Thursday, December 26, 2013

Should antibiotics be withheld before revision surgery? Are the rules for hip/knee the same as for shoulder?

The chitranjan ranawat award: should prophylactic antibiotics be withheld before revision surgery to obtain appropriate cultures?

The authors point out that on one hand, preoperative antibiotics are known to be critical for decreasing the risk of periprosthetic joint infection and on the other hand preoperative antibiotics may affect the surgeons ability to obtain meaningful intraoperative cultures.

The authors studied 65 patients with known preprosthetic joint infections after 37 TKAs and 28 THAs as documented by a culture-positive aspiration. Patients were randomized to receive prophylactic antibiotics either before the skin incision or after a minimum of three sets of intraoperative cultures were obtained.

There was no significant difference: intraoperative cultures yielded the same organisms as preoperative cultures in 28 of 34 patients (82%) randomized to receive antibiotics before the skin incision compared to 25 of 31 patients (81%) randomized to receive antibiotics after obtaining operative cultures.

The authors conclude that given the known benefits of prophylactic antibiotics in preventing periprosthetic joint infections, preoperative prophylaxis should not be withheld in revision surgery for fear of affecting cultures.

Comment: It is important to recognize that all these patients had known infections documented before surgery. These are not the individuals in whom one would want to withhold antibiotics because the purpose in doing so is to detect an unknown infection in suspicious cases. Their argument for giving prophylactic antbiotics is to prevent periprosthetic infections, however this series included patients that already had known infections.

We continue to withhold antibiotics before revision shoulder arthroplasty surgery because infections are rarely diagnosable before surgery by aspiration or other means, because the intraoperative evidence bearing on the presence or absence of infection is usually inconclusive, and because the common organisms (Propionibacterium and staph epidermidis) are relatively difficult to culture even without the additional confusion caused by the administration of preoperative antibiotics.


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