Prophylactic Antibiotics in Orthopaedic Surgery ...

1 ORIGINALARTICLEP rophylacticAntibioticsinOrthopaedicSurge ry:GuidelinesandPractice____rrllll!ll!ll lI!ll! !lllllllllllJll__rrllz!lIl__ J SYeap,FRCS*,JWLi1n*,MVergis*,P SAnYenng*,C KChin,MD**,HSingh,FRCS**-InternationalMe dicalUniversity,JalanRasah,Seremban70300 ,NegeriSembilan,--DepartmentofOrthopaedi cs,SerembanHospital,JalanRasah,Seremban7 0300,NegeriSembilanIntroductionInfection isa , ',althoughtheevidenceisnotentirelyundisp uted6 Insurgeriesofthehip, , ,thereisinfacta nationalclinicalpracticeguidelineonthera tionaluseofantibioticsinThisarticlewasac cepted:5 December2005 CorrespondingAuthor:YeapJooSeng,Seremban SpecialistHospital,JolonToman7,KemayanSq uare,Seremban70300,NegeriSembilanMedJ ,toidentifythecommonlyusedantibioticsfor prophylaxis, , ,therelevantdatawasobtainedfromthepatien ts'caserecordsandrecordedina 'sdemographicdetails,historyofallergiest oantibiotics, ,theoperationnotesorthedrugchart,andif it was, , ,it isusually'ordered' 'prescribed'onthedrugchart, ,andiftheywere,theantibioticschosen, ,thepatient'sdrugchartwascheckedtodeterm inewhethertheantibioticwasprescribedonth edrugchartandwhetherthenurses' ithadbeenprescribedonthedrugchartanda (68males,35females) ,24 Chinese,22 Indians,2 Sikhs,and3 (range13to93;median37years).

2 Totalof86patientswhohadsurgeryforfractur es( (86%),allbyintravenous(IV) (Zinacef)wasgivento39patients,cefoperazo ne(Cefobid)27,andceftriaxone(Rocephin) (95%) :cefuroximein46patients,24cefoperazone,s ixceftriaxone,onemetronidazoleandcefurox ime, (93%) ;itwasnotorderedinthepost-operativeinstr uctionsinfourpatients,theantibioticwasor deredinthepost-operativenotesbutnotpresc ribedonthedrugchartinonepatient, , ,it , , (10kneereplacementsandseventotalhiprepla cements).Pre-operativeantibioticwasgiven byintravenousroutetoall17patients(100%)( TableII).Sevenpatientsweregivenceftriaxo ne,sixcefoperazone,twopatientsweregivena combinationofcefoperazoneandgentamycin, MalaysiaVol61No2 June2006 ProphylacticAntibioticsinOrthopaedicSurg ery:GuidelinesandPracticeIntravenouspost -operativeantibioticwasorderedin16patien ts(94%)(ninecefoperazone,fiveceftriaxone andtwocefuroxime).)

3 (88%). , , ,post-operativeantibioticwasorderedinthe operationnotes, ,91patients(88%)weregivenpre-operativean tibioticsand95patients(92%)weregivenpost -operativeantibiotics(seeTableV).Inthree patients, 19-year-oldChinesemanwhounderwenttension bandwiringofa (p= ).TableI:Thetypesofinternalfixationforcl osedfracturesandthenumberofpatientsTypes ofinternalfixationNumberofpatientsPlatin g35 Intramedullarynailing(Interlockingnail/K untschernail)22(13+9)Wiring(Kirschner/ othertypesofwiring)10(6+4)Hipfixation(Dy namichip/ Dynamiccondylar/ cannulatedscrew)10(6+1+3)Hiphemiarthropl asty9 Total86 TableII:Thetyresanddosagesofthepre-opera tiveantibioticsgiventopatientswhohadinte rnafixationfortheirfracturesandpatientsw hohadjointreplacementTypesanddosageofant ibioticInternalfixationJointreplacementN umberofpatients(%)Numberofpatients(%)Cef uroxime750mg8 ( )0(0)Cefuroxime1 91( )0(0) ( )2 ( )Cefoperazone1 924( )4 ( )Cefoperazone2 93( )2 ( )Cefoperazone2 9 +Gentamicin80mg0(0)2 ( )Ceftriaxone1 94( )2 ( )Ceftriaxone2~4( )5 ( )Total7417 MedJ MalaysiaVol61No2 June2006183 ORIGINALARTICLET ableIII.

4 Thedosageanddurationofthepost-operativea ntibioticsorderedforpatientswhohadintern alfixationfortheirfracturesTypesanddosaa eofantibioticIVCefuroxime750mg8-hourlyIV Cefuroxime750mg8-hourly1 8-hourlyOtherdosesanddurationofcefuroxim eIVCefoperazone1 912-hourlyIVCefoperazone1 912-hourly3dosesIVCefoperazone1 9 3dosesIVCefoperazone1 912-hourly1 dayIVCefoperazone1 912-hourly2daysIVCefoperazone1 912-hourly3daysOtherdosesanddurationofce foperazoneIVCeftriaxone1 9daily3dosesIVCeftriaxone2 9daily2daysIVCeftriaxone1 912-hourlyIVCeftriaxone1 9 12-hourly2dosesIVCeftriaxone750mg12-hour lyOtherantibioticsTotalNumber18129115572 2215121111380 1week(laterchangedto750mg8-hourly1week)C efuroxime750m!=!8-hourlyTotal184 Number1611111111116 MedJ MalaysiaVol61No2 June2006 ProphylacticAntibioticsinOrthopaedicSurg ery:GuidelinesandPracticeTableV'Summaryo fantibioticsadministrationinthepatients, Pre-operativeantibioticPost-operativeant ibioticTotalnumberOrderedinNotorderedOrd eredinNotorderedActuallyofpatientsOpnote sOpnotesOpnotesinOpnotesadministeredPlat ing+/-K wiring3143323235 Intramedullarynailing1932202222K wiringorwirefixation9191910 DHS/DeS/cannulated9191810screwforhipfrac ture09*9 Hiphemiarthroplasty639 Totalkneereplacement10091810 Totalhipreplacement707077 TotalNumberofPatients911298595103 - 'Patientgroupandthepre-operativeantibiot icsgivenforprophylaxis,PatientgroupTypes ofantibioticsgivenTotal2ndgeneration3rdg enerationcephalosporincephalosporinJoint replacement21517 Internalfixationforfractures393574 Total415091(x'= ,df=1,p= )

5 DiscussionIt wasencouragingtonotethatprophylacticanti bioticsappearedtobewidelyusedinthisstudy , ,itislikelythatmorethan88%wouldprobablyh avereceivedpre-operativeantibioticsbecau seinsomecases,it ,prophylacticantibioticsmustbeusedapprop riately, , ,cefoperazonein365%, , , , , ,worldwide,judgingfromtheoverwhelmingnum berofpublishedstudiesandfromthefindingso fsurveys'o,,,..ChoiceofantibioticsThepre sentnationalguidelinesrecommendcloxacili nincombinationwithgentamicinasthefirstch oice,andasecondgenerationcephalosporinas thesecondchoiceantibioticsforprophylaxis insurgeryforInterestingly,thereappearsto bea preferenceforusingthirdgenerationcephalo sporins(cefoperazoneandceftriaxone)forar throplasty( )andsecondgenerationcephalosporin(cefuro xime)forfracturefixations( ) MalaysiaVol61No2 June2006185 ORIGINALARTiClEgenerationcephalosporinbe chosenforarthroplastyandasecondgeneratio ncephalosporinforfracturefixation?

6 ,coagulase-negativestaphylococcusandgram negativebacilli14" ,thirdgenerationcephalosporinsarelessact iveagainstGram-positivebacteriathanthese condgenerations,mostnotablystaphylococcu saureus,buttheyaremoreactiveagainstsomeG ram-negativebacteria' ' ' ,itwouldbeextremelydifficulttoshowthatan effectiveantibioticisstatisticallysuperi ortoanotherbecausetherateofinfectionwith prophylaxisisgenerallyalreadylow(lesstha n3%).CostimplicationsMazza4reportedthata singledoseceftriaxonegivenprophylactical lywasa thirdgenerationoverasecondgenerationceph alosporin? , (Zinacet) 750mgdose; 1 gdose; 1 gdose(figuresfromNSChineseMaternityHospi tal&MedicalCentre,Seremban).Ceftriaxonec anbegivenoncedaily, , ,11ofthe17patients( ) ,37of74patients(50%) ,intermsofthedosage, ,theantibioticsshouldpreferablybegiven30 to60minutesbeforethesurgery,orattheinduc tionofanaesthesiaoratleasttenminutesbefo reinflationoftourniquet6, ,buttherewasnorecordtoshowwhentheantibio ticswereactuallygiveninrelationtosurgica lincision, , ,althoughmoststudiesreportthatthereisnoa dditionalbenefitwhenantibioticprophylaxi swascontinuedbeyond24hourss, , ,a , (20%), ,thedurationornumberofdoseswasnotstatedi n44of82patients( )whileinsevenpatients( ), ,itcanbeseenthatthepost-operativeinstruc tionswereoftenunclear,withthedurationort henumberofdosesrequiredoftennotstated(Ta bleIV).

7 Whereitwasstated,therewasagreatvariation , , ,whichcanhappeninabusysettinglikethishos pital,canbeMedJ MalaysiaVol61No2 June2006 ProphylacticAntibioticsinOrthopaedicSurg ery:GuidelinesandPracticepreventedifthed octorswhoarewritingthepost-operativeinst ructionsalsoprescribeonthedrug" ,theantibioticswereprescribedonthedrugch art, , InScotlandin1996, ,there emergencyhipsurgeryontheotherhand,halfof theconsultantsdidnotprescribeantibiotics ,andonly33% ,fivewereomitted".InEngland, ,SmithRL,BallardA,LarsonI].Prophylactica ntibioticsinelectiveorthopedicsurgery:a prospectivestudyof1, 1977;70 Suppl1 ;53 ,BroekhuizenT,PatkaP, ;347(900) Chemother2000;12 Suppl3 , , , ,GrassiF,CherubinoP,NobiliS, Chemother2001;1 ,WichelhausTA,Schaferv, ;32 ,RussoRR, ;419 'J, ;(1) '' ''http: , RColiSurgEdinb1992;37 ,ChauL,WattersonJ,MackenzieT, !

8 1999;20 ,ChanFC,O'RourkeP, 2003;96 ;39 ,GarciaS,LozanoML,SorianoE, BoneJointSurg1987;69- ,LozanoML,GatellJM,SorianoE,RamonR, ;73- ; ,NoerHH,ScaveniusM,JorgensenPS, ;27 ,NurmiI, ;89 Surg1984;148 ,CarrionWV, ;296 , ;190 , ;205 ,EveillardM, ;56 ,DuthieR,MaffuliN, RColiEdinb1996;41 ,SreenivasM, ColiSurgEngl2004;86 MalaysiaVol61No2 June2006