware (ie, plates and screws) (table 1).

The addition of other antibiotics to cefazolin is not beneficial. For instance, the addition of vancomycin appears to have no benefit in patients who are not known to have MRSA colonization prior to joint replacement. In a randomized, double-blinded, placebo-controlled trial of over 4000 patients, the rate of surgical site infection within 90 days of surgery was similar in those who received preoperative cefazolin plus vancomycin compared with cefazolin alone (4.5 versus 3.5 percent, respectively; RR 1.28, 95% CI 0.94 to 1.73) [13]. There were no differences in the rates of PJI, or of infection due to MRSA or Staphylococcus epidermidis, between groups. Preoperative screening for MRSA colonization varied by site; those who were preoperatively identified through hospital protocols as having MRSA colonization were excluded.

●Known MRSA colonization – For patients with known MRSA colonization, we administer vancomycin and cefazolin for preoperative prophylaxis (table 1). Observational studies suggest that non-beta-lactam antibiotics, such as vancomycin, are inferior to cefazolin when used alone for prevention of hardware infection [14-18].

●Severe beta-lactam allergy – Patients with reported beta-lactam allergies should be evaluated prior to surgery to determine the level of risk from cefazolin. Many patients who report penicillin allergies can safely take cephalosporins. Preoperative evaluation of the allergy history, skin testing, and/or preoperative test-doses can identify candidates at low risk of severe reaction. For patients with a confirmed IgE-mediated penicillin allergy or other serious beta-lactam allergy, vancomycin is an acceptable alternative to cefazolin (table 1) [5,19]. (See "Allergy evaluation for immediate penicillin allergy: Skin test-based diagnostic strategies and cross-reactivity with other beta-lactam antibiotics".)

Most studies that have evaluated intravenous antimicrobial prophylaxis in orthopedic hardware placement have been conducted in patients undergoing total hip or knee arthroplasty [3,4,6,19-22]. Cefazolin has also been demonstrated to result in a lower risk of PJI compared to non-cefazolin alternatives in shoulder arthroplasty [17]. There is a lack of efficacy data involving elbow and ankle arthroplasty; however, the same principles of antimicrobial prophylaxis may be applied [5].

In general, the entire dose of antibiotic should be infused prior to tourniquet inflation. Administering part of the dose just prior to tourniquet release may be acceptable in some circumstances [23], particularly for patients undergoing replacement arthroplasty for management of preexisting infection of the prosthesis [24].

Antibiotic prophylaxis should not be delayed in patients undergoing revision arthroplasty for suspected or confirmed prosthetic joint infection (PJI) to optimize culture sensitivity [25].

For clean and clean-contaminated procedures, readministration of antimicrobial prophylaxis in the operating room following closure of the surgical incision is not warranted, even in the presence of a drain [1,3,5,26-28].

General principles related to antimicrobial prophylaxis to prevent surgical site infections are discussed further separately. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)

Local antibiotic delivery — Forms of local antibiotic delivery include antimicrobial-laden fixation cement and antimicrobial-laden sponges.

The use of low-dose antimicrobial-laden fixation cement for prevention of infection in primary cemented hip and knee arthroplasty (in conjunction with intravenous antimicrobial prophylaxis) is common practice [29-32]. The optimal use of this strategy and the potential for the development of antimicrobial resistance has not been fully assessed [33-36]; it may be appropriate in selected patients at increased risk for infection [37,38]. Issues related to use of antibiotic-laden cement for treatment of PJI are discussed separately. (See "Prosthetic joint infection: Treatment", section on 'Resection arthroplasty with reimplantation'.)

The use of gentamicin-containing collagen sponges has not been shown to reduce the incidence of surgical site infection after joint arthroplasty [39]. This issue is discussed further separately. (See "Overview of control measures for prevention of surgical site infection in adults", section on 'Topical and local antibiotic delivery'.)

FOLLOWING HARDWARE PLACEMENT — Signs or symptoms of wound infection following hardware replacement should be addressed promptly and aggressively with local wound measures and antibiotic therapy directed against likely pathogens.

There is no evidence to suggest that patients with orthopedic hardware undergoing procedures should receive antibiotic prophylaxis in the absence of other indications, such as heart valve disease requiring endocarditis prophylaxis or a surgical procedure for which antibiotics are given to prevent a surgical site infection. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)

Dental procedures — Based on available data and consistent with expert guidelines from both the American Dental Association (ADA) and the American Academy of Orthopedic Surgeons (AAOS), we advise against the routine use of antibiotic prophylaxis in patients with prosthetic joints undergoing dental procedures [40,41]. Dental procedures are not associated with an increased risk of orthopedic hardware infection, and use of routine antibiotic prophylaxis prior to dental procedures, including invasive procedures, does not alter the risk of subsequent orthopedic hardware infection [41-49]. We recommend maintaining good oral hygiene so that bacteremia due to oral flora is less likely to occur during routine daily oral care [50]. In addition, we recommend that dental infections be promptly treated. Treatment of dental infections is discussed in detail elsewhere.

In a hospital-based study of 339 patients with PJI and 339 matched-controls with a prosthetic joint but no infection, PJI was not associated with prior low-risk or high-risk dental procedures [43]. Review of dental records revealed that antibiotics prior to dental procedures did not alter the subsequent risk of PJI. Similarly, a nationwide observational study from England, where antibiotic prophylaxis for dental procedures is not used, found no temporal association between invasive dental procedures and late PJI among over 9000 individuals with PJI [48]. In the United States, an observational study of over 2300 late PJI cases demonstrated no association between invasive dental procedures and development of PJI, and there was no benefit of antibiotic prophylaxis for dental procedures in reducing the risk of PJI [51].

Urologic procedures — In general, antimicrobial prophylaxis for prevention of orthopedic hardware infection is not warranted for patients with orthopedic hardware undergoing cystoscopy [52]. Antimicrobial prophylaxis may be appropriate in selected patients, especially those with immunosuppression undergoing a procedure with increased risk of bacteremia, such as lithotripsy or surgery involving bowel segments [53].

Gastrointestinal procedures — In general, antimicrobial prophylaxis for prevention of orthopedic hardware infection is not warranted for patients with orthopedic hardware undergoing gastrointestinal endoscopies [54].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Osteomyelitis and prosthetic joint infection in adults".)

SUMMARY AND RECOMMENDATIONS

●Antibiotic prophylaxis during orthopedic surgery – Surgical antimicrobial prophylaxis is warranted for all patients undergoing orthopedic hardware placement; regimens are summarized in the table (table 1). (See 'Antimicrobial prophylaxis' above.)

●No role for antibiotic prophylaxis prior to dental procedures – Based on available data and consistent with expert guidelines from both the American Dental Association (ADA) and the American Academy of Orthopedic Surgeons (AAOS), we advise against the routine use of antibiotic prophylaxis in patients with prosthetic joints undergoing dental procedures (Grade 1B). Patients who have another indication for pre-dental-procedure prophylaxis (such as heart valve disease requiring endocarditis prophylaxis or a surgical procedure for which antibiotics are given to prevent a surgical site infection) should receive antibiotics. (See 'Dental procedures' above.)

●Antibiotic prophylaxis prior to other procedures – In general, antimicrobial prophylaxis for prevention of orthopedic infection is not warranted for patients with prosthetic joints undergoing urologic or gastrointestinal procedures. (See 'Following hardware placement' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Elie Berbari, MD, FIDSA, who contributed to earlier versions of this topic review.