TKA is a widely performed procedure with a high rate of success and a low complication rate. Though shortened hospital stays and improved surgical outcomes have been observed during the last decade, PJI remains a paramount concern. [13] Feng B, et al. reported the highest percentage of revision operations to be among patients that had SSI diagnosed during follow-up visits. [14] In addition to increased rates of morbidity and mortality, revision knee replacement is expensive. Antimicrobial prophylaxis has been proven to reduce the SSI rate in many types of surgery. The adverse effects of antibiotic overuse in arthroplasty surgery included worsened MRSA outbreak, increased incidence of Clostridioides difficile infection, and acute kidney injury. [15] A 24-hour course of antibiotic prophylaxis is considered enough to prevent SSI by reducing transient bloodstream infection. [16, 17] Thus, the International Consensus on Periprosthetic Joint Infection recommended a 24-hour course for the prevention of surgical site infection.
Published studies and guidelines have suggested/recommended that the duration of antibiotic prophylaxis not exceed 24 hours. [8, 9] However, in clinical practice, the decision how to prescribe antibiotic prophylaxis in TKA or UKA surgery depend on many factors, such as surgeon’s preference, drain usage, ambient temperature, degree of leukocytosis, hospital protocols, intraoperative findings, and patient perception. A study conducted in Canada showed that only 42% of orthopedic patients had antibiotics discontinued within 24 hours after surgery, and more than 70% of patients received > 72 hours of antibiotic after surgery in Taiwan. [18] In developing countries, many surgeons prefer to extend the course of antibiotic beyond 24 hours because their surgical environment, including operating rooms and surgical draping, failed to comply with the principles of surgical asepsis. Concerning patient-related factors, poor hygiene and history of high incidence of PJI also contributed to the decision regarding how to prescribe perioperative antibiotic prophylaxis. [19] To our knowledge, no study has investigated the incidence of PJI related to duration of ATB in developing countries. Our study compared the surgical outcomes of UKA and TKA patients between those who received antibiotic prophylaxis for ≤ 24 hours and those who received antibiotic prophylaxis for > 24 hours. Our results revealed no significant difference between groups for either superficial or deep SSI. Age at operation, BMI, ASA score, type of surgery, type of antibiotic drug, and hospital LOS were all found not to be significantly associated with infection following TKA. Blood transfusion appeared to increase SSI, but without statistical significance. Based on these findings, we recommend that antibiotic administration not exceed 24 hours to minimize adverse events associated with antimicrobial drugs, to save cost, and to reduce the length of hospital stay.
Nelson CL, et al. reported no statistically significant difference among patients with total joint arthroplasty (TJA) or hip fracture repair compared between those who received antibiotic for 24 hours or less, and patients who received antibiotic for more than 24 hours after surgery. [20] A double-blind multicenter study included 1,354 patients who underwent primary or revision TJA. One day of cefuroxime administration was compared with three days of cefazolin prophylaxis for surgical site infection. The infection rate was lower in patients who received antibiotics for 24 hours postoperatively in both TKA (0.6% vs. 1.4%) and total hip arthroplasty (THA) (0.5% vs. 1.2%). [21] A recent study in PJI following aseptic TKA revision demonstrated that first-generation cephalosporin prophylaxis for 24 hours did not result in a significantly different rate of infection compared with an extended course (p = 0.14). [22] Moreover, other studies demonstrated that postoperative antibiotic drug continuation with multiple dosing regimen is not more effective than single-dose regimen for preventing SSI or PJI. [23–25] In contrast, recent evidence suggested that prolonged oral antibiotic prophylaxis for up for 1 week may yield benefit in high-risk patients, especially in those with comorbidities that are associated with increased susceptibility to infection, by reducing the incidence of infection within 90 days following TJA. [26]
Blood transfusion was not found to be a significant risk factor for PJI in our study. We found infection rates of 2.2% and 0.8% in patients with and without blood transfusion, respectively. In contrast, a recently published study that investigated for risk factors significantly associated with PJI after TKA found red blood cell (RBC) transfusion to be a significant risk factor for postoperative infection (OR: 4.60). Other significant risk factors for PJI and TKA found in that study included prolonged operative time (> 90 minutes), tourniquet time (> 60 minutes), non-antibiotic-laden cement use, obesity (BMI > 30 kg/m2), diabetes, and ASA grade ≥ 3. [27]. In another study, surgical site infection developed in 2.82% of patients who received red blood cell (RBC) transfusion, but in only 0.4% of those who did not. [28]
This study has some limitations that should be disclosed. The first limitation is our study’s retrospective design, many confounding factors cannot be controlled. The second is that our groups were not equal in size. The extended course group was approximately 2 times larger than the standard course group. Third, the baseline characteristics of our patients were different from those reported in other studies, so comparisons between our study and other studies should take this factor into account. Fourth and last, we did not perform multivariate analysis to exclude potentially confounding factors. Having acknowledged those limitations, our finding that standard course is not inferior to extended course of antibiotic prophylaxis against postoperative PJI is consistent with the findings of previously reported studies.