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The Chitranjan Ranawat Award: Should prophylactic antibiotics be withheld before revision surgery to obtain appropriate cultures?

ABSTRACT: Preoperative antibiotics are known to be critical for decreasing the risk of periprosthetic joint infection (PJI) in primary THA and TKA. However, antibiotics often are withheld before revision surgery, as there is concern that even a single dose of prophylactic antibiotics may affect intraoperative cultures.In this prospective randomized controlled trial, we determined the effect of a single dose of prophylactic antibiotics on cultures obtained at the time of revision arthroplasty.We randomized 65 patients with known PJI after 37 TKAs and 28 THAs at three centers. Patients were included in the trial if they had a culture-positive aspiration and had not taken antibiotics within 2 weeks of the procedure. Patients were randomized to receive prophylactic antibiotics either before the skin incision or after a minimum of three sets of intraoperative cultures were obtained. Preoperative and intraoperative cultures were then compared. Results between patients who did and did not receive antibiotics were compared using an equivalence test for proportion differences (two one-sided t-tests [TOST]) with a 0.2 margin.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 (statistically equivalent by TOST estimate: p = 0.0290).In this randomized controlled trial, there was no effect on the results of cultures obtained intraoperatively when prophylactic antibiotics were administered before skin incision. Given the known benefits of prophylactic antibiotics in preventing PJI, preoperative prophylaxis should not be withheld in revision surgery for fear of affecting cultures.

SUBMITTER: Tetreault MW

PROVIDER: S-EPMC3889433 | biostudies-literature | 2014 Jan

REPOSITORIES: biostudies-literature

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The Chitranjan Ranawat Award: Should prophylactic antibiotics be withheld before revision surgery to obtain appropriate cultures?

Tetreault Matthew W MW Wetters Nathan G NG Aggarwal Vinay V Mont Michael M Parvizi Javad J Della Valle Craig J CJ

Clinical orthopaedics and related research 20140101 1

<h4>Background</h4>Preoperative antibiotics are known to be critical for decreasing the risk of periprosthetic joint infection (PJI) in primary THA and TKA. However, antibiotics often are withheld before revision surgery, as there is concern that even a single dose of prophylactic antibiotics may affect intraoperative cultures.<h4>Questions/purposes</h4>In this prospective randomized controlled trial, we determined the effect of a single dose of prophylactic antibiotics on cultures obtained at t ...[more]

PMID: 23633187

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Project description:BackgroundPrevious studies about antibiotic prophylaxis in foot and ankle surgery have focused on perioperative intravenous administration, with few studies reporting on the efficiency of postoperative oral antibiotics. The purpose of this study is to investigate differences in the rate of postoperative infection and wound complications between patients with and without postoperative oral antibiotics and to identify independent risk factors for these complications following foot and ankle surgeries.MethodsA retrospective review of all elective foot and ankle surgeries with at least a 6-month follow-up was performed over a 2-year time span. Patients were divided into 2 groups based on if they received postoperative oral antibiotics. We compared the rates of postoperative infections and wound complications between the 2 groups. The surgical site, the number of Current Procedural Terminology codes, and the number of surgical incisions were also noted. Multivariable logistic regression analysis was performed to identify independent risk factors of postoperative infection and wound complications.ResultsA total of 366 patients were included in this study-240 with antibiotics and 126 without antibiotics. There was no significant difference in the rates of postoperative infection and wound complications between the 2 groups. The rate of superficial infection, deep infection, and wound complications was 1.7%, 0.8%, and 5.8% in the antibiotic group vs 3.2%, 0.0%, and 4.0% in patients without antibiotics, respectively. Multivariable logistic regression analysis identified independent risk factors of postoperative infection and wound complications as follows: smoking (OR: 4.7), male (OR: 4.0), history of neoplasm (OR: 6.7), and multiple incisions (OR: 4.1).ConclusionOur results suggest that routine postoperative prophylactic oral antibiotics are not needed following elective foot and ankle surgeries. However, certain risk factors may increase the risk for postoperative infection and wound complications in foot and ankle surgery.Level of evidenceLevel III, case-control study.

Project description:BackgroundThe estimated annual global burden of miscarriage is 33 million out of 210 million pregnancies. Many women undergoing miscarriage have surgery to remove pregnancy tissues, resulting in miscarriage surgery being one of the most common operations performed in hospitals in low-income countries. Infection is a serious consequence and can result in serious illness and death. In low-income settings, the infection rate following miscarriage surgery has been reported to be high. Good quality evidence on the use of prophylactic antibiotics for surgical miscarriage management is not available. Given that miscarriage surgery is common, and infective complications are frequent and serious, prophylactic antibiotics may offer a simple and affordable intervention to improve outcomes.MethodsEligible patients will be approached once the diagnosis of miscarriage has been made according to local practice. Once informed consent has been given, participants will be randomly allocated using a secure internet facility (1:1 ratio) to a single dose of oral doxycycline (400 mg) and metronidazole (400 mg) or placebo. Allocation will be concealed to both the patient and the healthcare providers. A total of 3400 women will be randomised, 1700 in each arm. The medication will be given approximately 2 hours before surgery, which will be provided according to local practice. The primary outcome is pelvic infection 2 weeks after surgery. Women will be invited to the hospital for a clinical assessment at 2 weeks. Secondary outcomes include overall antibiotic use, individual components of the primary outcome, death, hospital admission, unplanned consultations, blood transfusion, vomiting, diarrhoea, adverse events, anaphylaxis and allergy, duration of clinical symptoms, and days before return to usual activities. An economic evaluation will be performed to determine if prophylactic antibiotics are cost-effective.DiscussionThis trial will assess whether a single dose of doxycycline (400 mg) and metronidazole (400 mg) taken orally 2 hours before miscarriage surgery can reduce the incidence of pelvic infection in women up to 2 weeks after miscarriage surgery.Trial registrationRegistered with the ISRCTN (international standard randomised controlled trial number) registry: ISRCTN 97143849 . (Registered on April 17, 2013).

Project description:BackgroundWeb-based services for testing of sexually transmitted infections are widely available across the United Kingdom. Remote prescriptions with medications posted home may support prompt treatment; however, the absence of face-to-face contact with clinicians raises clinical safety issues as medical history may not be accurately provided.ObjectiveThis service evaluation aimed to capture the use and explore the safety of 3 remote communication strategies employed within a web-based service offering remote prescriptions of antibiotics, delivered via post, for uncomplicated genital Chlamydia trachomatis. User acceptability and time-from-diagnosis-to-treatment were also obtained.MethodsThree iterations of the service were compared, where medical history was collected via SMS text message, telephone, or a secure web form before a prescription was issued. We contacted users after they were issued a prescription and completed the medical history a second time via telephone, asking when they took their medication and how they felt about the service. The primary safety measure was agreement in information supplied at 2 assessments (ie, clinical and evaluation assessment) on key elements of safe prescribing: allergies, current medications, or contraindicating clinical conditions or symptoms. Agreement in information between clinical and evaluation assessment was summarized as a binary variable. Factors associated with the assessment agreement variable were explored using univariate and multivariate analysis. The secondary evaluation measures were recall of and adherence to instructions for taking medication, time-from-diagnosis-to-treatment, and acceptability of the web-based service.ResultsAll web-based service users, resident in the London Boroughs of Lambeth and Southwark with a positive chlamydia diagnosis, who were eligible for and chose postal treatment between February 15, 2017, and October 24, 2017, were invited to participate in this service evaluation. Of 321 eligible users, 62.0% (199) participated. A total of 27.6% (55/199) users completed the clinical assessment via SMS text message, 40.7% (81/199) users via telephone, and 31.7% (63/199) users via a secure web form. Those who were assessed for prescription via SMS text message were less likely to have an agreement in safe prescribing information than those assessed via telephone (adjusted odds ratio [aOR] 0.22, 95% CI 0.08-0.61; P=.004). We found no statistically significant difference in odds of agreement between the web form and telephone assessment (aOR 0.50, 95% CI 0.17-1.43; P=.20). Median time-to-treatment was 4 days (IQR 3-5.5). In addition, 99.0% (196/199) of users reported understanding remote communication, and 89.9% (178/198) would use the service again.ConclusionsPostal treatment is an acceptable and rapid treatment option for uncomplicated genital chlamydia. Clinical assessment via SMS text message before remote prescription may not be accurate or sufficient. As health care is delivered via the web, strategies that support safe remote prescribing are increasingly important, as is their evaluation, which should be robust and carefully considered.

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The Chitranjan Ranawat Award: Should prophylactic antibiotics be withheld before revision surgery to obtain appropriate cultures?

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The Chitranjan Ranawat Award: Should prophylactic antibiotics be withheld before revision surgery to obtain appropriate cultures?

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