Guideline for antimicrobial prophylaxis for trauma orthopaedic surgery (excl. hand surgery)

1. Summary table of routine recommendations
2. Background information
3. Special antimicrobial prophylaxis recommendations

• Appendix 1 - Guide to urine screening in pre-operative joint arthroplasty patients

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 before incision.

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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 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.
One Cochrane systematic review was identified that investigated the effect of antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. [EL = 1+] This review included trials examining wound infection for hip fracture as well as trials for long bone and other unspecified closed fractures. Only long bone and other unspecified closed fracture trials that examined the effect of prophylactic antibiotics versus placebo were included. This left five trials available for inclusion in this review. A meta-analysis (Figure 5.14) of three trials that considered the deep and superficial infection rates following multiple doses of a single antibiotic compared with placebo found that statistically significantly fewer wound infections occurred in the antibiotic group (RR 0.49, 95% CI 0.25 to 0.96, 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 given 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.

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