Article
International Survey about the Clinical Practice of Perioperative Antibiotic Prophylaxis in Arthroplasty in Europe
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Authors
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Christof Berberich
- Department Medical Training, Heraeus Medical GmbH, Wehrheim, Germany
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Andrej Trampuz
- Charité - Universitätsmedizin Berlin, Centrum für Muskuloskeletale Chirurgie, Centrum für Septische Chirurgie, Berlin, Germany
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Nora Renz
- Charité - Universitätsmedizin Berlin, Centrum für Muskuloskeletale Chirurgie, Klinik für Unfall- und Wiederherstellungschirurgie, Berlin, Germany
| Published: | November 6, 2018 |
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Outline
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Objectives: Due to the easy bacterial colonization of implants, perioperative antibiotic prophylaxis (PAP) is considered mandatory in arthroplasty. However, concerns have been raised that PAP recommendations in guidelines may not take sufficiently into consideration the problem of growing antibiotic resistancies & higher infection risks of elder, comorbid patients.
These controversies have prompted the idea to perform a larger survey among different gatekeepers of PAP decisions across several countries.
Methods: >2000 registered subscribers of the Newsletter of the PRO-IMPLANT Foundation (https://www.pro-implant-foundation.org/) were invited to participate in an anonymous, web-based survey between February & March 2017. The vast majority of the subscribers are orthopaedic surgeons, infectious disease specialists (IDS) & clinical microbiologists (MiBi).
Except from simple yes o no questions, participants of the survey could choose among different already given answer options in a multiple-choice format.
Results: A total of 358 filled questionnaires were received & analysed. Countrywise, the majority of answers came from Germany (n=141), Spain (n=38) & Switzerland/Austria (n=37). 249 (70%) questionnaires were filled out by surgeons, 85 (24%) by IDS & MiBi. Most participants work in university or larger community hospitals (>80%).
Key Observations:
1. Cephalosporins (1./2. gen.) are still most widely used in routine PAP (94%).
2. First alternative antibiotic of choice is vancomycin/teicoplanin (65%, in Spain 85%), followed by clindamycin (40%, in Spain only 6%)
3. Single shot prophylaxis was reported by 62%. In Spain, however, most participants (70%) favor multiple doses (15% even beyond 24h).
4. Customization of PAP in response to bacterial resistance (MRSA, GNB) was reported by 33% (in Spain 53%).
5. Customization of PAP because of higher infections risks was reported by 72% (in Spain 84%). Main reasons were: septic revisions (80%), long duration of surgery (65%), unclear MRSA status (51%).
6. Dual PAP was considered in determined risk situations in 51% (in Spain 77%). A combination of glycopeptide & cephalosporin was then preferred (57%).
7. Use of a combination of systemic & local antibiotics was reported by 87%. Antibiotic-loaded bone cement (ALBC) with gentamicin was the preferred choice as local antibiotic carrier (92%). 50% use high dose ALBC in high risk patients & septic revisions.
Conclusions: The clinical practice reflects guideline recommendations in most countries. A standard PAP with a single cephalosporin prevails, except for UK where a dual PAP with flucloxacillin & gentamicin has been reported as the most common prophylactic regimen. However, deviations from the standard (PAP customization/dual antibiotics) are frequently performed in response to antimicrobial resistance & infections risks. This trend was more pronounced in the South of Europe (e.g. Spain), which may be explained by the higher prevalence of multiresistant pathogens there.
