Prophylactic antibiotic use in orthopaedic surgery - is it worth it?

Abstract

Introduction: The administration of pre-operative prophylactic antibiotic is widely accepted in decreasing the risk of developing surgical site infections in orthopaedic surgery. The choice of antibiotic, duration, dosage and use of antibiotic laden bone cement varies substantially in clinical practise. Aims: This meta-analysis was conducted to assess the association of antibiotic choice, duration and dosage on the prevalence of surgical site infections in different types of orthopaedic surgery (hip replacements, knee arthroplasty, spinal surgery, ankle and foot surgery, shoulder surgery) and the identification of causative microorganisms. Methods: A literature search was performed in MEDLINE databases, Cochrane Controlled Trials Register published in the Cochrane Library, and Science Direct from January 2000-February 2018. Outcomes of interest included presence of post-operative surgical site infections. The Critical Appraisal Skills Programme tool was used to assess the risk of bias, extract outcomes of interest and to identify studies for inclusion in the meta-analysis. Results: The literature search revealed 169 studies out of which 18 studies were analysed and ultimately six studies in total were included in this meta-analysis. The pooled data investigating the post-operative deep surgical site infections rates favouring the use of prophylactic antibiotics (p=0.03). Only one study showed statistical significance (p=0.041) favouring the usage of high dosage antibiotic loaded bone cement in hemiarthroplasty procedures. Conclusion: This systematic review and meta-analysis recommends the use of high-dose antibiotic loaded bone cement and prophylactic oral antibiotics concurrently and as indicated, to prevent surgical site infections in hemiarthroplasties. The duration of prophylactic antibiotic use should be restricted to 24 hours commenced preoperatively or within 1-2 hours from incision. This systematic review also highlights the urgent need for more double blind RCT to validate the prophylactic use of antibiotics.