Journal of Orthopaedic Surgery 2013;21(3):273-4
Editorial: Antibiotic prophylaxis for hip fracture surgery: three-dose cefuroxime versus single-dose gentamicin and amoxicillin Edward HM Wang, Donnel Alexis Rubio
Department of Orthopaedics, University of the Philippines-Philippine General Hospital, The Philippines
Surgical site infection (SSI) is an important concern in orthopaedic practice. In this issue, Jettoo et al.1 investigated issues related to (1) single versus multiple doses of antibiotic prophylaxis, (2) adverse effects of multiple dosing, and (3) choice of an appropriate antibiotic. In an attempt to address the concomitant problems of cefuroxime-resistant pathogens and Clostridium difficile infections, the authors’ hospital changed the antibiotic prophylaxis regimen from 3 doses of cefuroxime to a single dose of gentamicin plus amoxicillin. The authors made a historical comparison (2006 and 2008) of 2 groups of hip arthroplasty patients who received these 2 different antibiotic protocols in terms of incidence of C difficile infection, length of hospital stay, use of postoperative antibiotics, and overall 180-day mortality. Without doubt, antibiotic prophylaxis reduces SSI in hip fracture surgery.2,3 A meta-analysis showed a highly significant 45% relative risk reduction with antibiotic usage (p=0.008). The incidence of infection in the treatment group was half that in the controls (5.4% vs. 10.4%), and the number needed to treat was 20.2 Whether a single dose of antibiotics is sufficient compared to antibiotic prophylaxis for 24 to 48 hours is not known. A meta-analysis failed to demonstrate superiority of multiple-dose prophylaxis over a singledose strategy.4 Available data do not show superiority of either regimen in preventing postoperative wound infection.5 The issue remains unresolved because of the relatively low incidence of SSI. A multicentre randomised controlled trial with a large number of patients per arm (over 10 000) is needed to detect small differences.4
An increase in C difficile infection is usually attributed to disruption of normal gut microflora, often by the use of antibiotics such as cephalosporins, and the consequent loss of the protective effect provided by normal intestinal microflora against C difficile.6 Other risk factors for C difficile infection include age, hospitalisation, and being immunecompromised as a result of trauma.7 In this issue, Jettoo et al.1 show a significant drop in C difficile infection (6% vs 0%) in the 2008 patient group, but whether the improvement can be attributed solely to the change in antibiotic prophylaxis protocol is difficult to verify. Many other variables including changes in hospital policy and operations may have contributed to this improvement. Neither the efficacy nor the cost-effectiveness for SSI resulting from this shift in antibiotics was described. In 1980, a study reported an increased trend in cephalothin-resistant bacterial infection in hip fracture patients given prophylactic cephalothin for 72 hours.8 In 1970, another study reported an increased incidence of penicillin-resistant Staphylococcus aureus in a hospital from 10% to 60% over 3 years, even if SSI was controlled with a penicillin-based prophylaxis protocol given over 5 days (1.7% vs 8.9% in the placebo group).9 Jettoo et al.1 advocate the use of a single prophylactic dose of gentamicin plus amoxicillin and avoid the use of cephalosporins. The aminoglycosides, however, are not without their own side-effects. Development of acute kidney injury after antibiotic prophylaxis with single-dose gentamicinflucloxacillin has been reported.10,11
Optimal prophylaxis should ensure adequate concentrations of an appropriate antibiotic in serum and tissue during the time that the surgical wound is open and at risk for bacterial contamination. The chosen antibiotic should be active against bacteria likely to contaminate the wound as well as be safe and inexpensive. Antibiotic prophylaxis should have the smallest impact possible on the normal
bacterial flora of the patient and the biogram of the community.12 Antibiotic prophylaxis is one of many methods for decreasing SSI. More importantly, maintaining sterility within the operating room environment, proper tissue handling, and ensuring patients and caregivers hygiene are keys to a minimal yet optimal antibiotic prophylaxis.
REFERENCES 1. Jettoo P, Jeavons R, Siddiqui B, O’Brien S. Antibiotic prophylaxis for hip fracture surgery: three-dose cefuroxime versus single-dose gentamicin and amoxicillin. J Orthop Surg (Hong Kong) 2013;21:324–7. 2. Southwell-Keely JP, Russo RR, March L, Cumming R, Cameron I, Brnabic AJ. Antibiotic prophylaxis in hip fracture surgery: a metaanalysis. Clin Orthop Relat Res 2004;419:179–84. 3. Gillespie WJ, Walenkamp GH. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev 2010;3:CD000244. 4. Slobogean GP, Kennedy SA, Davidson D, O’Brien PJ. Single- versus multiple-dose antibiotic prtophylaxis in the surgical treatment of closed fractures: a meta-analysis. J Orthop Trauma 2008;22:264–9. 5. Morrison S, White N, Asadollahi S, Lade J. Single versus multiple doses of antibiotic prophylaxis in limb fracture surgery. ANZ J Surg 2012;82:902–7. 6. Freeman J, Wilcox MH. Antibiotics and Clostridium difficile. Microbes Infect 1999;1:377–84. 7. Bartlett JG. Clinical practice. Antibiotic-associated diarrhea. N Engl J Med 2002;346:334–9. 8. Burnett JW, Gustilo RB, Williams DN, Kind AC. Prophylactic antibiotics in hip fractures. A double-blind, prospective study. J Bone Joint Surg Am 1980;62:457–62. 9. Fogelberg EV, Zitzmann EK, Stinchfield FE. Prophylactic penicillin in orthopaedic surgery. J Bone Joint Surg Am 1970;52:95– 8. 10. Challagundla SR, Knox D, Hawkins A, Hamilton D, W V Flynn R, Robertson S, et al. Renal impairment after high-dose flucloxacillin and single-dose gentamicin prophylaxis in patients undergoing elective hip and knee replacement. Nephrol Dial Transplant 2013;28:612–9. 11. Craxford S, Bayley E, Needoff M. Antibiotic-associated complications following lower limb arthroplasty: a comparison of two prophylactic regimes. Eur J Orthop Surg Traumatol 2013 Nov 1. 12. Prokuski L. Prophylactic antibiotics in orthopaedic surgery. J Am Acad Orthop Surg 2008;16:283–93.
Editorial: Antibiotic prophylaxis for hip fracture surgery: three-dose cefuroxime versus single-dose gentamicin and amoxicillin Edward HM Wang, Donnel Alexis Rubio
Department of Orthopaedics, University of the Philippines-Philippine General Hospital, The Philippines
Surgical site infection (SSI) is an important concern in orthopaedic practice. In this issue, Jettoo et al.1 investigated issues related to (1) single versus multiple doses of antibiotic prophylaxis, (2) adverse effects of multiple dosing, and (3) choice of an appropriate antibiotic. In an attempt to address the concomitant problems of cefuroxime-resistant pathogens and Clostridium difficile infections, the authors’ hospital changed the antibiotic prophylaxis regimen from 3 doses of cefuroxime to a single dose of gentamicin plus amoxicillin. The authors made a historical comparison (2006 and 2008) of 2 groups of hip arthroplasty patients who received these 2 different antibiotic protocols in terms of incidence of C difficile infection, length of hospital stay, use of postoperative antibiotics, and overall 180-day mortality. Without doubt, antibiotic prophylaxis reduces SSI in hip fracture surgery.2,3 A meta-analysis showed a highly significant 45% relative risk reduction with antibiotic usage (p=0.008). The incidence of infection in the treatment group was half that in the controls (5.4% vs. 10.4%), and the number needed to treat was 20.2 Whether a single dose of antibiotics is sufficient compared to antibiotic prophylaxis for 24 to 48 hours is not known. A meta-analysis failed to demonstrate superiority of multiple-dose prophylaxis over a singledose strategy.4 Available data do not show superiority of either regimen in preventing postoperative wound infection.5 The issue remains unresolved because of the relatively low incidence of SSI. A multicentre randomised controlled trial with a large number of patients per arm (over 10 000) is needed to detect small differences.4
An increase in C difficile infection is usually attributed to disruption of normal gut microflora, often by the use of antibiotics such as cephalosporins, and the consequent loss of the protective effect provided by normal intestinal microflora against C difficile.6 Other risk factors for C difficile infection include age, hospitalisation, and being immunecompromised as a result of trauma.7 In this issue, Jettoo et al.1 show a significant drop in C difficile infection (6% vs 0%) in the 2008 patient group, but whether the improvement can be attributed solely to the change in antibiotic prophylaxis protocol is difficult to verify. Many other variables including changes in hospital policy and operations may have contributed to this improvement. Neither the efficacy nor the cost-effectiveness for SSI resulting from this shift in antibiotics was described. In 1980, a study reported an increased trend in cephalothin-resistant bacterial infection in hip fracture patients given prophylactic cephalothin for 72 hours.8 In 1970, another study reported an increased incidence of penicillin-resistant Staphylococcus aureus in a hospital from 10% to 60% over 3 years, even if SSI was controlled with a penicillin-based prophylaxis protocol given over 5 days (1.7% vs 8.9% in the placebo group).9 Jettoo et al.1 advocate the use of a single prophylactic dose of gentamicin plus amoxicillin and avoid the use of cephalosporins. The aminoglycosides, however, are not without their own side-effects. Development of acute kidney injury after antibiotic prophylaxis with single-dose gentamicinflucloxacillin has been reported.10,11
Optimal prophylaxis should ensure adequate concentrations of an appropriate antibiotic in serum and tissue during the time that the surgical wound is open and at risk for bacterial contamination. The chosen antibiotic should be active against bacteria likely to contaminate the wound as well as be safe and inexpensive. Antibiotic prophylaxis should have the smallest impact possible on the normal
bacterial flora of the patient and the biogram of the community.12 Antibiotic prophylaxis is one of many methods for decreasing SSI. More importantly, maintaining sterility within the operating room environment, proper tissue handling, and ensuring patients and caregivers hygiene are keys to a minimal yet optimal antibiotic prophylaxis.
REFERENCES 1. Jettoo P, Jeavons R, Siddiqui B, O’Brien S. Antibiotic prophylaxis for hip fracture surgery: three-dose cefuroxime versus single-dose gentamicin and amoxicillin. J Orthop Surg (Hong Kong) 2013;21:324–7. 2. Southwell-Keely JP, Russo RR, March L, Cumming R, Cameron I, Brnabic AJ. Antibiotic prophylaxis in hip fracture surgery: a metaanalysis. Clin Orthop Relat Res 2004;419:179–84. 3. Gillespie WJ, Walenkamp GH. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev 2010;3:CD000244. 4. Slobogean GP, Kennedy SA, Davidson D, O’Brien PJ. Single- versus multiple-dose antibiotic prtophylaxis in the surgical treatment of closed fractures: a meta-analysis. J Orthop Trauma 2008;22:264–9. 5. Morrison S, White N, Asadollahi S, Lade J. Single versus multiple doses of antibiotic prophylaxis in limb fracture surgery. ANZ J Surg 2012;82:902–7. 6. Freeman J, Wilcox MH. Antibiotics and Clostridium difficile. Microbes Infect 1999;1:377–84. 7. Bartlett JG. Clinical practice. Antibiotic-associated diarrhea. N Engl J Med 2002;346:334–9. 8. Burnett JW, Gustilo RB, Williams DN, Kind AC. Prophylactic antibiotics in hip fractures. A double-blind, prospective study. J Bone Joint Surg Am 1980;62:457–62. 9. Fogelberg EV, Zitzmann EK, Stinchfield FE. Prophylactic penicillin in orthopaedic surgery. J Bone Joint Surg Am 1970;52:95– 8. 10. Challagundla SR, Knox D, Hawkins A, Hamilton D, W V Flynn R, Robertson S, et al. Renal impairment after high-dose flucloxacillin and single-dose gentamicin prophylaxis in patients undergoing elective hip and knee replacement. Nephrol Dial Transplant 2013;28:612–9. 11. Craxford S, Bayley E, Needoff M. Antibiotic-associated complications following lower limb arthroplasty: a comparison of two prophylactic regimes. Eur J Orthop Surg Traumatol 2013 Nov 1. 12. Prokuski L. Prophylactic antibiotics in orthopaedic surgery. J Am Acad Orthop Surg 2008;16:283–93.
