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American Association of Hip and Knee Surgeons

Advocacy, Education, Research

AAHKS Position Statement on CDC Guideline: Post-Operative Prophylactic Antibiotics

For Immediate Release
November 17, 2017

Rosemont, IL – The Centers for Medicare & Medicaid Services (CMS) released their 2017 Guideline for the Prevention of Surgical Site Infection, which recommends against the use of post-operative prophylactic antibiotics – including patients undergoing total joint arthroplasty (TJA).

At this time, we do not agree with this recommendation vis a vis TJA in that it contradicts current international standards of care[1] with limited evidence and study.

There are several reasons for our concerns. The cited literature[2][3][4][5][6][7]is heterogeneous in terms of actual procedures, antibiotic regiments, and antibiotics used. It includes older papers and higher than expected infection rates. This is of particular concern given current ideal primary TJA infection rates that run less than 1%; the citations used appear to be underpowered to discern the true safety of withholding the post-operative antibiotics.

A recent TJA focused meta-analysis of this specific topic could only find four appropriate randomized control trials, two of which overlap with the citations given by the CDC.[8] Again, the aggregate infection rate is higher than ones reported as ideal and expected in the literature. The authors showed non-superiority for the post-operative antibiotics. Their conclusion, however, carried significant caveats. The available literature was considered flawed: “both reviewers rated down the quality of evidence from the 4 trials from high to very low based on (a) unclear risk of bias, (b) imprecision due to few outcome events and (c) inconsistency due to residual unexplained heterogeneity.” The very low quality of evidence rating was based on the widely accepted Grade methodology. The authors recommended that more rigorous multicenter trials were needed.

As an organization we agree with that recommendation. The consequences of a TJA infection are devastating to the patient, hard to eradicate, and costs society hundreds of thousands of dollars per case. It is our recommendation that implementation of this recommendation be delayed. We further recommend that the CDC join AAHKS in calling for funding to more rigorously answer this question.

To that end, the 2017 Foundation for Arthroplasty Research and Education (FARE) grant recipient, Thorsten M. Seyler, MD, PhD of Duke University, is conducting a prospective, randomized study, “Perioperative Antibiotic Prophylaxis in Patients Undergoing Elective Total Knee Arthroplasty.” This study is aiming to provide Level I evidence for or against single-dose versus 24-hour antibiotic prophylaxis in primary total knee arthroplasty (TKA) and is based on the most recent release of the Centers for Medicare & Medicaid Service’s guideline for perioperative antibiotics, which is based on limited evidence.

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Citations

[1] Gehrke T, Parvizi J. Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection. Rolle (Switzerland): European Federation of National Associations of Orthopaedics and Traumatology; 2013. Available: www.efort.org/wp-content/uploads/2013/10/Philadelphia_Consensus.pdf (accessed 2014July 03).
[2] Gatell JM, Garcia S, Lozano L, Soriano E, Ramon R, SanMiguel JG. Perioperative cefamandole prophylaxis against infections. The Journal of bone and joint surgery. American volume. Oct 1987;69(8):1189-1193.
[3]Buckley R, Hughes GNF, Snodgrass T, Huchcroft SA. Perioperative cefazolin prophylaxis in hip fracture surgery. Can J Surg. Apr 1990;33(2):122-127.
[4] Garotta F, Pamparana F. Antimicrobial prophylaxis with ceftizoxime versus cefuroxime in orthopedic surgery. Ceftizoxime Orthopedic Surgery Italian Study Group. Journal of chemotherapy. Feb 1991;3 Suppl 2:34-35.
[5] Ali M, Raza A. Role of single dose antibiotic prophylaxis in clean orthopedic surgery. Journal of the College of Physicians and Surgeons–Pakistan : JCPSP. Jan 2006;16(1):45-48.
[6] Ritter MA, Campbell E, Keating EM, Faris PM. Comparison of intraoperative versus 24 hour antibiotic prophylaxis in total joint replacement. A controlled prospective study. Orthopaedic review. Jun 1989;18(6):694-696.
[7] Wymenga AB, Hekster YA, Theeuwes A, Muytjens HL, van Horn JR, Slooff TJ. Antibiotic use after cefuroxime prophylaxis in hip and knee joint replacement. Clinical pharmacology and therapeutics. Aug 1991;50(2):215-220.
[8] Thornley P, Evaniew N, Riediger, Winemaker M, Bhandari M, Ghert M. Postoperative antibiotic prophylaxis in total hip and knee arthroplasty: a systematic review and meta-analysisof randomized controlled trialsCMAJ Open 2015. DOI:10.9778/cmajo.20150012

Additional Links

» Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection (2017)

» American Academy of Orthopaedic Surgeon (AAOS) 2014 Comment Letter on CDC Draft Guideline for the Prevention of Surgical Site Infections.

» American Academy of Orthopaedic Surgeon (AAOS) advisory opinion passed jointly by the Board of Councilors and Board of Specialty Societies in May of 2017, and then adapted by the AAOS Board in June of 2017 calling for further research on this issue.

About the American Association of Hip and Knee Surgeons:

Established in 1991, the mission of AAHKS is to advance hip and knee patient care through education and advocacy. AAHKS has a membership of over 3,700 surgeons and other hip and knee health care professionals.

Contact:
Denise Smith Rodd
drodd@aahks.org