Orthopaedic and Trauma Surgery - Guideline for Antimicrobial Prophylaxis

Publication: 22/12/2009  
Last review: 14/10/2016  
Next review: 14/10/2019  
Clinical Guideline
CURRENT 
ID: 1747 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2016  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for antimicrobial prophylaxis for orthopaedic and trauma surgery (excluding hand surgery)

1. Summary table of routine recommendations

It is the responsibility of the surgical team to prescribe the prophylactic antibiotics, and the anaesthetist to give them.

Procedure

Recommendation for antibiotic prophylaxis

Evidence level

Prophylaxis aims to reduce

NNT

Antimicrobial dose/route ≤ 1 hour before procedure or more than 20 minutes before tourniquet

Routine

Penicillin allergy OR MRSA risk factors

Elective surgery

Joint replacement surgery

Highly recommended.

B 2,3

Joint infection

42/
57

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV single dose.
For cemented implant use Gentamicin-loaded cement.

Other  orthopaedic implant surgery

Recommended

D

Wound infection

 

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin 1g IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV single dose.

Arthroscopy – no prosthetic material

Not recommended

C 2,3

 

 

 

Procedures for infected joints

Joint aspiration

Not recommended.

C 2,3

 

 

Follow septic arthritis or infected hip or knee guideline.

Hip and knee revision (any stage)

Recommended

A2,3

 

 

Follow the treatment guideline

Acute surgery

Closed fractures

Highly recommended

A2,3

Deep wound infection

38

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin 1g IV single dose & Gentamicin 2 mg/kg IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV single dose & Gentamicin 2mg/kg IV single dose.

Intracapsular NOF fractures -  cemented hemi-arthroplasty

Highly recommended.

B 2,3

Joint infection

42/
57

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV single dose.
For cemented implant use Gentamicin-loaded cement.

Open fracture (including unsalvageable limb amputation)
Antibiotics should start ASAP after injury & ideally within 3 hours with Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav IV 1.2g 8-hourly9 (or oral where appropriate) for three doses if skin closure is achieved within 24 hours of the injury. Continue 8-hourly for 72 hours after initial debridement if skin closure is not achieved within 24 hours of the injury.
For penicillin allergy, Clindamycin electronic Medicines Compendium information on Clindamycin 600mg IV 6-hourly (unless over 65 years old).  Contact microbiology for advice on patients at high risk for MRSA.

Initial debridement*

Highly recommended.

A2,3 C9

Wound infection

14

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV single dose.

Skeletal stabilisation  & definitive wound closure*

Highly recommended.

A2,3 C9

Wound infection

14

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV single dose.

* Give additional peri-operative doses if patient undergoes total body volume transfusion procedure or if long procedure. Re-dose  Teicoplanin electronic Medicines Compendium information on Teicoplanin after 12 hours. Teicoplanin electronic Medicines Compendium information on Teicoplanin takes up to 15 minutes to reconstitute so allow time for preparation.

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2. Background information

The aim of antimicrobial prophylaxis in orthopaedic and trauma surgery is a reduction in surgical site infection.
Current practise has been reviewed in light of publication of new guidance from the National Institute for Health and Clinical Excellence (NICE)3 and the Scottish Intercollegiate Guideline Network 2 and in the current era of increasing Clostridium difficile infection, meticillin-resistant Staphylococcus aureus (MRSA) infection and increasing concerns about community-acquired MRSA. Reducing the risk of acquisition of these pathogens by avoiding unnecessary antimicrobial exposure is a pressing concern.

For some orthopaedic procedures there is no evidence that antimicrobial prophylaxis is of benefit to patients and its use is therefore not recommended. These guidelines should be applicable to the majority of patients but where the recommendations in these guidelines do not seem appropriate for a particular patient, the surgeon is advised to discuss the case with a microbiologist.

There is increasing evidence linking the use of cephalosporins even as a 24 hour prophylaxis to increased C.difficile infection4

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3. Special antimicrobial prophylaxis recommendations

Limb surgery3
Open fracture
One systematic review was identified.
A Cochrane review (seven trials, n = 913 participants) was identified that investigated the effect of antibiotics compared with placebo or no antibiotic in patients who had open fractures of the limbs. [EL = 1+] Two of the included trials were RCTs, three were quasi-RCTs and the randomisation process was unclear in the other two studies.  Statistically significantly fewer wound infections were found in the participants treated with antibiotics compared with those treated with either placebo or no antibiotic (RR 0.41, 95% CI 0.27 to 0.63).

Open surgery for closed long bone fracture
One systematic review was identified.
I2 = 28.8%) overall. No statistically significant difference in either deep or superficial wound infection rates individually was observed.

A meta-analysis (Figure 5.15) of two trials that considered the deep and superficial infection rates following a single dose of one antibiotic as prophylaxis compared with placebo found that statistically significantly fewer wound infections occurred in the antibiotic group (RR 0.44, 95% CI 0.30 to 0.64) overall. Statistically significant differences in both deep and superficial wound infection rates individually were also observed.

Hip fracture3
One systematic review was identified.
The systematic review investigated the effect of antibiotic prophylaxis administered pre-, peri and/ or postoperatively compared with placebo for hip fracture surgery. [EL = 1+] The main outcome was wound infection rate and further analysis of deep and superficial infection was provided.
Ten trials (n = 2417 participants) investigated wound infection and found that statistically significantly fewer wound infections occurred in those patients given antibiotics compared with those given placebo (OR 0.55, 95% CI 0.35 to 0.85).

Seven studies (n = 1782 participants) investigated superficial infection (OR 0.67, 95% CI 0.44 to 1.01) and six studies investigated deep infection (OR 0.53, 95% CI 0.20 to 1.38), although neither reached statistical significance. Addition of a further two studies (n = 419 participants) describing infections as ‘major’ rather than deep found significantly fewer infections in the antibiotic prophylaxis group (OR 0.52, 95% CI 0.28 to 0.99).

Lower limb amputation
One systematic review was identified.
One RCT (n = 152 participants) was identified that examined the use of cefoxitin (five doses of 2 g during the first 24 hours, starting 30 minutes before amputation and then every 6 hours) compared with placebo (no further details) in patients admitted for amputation due to arteriosclerosis. [EL = 1+] There were statistically significantly more wound infections in the placebo group compared with the antibiotic group (RR 3.3, 95% CI 1.5 to 7.5, P < 0.004).

Micro-organisms isolated from surgical site infections5
There has been a mandatory orthopaedic surgical site infection program in the UK for a number of years.  Data on micro-organisms causing SSIs were available in 81% of infections for the four years of the mandatory surveillance6. The main causative organisms are illustrated below. Staphylococcus aureus was the most common micro-organism reported, accounting for 44% of all SSIs. Methicillin-resistant S. aureus (MRSA) was reported as a causative micro-organism in 26% of all SSIs.
Of all S. aureus reported, 60% were MRSA. This pattern was similar to that reported in the previous three years of mandatory surveillance in orthopaedic surgery.

Choice of agent
The mandatory surveillance scheme does not collect data on the antimicrobial given or the duration of prophylaxis.  Data from the Mandatory Surveillence Scheme shows that the risk of SSI increases significantly for each increase in age group relative to the youngest age group (<45 years) in hip prosthesis and open reduction of long bone fracture. However the increases relate only to patients falling in the older age groups. In hip prosthesis the risk compared to the youngest group is significantly higher in the following groups: 75-84 years and 85 years or more. In open reduction of long bone fracture, the risk is significantly higher in the following groups: 65-74 years, 75-84 years and 85 years or more. For example, the group comprising patients aged 85 years or more has a significantly higher risk of SSI compared to the youngest group: risk ratio=3.95 (p<0.001) for hip prosthesis; risk ratio=5.38 (p<0.001) for open reduction of long bone fracture. Grouped data may mask the true risk of SSI so further analysis indicates that the risk of SSI increases significantly for each one year increase in patient age in each surgical category: (p=0.021 for hip hemiarthroplasty, p<0.001 for each of the other three categories). Some of the increased risk may be explained by older patients staying in hospital longer, thus increasing the possibility that a SSI will be detected.5


There is data to show that the traditional use of three doses of cefuroxime6 is associated with Clostridium difficile infection, and that a move away significantly reduces the incidence of this adverse effect.7
For elective joint replacement procedures, single dose teicoplanin will be the agent of choice due to the large rate of MRSA and other resistant organisms in this population. A prospective open label study identified single dose teicoplanin as more effective than second generation cephalosporin or combination penicillin & beta-lactamase inhibitor in preventing early SSI8.  For those patients tested as MRSA positive as part of elective screening, or classified as high risk on acute admission, they would receive teicoplanin as prophylaxis. For fixation of closed fractures either flucloxicillin or teicoplanin (dependent on penicillin hypersensitivity and MRSA risk) will be the agent of choice reflecting the predominance of gram positive infections encountered. A stat dose of low dose gentamicin should also be give to provide protection from early infection with gram negative organisms although the incidence of this is rare. There have been a number of incidences of Clostridium difficile infection in trauma and orthopaedic patients where the only antibiotic trigger has been single dose co-amoxiclav prophylaxis. Prolonged episodes of diarrhoea will increase the risk of wound contamination and may lead to wound infection. For that reason we are suggesting this alternative regimen which maintains the spectrum of cover but reduces the impact on the patients bowel flora.

For open fractures, the guidance from the British orthopaedic Association and British Association of Plastic Reconstructive and Aesthetic Surgeons Standard for Trauma (2009)9 will be followed but peri-operative gentamicin will be replaced by ciprofloxacin due to the high incidence of post-operative renal impairment in severe trauma patients.

Provenance

Record: 1747
Objective:

The aim of antimicrobial prophylaxis in orthopaedic and trauma surgery is a reduction in surgical site infection.

Clinical condition:

Orthopaedic and trauma surgical procedures

Target patient group: All patients undergoing Orthopaedic and trauma surgery
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

Evidence level (A,B,C, D)

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. LTHT Consensus (no national guidelines exist, guidelines from different learned bodies   contradict each other, or no evidence exists)

References

  1. Gemmell CG, Edwards DI, Fraise AP, Gould FK, Ridgway GL, Warren RE, et al. Guidelines for the prophylaxis and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in the UK. 2006. p. 589-608
  2. SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Ed Leaper D, Collier M, Evans D, Farrington M, Gibbs E, Gould K, et al.
  3. Surgical Site Infection: prevention and treatment of surgical site infection. In: health NCcfwac, editor.: Royal College of Obstetrics and Gynaecology, Press; 2008. (NICE)
  4. Fenton P et al. Journal Hospital Infection Volume 68, Issue 4, April 2008, Pages 376-37 Clostridium infection following hip surgery.
  5. Health Protection Agency. Fourth Report of the Mandatory Surveillance of Surgical Site Infection in Orthopaedic Surgery. April 2004 to March 2008. London: Health Protection Agency, November 2008.
  6. Eur J Orthop Surg Traumatol (2009) 19:23–26  Ansari A Antibiotic prophylaxis for joint replacement surgery: the current practice in Britain
  7. Injury, Int. J. Care Injured 40 (2009) 746–751  Gulihar A. Clostridium difficile in hip fracture patients: Prevention, treatment and associated mortality
  8. International Journal of Antimicrobial Agents 33 (2009) 437–440 Kanellakopoulous K Efficacy of teicoplanin for the prevention of surgical site infections after total hip or knee arthroplasty: a prospective, open-label study
  9. British orthopaedic Association and British Association of Plastic Reconstructive and Aesthetic Surgeons Standard for Trauma (2009)

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

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