ANTIBIOTIC PROPHYLAXIS IN

ORTHOPAEDIC SURGERY

Rhyan Darma Saputra

Musculoskeletal Tumor Division

FK Universitas Sebelas Maret / RSUD. Dr. Moewardi / RSO Prof. dr.
R. Soeharso
Surakarta
SURGICAL SITE INFECTION (SSI)

WHAT IS SSI??

Infection of the surgical wound within 30 days after

an operation or 1 year after an implant is placed in
a patient
The worldwide incidence of SSI is between
2.6% - 41.9%
•SSI INCIDENCE
•SAUDI ARABIA
• a 5-year analysis of SSI in orthopaedic surgery in one hospital is ± 2.55%
•UNITED STATES ± 1.07% /year with 8000 death case

•OTHER STUDY FROM IRAN

•The incidence of SSI was 3.84%
•Preoperative Antibiotic prophylaxis
•reduce the infection risk in major operation from 4-8% to 1-3% in Arthroplasty
Antibiotic prophylaxis is very useful, but if we
don’t follow the right guideline or protocol it
may lead to antibiotic resistance
•Effect of SSI
•Worse Outcome
•Prolong Duration of Operation
•↑ Morbidity
•and Mortality
•Increased Patient Cost
•Related to Success Operation Procedure Rate
 •MRSA
•MRSE

Methicillin Resistant Methicillin Resistant

Staphylococcus aureus Staphylococcus Epidermidis
65% of coagulase-negative staphylococci have become
resistant to meticillin during the past two decades
US National Nosocomial Infection Surveilance
Strain S. Aureus is a common body
commensal and they colonize skin
surface about 1/3 of the general
population

Nasal carriage is the

commonest site of colonisation of
S. Aureus

Nasal screening has shown to

detect 66% of carriers and
combined nasal and perineal
swabs have improved detection
rates up to 82%
• Bacteria Decolonisation in nasal and perineal area can ↓ SSI Rates
•Chlorhexidine Body Washes for 5 Days Immediately Before Surgery

•Topikal Intranasal
•Mupirocin
•Preoperative Antibiotic Prophylaxis
SURGICAL SITE INFECTION
BIOFILM IN ORTHOPAEDIC
AX & PE
DIAGNOSIS LABORATORY PARAMETERS

X RAY HISTOLOGIC &

MICROBIOLOGIC ANALYSIS CT SCAN
 Surgical Wound
Classification by Centers for Diseases
Control (CDC)
Class 1 (Clean)

Class 2 (Clean-contaminated)

Class 3 (Contaminated)

Class 4 (Dirty/infected)
SISTEMIC FACTOR

•Malnutrition
•Obese
•Diabetes Mellitus
•Smoking
•Iatrogenic Immune Suppression
•Rheumatoid Arthritis
Prevention of surgical site
infections

•Hand Scrub
•Preoperative Showering
•Preoperative Skin Preparation
•Double Gloving
•Or Regular Glove-changing
•Hair Removal
 ANTIBIOTIC PROPHYLACTIC IN
ORTHOPAEDIC SURGERY

Reducing the risk of infection of prosthetic implant 3 Times lower

Close Fracture → Reducing the risk of infection > 50% compare to

placebo

Open Fracture → efective in gram (-) & gram (+), antibiotic should be
administered within 3 hours after initial injury

Arthroplasty Procedure → Reducing the risk of infection to 81%

Timing of pre-operative antibiotics
Time reccomendation between 15 to 120
minutes before operation procedure

Other study → the antibiotics should

preferably be given 30 to 60 min before
the surgery, or at the induction of anaesthesia
10 min before inflation of
or at least
tourniquet

To reach antibiotic level above minimum

inhibitory concentration (MIC) during
operation procedure
 Duration of Antibiotics

• The duration of antibiotics prophylactic

• should not be more than 24 hours to reduce resistence risk of antibiotics

• Other study, antibiotic prophylactic should be initiated before operation procedure and be continued at 8
hours & 16 hours post operation
• Meta analysis study doesn’t reccomend the use of single dose antibiotic prophylactic

• The ideal duration of post-operative antibiotics is not so

• clearly defined, although most studies report that there
• is no additional benefit when antibiotic prophylaxis
• was continued beyond 24 hours
 CHOICE OF ANTIBIOTIC

In Orthopaedic the antibiotic should be The most common causa of infection is

better if has broad spectrum, non toxic and Staphylooccus aureus dan S. Epidermidis
inexpensive

The most commonly antibiotic that used are

beta lactam antibiotics such as cephalosphorin,
penicillin, and other derivates
 CEPHALOSPORIN

•Active against gram negative bacteria

•Have a long half life & an acceptable safety profile

•Have a good penetration in bone, synovium and muscle

•90% does not proviede coverage against coagulaase-negative Streptococci (CoNS)

•Not efecctive against MRSA

 COMBINATION DRUGS

•The combination can be used →cephalosphorin and

aminoglycoside
•American Society of Health Systems Phamacist (ASHP) →the most used
antibiotic prophylactic in orthopaedic is cefazolin then
combination of cefazolin and gentamycin are the second
common regimen
•The other choice is the third generation of cephalosphorin
STUDY IN ENGLAND
during the current epidemic of
virulent Clostridium difficile strains
some centres in England are moving
away from cephalosporins

Flucoxacillin or Teicoplanin and

Gentamycin ↓ risk of infection ec Clostridium
difficile
 STUDY IN ENGLAND
• Other study show risk of infection can be reduced
with change the antibiotic from Cefuroxime →
Co-amoxiclav
• Co-Amoxiclav also used in open fracture
• Antibiotic that reccomend by orthopaedic
centre → antibiotic with broad spectum which
can active agains gram (+),gram (-), and anaerob
bacteria
• The other study use Clindamycin as alternative
choice of antibiotic prophylaxis
 THE OTHER CHOICES OF ANTIBIOTIC
PROPHYLACTIC

•VANCOMYCIN
• Glycopeptide antibiotic that active against gram positive including MRSA dan MSSA
• Use as addition in polymethylmetacrilate (PMMA) bone cement to treat orthopaedic
infection
•GENTAMYCIN
•Most common use as combination with flucoxacillin
•Effective agains gram (+) & (-) bacteria including Staphylococcus aureus
•Reduce the risk of infection, including MRSA

•QUINOLONES
•Quinolones also can be used as antibiotic, but not as prophylactic agent
ANTIBIOTIC PROPHYLACTIC IN OPEN
FRACTURE
Antibiotics should be directed at gram-positive
organisms with additional gram-negative
coverage for type III fractures

•Open Fr Grade I
• The antibiotic be discontinued 24 hours after wound closure

•Open Fr Grade II
•The antibiotic be discontinued 24 hours after wound closure
•Aminoglycoside regiment is suggested

•Open Fr Grade III

•Antibiotic should be continued for 72 hours subsequent to the injury or not >24
hours subsequent to succesfull soft tissue coverage of the wound
•Aminoglycoside regiment is suggested
 ARTHROPLASTY PRODCEDURE
PROPHYLACTIC
American Academy of Orthopaedic Surgeon
(AAOS) recommends Cefazolin or
Cefuroxime as antibiotic prophylactic in
arthroplasty procedure

The other choice is combination

Cloxacillin+Gentamycin

The orther study→ third generation

cephalosporin (Ceftriaxone dan
Cefoperazaone)
 REFFERENCES
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Sourena, et.al., Surgical Site Infections in Orthopedic Surgery:
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Site Infections in Orthopaedic Surgery and Bone Trauma:
State-of-the-art Update. Journal of Hospital Infection. 2013;
84:5-12
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