Intraoperative Bacterial Contamination and Activity of Different Antimicrobial Prophylaxis Regimens in Primary Knee and Hip Replacement.

Alba Rivera,Alba Rivera,Aránzazu González,Juan Pablo Horcajada,Juan Pablo Horcajada,Juan Pablo Horcajada,Luisa Sorlí,Luisa Sorlí,Luisa Sorlí,Isabel Mur,José Carlos González,Sonia Luque,Ferran Navarro,Alba Sánchez,Alba Sánchez,Xavier Crusi,Lluís Puig,Lluís Puig,Isabel Mur,Natividad Benito,Natividad Benito

doi:10.3390/antibiotics10010018

Abstract

Surgical antimicrobial prophylaxis (SAP) is important for the prevention of prosthetic joint infections (PJIs) and must be effective against the microorganisms most likely to contaminate the surgical site. Our aim was to compare different SAP regimens (cefazolin, cefuroxime, or vancomycin, alone or combined with gentamicin) in patients undergoing total knee (TKA) and hip (THA) arthroplasty. In this preclinical exploratory analysis, we analyzed the results of intraoperative sample cultures, the ratio of plasma antibiotic levels to the minimum inhibitory concentrations (MICs) for bacteria isolated at the surgical wound and ATCC strains, and serum bactericidal titers (SBT) against the same microorganisms. A total of 132 surgical procedures (68 TKA, 64 THA) in 128 patients were included. Cultures were positive in 57 (43.2%) procedures (mostly for coagulase-negative staphylococci and Cutibacterium spp.); the rate was lower in the group of patients receiving combination SAP (adjusted OR 0.475, CI95% 0.229–0.987). The SAP regimens evaluated achieved plasma levels above the MICs in almost all of intraoperative isolates (93/94, 98.9%) and showed bactericidal activity against all of them (SBT range 1:8–1:1024), although SBTs were higher in patients receiving cefazolin and gentamicin-containing regimens. The potential clinical relevance of these findings in the prevention of PJIs remains to be determined.

Highlights

Prosthetic joint infection (PJI) is a serious complication associated with substantial morbimortality and economic costs [1]
Antimicrobial prophylaxis plays a crucial role in reducing the incidence of PJIs, there is no consensus about antibiotic choice [26]
Another study found that the addition of gentamicin to cefazolin reduced the surgical site infections (SSIs) rate following THA [15]

Summary

Introduction

Prosthetic joint infection (PJI) is a serious complication associated with substantial morbimortality and economic costs [1]. Surgical antimicrobial prophylaxis (SAP), considered to be one of the most important preventive strategies, can help offset this by reducing the risk of surgical site infections (SSIs), including PJIs [3,4]. Cefazolin or cefuroxime (first- and second-generation cephalosporins, respectively) and vancomycin in cases of beta-lactam allergy, are the antibiotics most commonly used and recommended in current guidelines, there are no data supporting the superiority of one class of antimicrobials over another for SAP in total joint replacement [5,6]. Studies have suggested that a growing proportion of SSIs (including PJIs) following arthroplasty procedures are caused by organisms resistant to firstand second-generation cephalosporins, including both Gram-positive (mainly methicillinresistant staphylococci), and Gram-negative bacteria (such as some Enterobacterales or Pseudomonas aeruginosa) [8,9,10,11]. Routine prophylactic use of dual antibiotics (such as cephalosporins and aminoglycosides or cephalosporins and vancomycin) is not currently recommended [18]

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