Aims. Antibiotic prophylaxis involving timely administration of appropriately dosed antibiotic is considered effective to reduce the risk of surgical site infection (SSI) after total hip and total knee arthroplasty (THA/TKA). Cephalosporins provide effective prophylaxis, although evidence regarding the optimal timing and dosage of prophylactic antibiotics is inconclusive. The aim of this study is to examine the association between cephalosporin prophylaxis dose, timing, and duration, and the risk of SSI after THA/TKA. Methods. A prospective multicentre cohort study was undertaken in consenting adults with osteoarthritis undergoing elective primary TKA/THA at one of 19 high-volume Australian public/private hospitals. Data were collected prior to and for one-year post surgery. Logistic regression was undertaken to explore associations between dose, timing, and duration of cephalosporin prophylaxis and SSI. Data were analyzed for 1,838 participants. There were 264 SSI comprising 63 deep SSI (defined as requiring intravenous antibiotics, readmission, or reoperation) and 161 superficial SSI (defined as requiring oral antibiotics) experienced by 249 (13.6%) participants within 365 days of surgery. Results. In adjusted modelling, factors associated with a significant reduction in any SSI and deep SSI included: correct weight-adjusted dose (any SSI; adjusted odds ratio (aOR) 0.68 (95% confidence interval (CI) 0.47 to 0.99); p = 0.045); commencing preoperative cephalosporin within 60 minutes (any SSI, aOR 0.56 (95% CI 0.36 to 0.89); p = 0.012; deep SSI, aOR 0.29 (95% CI 0.15 to 0.59); p < 0.001) or 60 minutes or longer prior to skin incision (aOR 0.35 (95% CI 0.17 to 0.70); p = 0.004; deep SSI, AOR 0.27 (95% CI 0.09 to 0.83); p = 0.022), compared to at or after skin incision. Other factors significantly associated with an increased risk of any SSI, but not deep SSI alone, were receiving a non-cephalosporin antibiotic preoperatively (aOR 1.35 (95% CI 1.01 to 1.81); p = 0.044) and changing cephalosporin dose (aOR 1.76 (95% CI 1.22 to 2.57); p = 0.002). There was no difference in risk of any or deep SSI between the duration of prophylaxis less than or in excess of 24 hours. Conclusion. Ensuring adequate, weight-adjusted dosing and early, preoperative delivery of prophylactic antibiotics may reduce the risk of SSI in THA/TKA, whereas the duration of prophylaxis beyond 24 hours is unnecessary. Cite this article: Bone Jt Open 2022;3(3):252–260

Aims. To explore the effect of different durations of antibiotics after stage II reimplantation on the prognosis of two-stage revision for chronic periprosthetic joint infection (PJI). Methods. This study involved a retrospective collection of patients who underwent two-stage revision for chronic PJI and continued to use extended antibiotic prophylaxis in two regional medical centres from January 2010 to June 2018. The patients were divided into a short (≤ one month) or a long (> one month) course of treatment based on the duration of antibiotics following stage II reimplantation. The difference in the infection control rate between the two groups was compared, and prognostic factors for recurrence were analyzed. Results. A total of 105 patients with chronic PJI were enrolled: 64 patients in the short course group and 41 patients in the long course group. For 99 of the patients, the infection was under control during a follow-up period of at least 24 months after two-stage revision. For the short course group, the mean duration of antibiotic prophylaxis after stage II reimplantation was 20.17 days (SD 5.30) and the infection control rate was 95.3%; for the long course group these were 45.02 days (SD 15.03) and 92.7%, respectively. There was no significant difference in infection control rates between the two groups (p = 0.676). Cox regression analysis found that methicillin-resistant staphylococcus infection (p = 0.015) was an independent prognostic factor for recurrence. Conclusion. After stage II reimplantation surgery of two-stage revision for chronic PJI, extended antibiotic prophylaxis for less than one month can achieve good infection control rate. Cite this article: Bone Joint Res 2021;10(12):790–796

Despite the routine use of systemic antibiotic prophylaxis, postoperative infection following fracture surgery remains a persistent issue with substantial morbidity. The use of additional local antibiotic prophylaxis may have a protective effect and some orthopaedic surgeons have adopted their use in recent years, despite limited evidence of its beneficial effect. The purpose of this systematic review and meta-analysis was to evaluate the current literature regarding the effect of prophylactic local antibiotics on the rate of infection in fracture surgery in both open and closed fractures. A comprehensive search of Medline, EMBASE, and PubMed was performed. Cohort studies were eligible if they investigated the effect on infection rate of additional local antibiotic prophylaxis compared with systemic prophylaxis alone following fracture surgery. The data were pooled in a meta-analysis. In total, four randomized controlled trials and 11 retrospective cohort studies with a total of 6161 fractures from various anatomical locations were eligible for inclusion. The majority of the included studies were Level 3 evidence and had a moderate risk of bias. When all fractures were pooled, the risk of infection was significantly reduced when local antibiotics were applied compared with the control group receiving systemic prophylaxis only (OR = 0.39; 95%CI: 0.26 to 0.53, P < 0.001). In particular, there was a significant reduction in deep infections (OR = 0.59; 95%CI: 0.38 to 0.91, P = 0.017). The beneficial effect of local antibiotics for preventing total infection was seen in both open fractures (OR = 0.35; 95%CI: 0.23 to 0.53, P < 0.001) and closed fractures (OR = 0.58; 95%CI: 0.35 to 0.95, P = 0.029) when analyzed separately. This meta-analysis suggests a significant risk reduction for postoperative infection following fracture surgery when local antibiotics were added to standard systemic prophylaxis, with a protective effect present in both open and closed fractures

Aims. Wrist arthroscopy is a standard procedure in hand surgery for diagnosis and treatment of wrist injuries. Even though not generally recommended for similar procedures, general administration of perioperative antibiotic prophylaxis (PAP) is still widely used in wrist arthroscopy. Methods. A clinical ambispective dual-centre study was performed to determine whether PAP reduces postoperative infection rates after soft tissue-only wrist arthroscopies. Retrospective and prospective data was collected at two hospitals with departments specialized in hand surgery. During the study period, 464 wrist arthroscopies were performed, of these 178 soft-tissue-only interventions met the study criteria and were included. Signs of postoperative infection and possible adverse drug effects (ADEs) of PAP were monitored. Additionally, risk factors for surgical site infection (SSIs), such as diabetes mellitus and BMI, were obtained. Results. The overall infection rate of SSI was zero. Neither in the PAP group (n = 69) nor in the control group (n = 109) were signs of postoperative infection observed. Observed symptoms of ADEs were three-times higher in the PAP group when compared to the control-group (16.3 vs 5.5%; p = 0.043). No major ADEs were observed, but one in ten patients in the PAP group reported mild to severe intestinal or hypersensitivity symptoms. Conclusion. We demonstrate that the number needed to treat (NNT) with PAP to prevent one postoperative infection in soft-tissue arthroscopies of the wrist is > 109. Conversely, symptoms of ADEs were reported by one out of ten patients given PAP. Considering the high NNT to prevent postoperative infection and the large number of ADEs caused by PAP, we recommend not to use PAP routinely in soft-tissue arthroscopies of the wrist. Subsequent large-scale studies should be conducted to substantiate these results. Cite this article: Bone Jt Open 2023;4(4):219–225

Objectives. As well as debridement and irrigation, soft-tissue coverage, and osseous stabilization, systemic antibiotic prophylaxis is considered the benchmark in the management of open fractures and considerably reduces the risk of subsequent fracture-related infections (FRI). The direct application of antibiotics in the surgical field (local antibiotics) has been used for decades as additional prophylaxis in open fractures, although definitive evidence confirming a beneficial effect is scarce. The purpose of the present study was to review the clinical evidence regarding the effect of prophylactic application of local antibiotics in open limb fractures. Methods. A comprehensive literature search was performed in PubMed, Web of Science, and Embase. Cohort studies investigating the effect of additional local antibiotic prophylaxis compared with systemic prophylaxis alone in the management of open fractures were included and the data were pooled in a meta-analysis. Results. In total, eight studies which included 2738 patients were eligible for quantitative synthesis. The effect of antibiotic-loaded poly(methyl methacrylate) beads was investigated by six of these studies, and two studies evaluated the effect of local antibiotics applied without a carrier. Meta-analysis showed a significantly lower infection rate when local antibiotics were applied (4.6%; 91/1986) than in the control group receiving standard systemic prophylaxis alone (16.5%; 124/752) (p < 0.001) (odds ratio 0.30; 95% confidence interval 0.22 to 0.40). Conclusion. This meta-analysis suggests a risk reduction in FRI of 11.9% if additional local antibiotics are given prophylactically for open limb fractures. However, due to limited quality, heterogeneity, and considerable risk of bias, the pooling of data from primary studies has to be interpreted with caution. Cite this article: M. Morgenstern, A. Vallejo, M. A. McNally, T. F. Moriarty, J. Y. Ferguson, S. Nijs, WJ. Metsemakers. Bone Joint Res 2018;7:447–456. The effect of local antibiotic prophylaxis when treating open limb fractures: A systematic review and meta-analysis. DOI: 10.1302/2046-3758.77.BJR-2018-0043.R1

Introduction: The delivery of regional antibiotic prophylaxis has been described in reconstructive knee surgery as well as in the management of hand injuries. In this study, we describe a technique for the delivery of regional antibiotic prophylaxis to the upper extremity in patients undergoing elbow surgery, and compare tissue antibiotic concentrations achieved with this technique to those achieved with standard systemic intravenous antibiotic prophylaxis. Methods: We collected bone and fat samples from eight patients undergoing elective elbow surgery who had received regional antibiotic prophylaxis, and measured tissue antibiotic concentration by high performance liquid chromatography. In these patients, prior to the surgical incision, we exsanguinated the arm, inflated the tourniquet, and delivered a standard dose of Cephazolin into a dorsal hand vein. For comparison, we measured antibiotic concentrations in bone and fat samples taken from eight patients undergoing elective shoulder surgery who had received standard systemic antibiotic prophylaxis. Results: Mean tissue antibiotic concentrations were significantly higher in the patients who received regional antibiotic prophylaxis compared with those who received standard systemic prophylaxis (Bone: 1060 mcg/gm versus 41 mcg/gm; Fat: 649 mcg/gm versus 10 mcg/gm; p < 0.05.). Discussion/conclusions: The delivery of regional antibiotic prophylaxis in elbow surgery achieved higher tissue antibiotic concentrations than those achieved with standard systemic delivery. This technique may help reduce the risk of acute infection in elbow surgery, and may be especially valuable in elective surgery in predisposed patients (e.g. rheumatoid arthritis), in the management of open fractures, as well as in protection against particularly virulent organisms

Aim: To assess the infection rate following Lower Limb Arthroplasty using single dose gentamicin antibiotic prophylaxis compared to a traditional three doses of cephalosporin. Material and Methods: All patients undergoing Total Hip and Knee joint replacements over 6 months (October 2007 to March 2008) at 3 participating hospitals were prospectively followed up to assess perioperative infection rates. Joint replacements were defined as having infection by the UK Health Protection Agency Surgical Site Surveillance criteria. All patients received single dose antibiotic prophylaxis using intravenous Gentamicin 4.5mg/kg body weight adjusted for body mass index. This group of patients were compared with previous data collected over a 6 month period (Jan to Mar 2007 and Oct to Dec 2005) from the same hospitals for infection rates in Lower Limb Arthroplasty using 3 doses of Cefuroxime 750mg as antibiotic prophylaxis. Results: 408 patients underwent Total Hip Replacements (THR) and 458 patients underwent Total Knee Replacements (TKR) during the study period. This was compared with 414 patients who underwent THR and 421 patients who underwent TKR during a 6 month period over 2 years. Surgical site infection was detected in 9 THRs (2.2%) and 2 TKRs (0.44%) in the study group as compared to infection in 13 THRs (3.1%) and 12 TKRs (2.9%) in the control group. Using the Fisher Exact test the infection rates in THRs were not significantly different between the 2 groups (p value – 0.52) but the infection rates were significantly reduced in the study group for TKRs (p value – 0.005). There were no complications with the use of Gentamicin as antibiotic prophylaxis. Cefuroxime is known to promote Clostridium difficile infection and was removed from the hospital pharmacy to help meet a UK government targets to reduce the incidence. The rate of Clostridium difficile infection was reduced within the hospital with the use of single dose antibiotic prophylaxis although other measures to reduce its incidence were also introduced. Conclusions: This study shows that the use of single dose antibiotic prophylaxis using Gentamicin is effective for elective Lower Limb Arthroplasty. This is recommended for routine use in all elective joint replacements as it is safe, effective and easy to administer

Aim: To assess the infection rate following Primary Lower Limb Arthroplasty using single dose gentamicin antibiotic prophylaxis compared to a traditional three doses of cephalosporin. Material And Methods: All patients undergoing primary Total Hip and Knee joint replacements over 6 months (October 2007 to March 2008) at 3 participating hospitals were prospectively followed up to assess perioperative infection rates. Joint replacements were defined as having infection by the UK Health Protection Agency Surgical Site Surveillance (SSI) criteria. All patients received single dose antibiotic prophylaxis using intravenous Gentamicin 4.5mg/kg body weight adjusted for body mass index. This group of patients were compared with previous data collected over a 6 month period (Jan to Mar 2007 and Oct to Dec 2005) from the same hospitals for infection rates in Lower Limb Arthroplasty using 3 doses of Cefuroxime 750mg as antibiotic prophylaxis. Return to theatre data was collected independently after introduction of gentamicin to compare with previous data. Results: 408 patients underwent Total Hip Replacements (THR) and 458 patients underwent Total Knee Replacements (TKR) during the study period. This was compared with 414 patients who underwent THR and 421 patients who underwent TKR during a 6 month period over 2 years. Surgical site infection was detected in 9 THRs (2.2%) and 2 TKRs (0.44%) in the study group as compared to infection in 13 THRs (3.1%) and 12 TKRs (2.9%) in the control group. Using the Fisher Exact test the infection rates in THRs were not significantly different between the 2 groups (p value – 0.52) but the infection rates were significantly reduced in the study group for TKRs (p value – 0.005). There were no complications with the use of Gentamicin as antibiotic prophylaxis. The return to theatre was 2.42% (28/1157) after introduction of Gentamicin as compared with 1.85% (37/2005) [p value – 0.172] before this. This was a cause for concern, although not a significant difference. Cefuroxime is known to promote Clostridium difficile infection and was removed from the hospital pharmacy to help meet a UK government targets to reduce the incidence. The rate of Clostridium difficile infection was reduced within the hospital with the use of single dose antibiotic prophylaxis although other measures to reduce its incidence were also introduced. Conclusions: This study shows that the use of single dose antibiotic prophylaxis using Gentamicin is effective in preventing SSI as defined in the HPA definition. It is safe to use and reduces rate of Clostridium difficile associated diarrhoea. However, be wary of increased rate of return to theatre following use of gentamicin. Further period of evaluation and study is needed before it is recommended for routine use in present or modified form

Culture negative prosthetic joint infections (PJI) still remain an issue even the advantages in PJI diagnosis. This is the reason why some orthopedic surgeons fear to use preoperative antibiotic prophylaxis when a PJI is suspected. The purpose of the present study was to evaluate the influence of preoperative antibiotic prophylaxis in intraoperative cultures. An enhanced diagnostic protocol for PJI (Zimmerli criteria) was used for the inclusion criteria in order to collect all PJI accounted in a University Hospital. Patients were prospectively randomized in two groups. The control group received the classical preoperative antibiotic prophylaxis. The study group did not receive prophylaxis prior to surgery. There were 14 patients in each group. They correspond to 13 infections of total hip arthroplasty (THA), 12 infections of total knee arthroplasty (TKA) and 3 reverse shoulder prosthesis (RSA) infections. There were 10 patients in the study group and 10 patients in the control group with at least one positive microbiological criterion. There were 8 patients in each group with culture negative PJI (p>0.05). Preoperative antibiotic prophylaxis does not affect intraoperative cultures in suspected or confirmed PJI. Therefore it is essential to deliver antibiotic prophylaxis in any patient in which prosthesis is to be implanted in order to protect the prosthesis from infection

Purpose. Antibiotic prophylaxis plays an important role in minimizing surgical site infections as well as other nosocomial peri-operative infections in orthopaedic trauma patients. Pre-operative prophylaxis has been shown to be efficacious, but the role and duration of post-operative prophylaxis remains controversial. The goal of this study was to assess whether patients receive their antibiotic prophylaxis as prescribed. What dose and duration of antibiotics are typically ordered, what patients actually receive, and factors causing the ordered antibiotic regime to be altered were also investigated. This study did not investigate infection rates or the efficacy of various antibiotic prophylactic regimes. Method. This study presents data collected through a retrospective chart review of 205 patients treated surgically for a closed fracture at one institution. A national survey was also distributed to all surgeon members of the Canadian Orthopaedic Trauma Society (COTS) concerning antibiotic prophylaxis in the setting of surgical treatment for closed fractures. Results. Ninety three percent (179/193) of patients received an appropriate pre-operative dose, while less than 32% (58/181) of patients received their post-operative antibiotics as ordered. The most common stated reason for patients not receiving their post-operative antibiotics as ordered was patients being discharged before completing three post-op doses. There was a 70% (39/56) response rate to the survey sent to COTS surgeons. A single dose of a first-generation cephalosporin pre-operatively followed by three doses post-operatively is the most common practice amongst orthopaedic trauma surgeons across Canada, but several surgeons use only pre-operative prophylaxis. Conclusion. Adherence to multi-dose post-operative antibiotic regimens is poor. Meta-analyses have failed to demonstrate the superiority of multi-dose regimens over single-dose prophylaxis. Single-dose pre-operative antibiotic prophylaxis may be a reasonable choice for most orthopedic trauma patients with closed fractures

Background. Total hip replacement (THR) has become the ideal treatment for any disorder causing joint destruction. Surgery-related infections are reported only in 1–2 % of THR, but antibiotic prophylaxis is necessary because infections are associated with significant morbidity and occasionally death. 1st and 2nd –generation cephalosporin or, in hospital with methicillin-R Staphylococcus spp (MRSA, MRSE) high prevalence, vancomycin, are the most frequently drug emplojed. The most frequent side effects of antibiotic prophylaxis are allergic reaction and pseudomembranous enterocolitis. The objective of the present study was to assess the efficacy and tolerability of antibiotic prophylaxis for THR at S. Corona Hospital Pietra Ligure SV (Italy). In our hospital the majority of prostethic device infections are due to MRSA, but recently we have described increment of infection due to Pseudomonas spp and other gram-. For this reason we used association of vancomycin plus pefloxacin in primary prophylaxis. Methods. Retrospective analysis of 1118 THR performed in the period 2003–2004, receiving surgical prophylaxis with a single dose of the association vancomycin 1000 mg plus pefloxacin 400 mg. Data collection regarded patients’ age at surgery and reasons for THR. The presence of a surgery-related infection was investigated by means of a phone interview about the function of the hip device (presence of pain, deambulation impairment, fever). Patients with pain or other problems were submitted to physical exam, laboratory tests, plain radiograph and if necessary to exclude of infection, radioisotopic scans. Results. We report the preliminary data on 218 THR in 211 patients (81 M, 122 F, median age 67.49 aa, range 29–91). THR was performed for: osteoarthrites in 168 cases, trauma in 26, osteonecrosis in 9, displasia in 4 cases, previous osteotomy in 4. 167/211 patients were submitted to a phone interview and 44 to a clinical examination. Conclusions. In our center, the association of vancomycin-pefloxacin resulted effective and well tolerated as single dose prophylaxis for THR

The role of perioperative antibiotic prophylaxis in sarcoma surgery is well established. There are no guidelines for their use in this context but there is pressure from microbiologists to comply with agreed prophylaxis for joint arthroplasty despite major differences between patient groups and risks of infection in sarcoma surgery. Two simple surveys were conducted online, the first for bone sarcoma surgery, the second for soft tissue sarcomas. An email was sent to the major centres worldwide conducting such surgery with links to the online surveys to assess current practice regarding antibiotic prophylaxis and surgical drains. The survey was limited to 8 questions, the emphasis being a simple survey, but included questions on indications, choice, duration of therapy as well as use, size and duration of surgical drains. We received 38 responses from 15 countries to the bone sarcoma survey and 33 responses from 12 countries to the soft tissue sarcoma survey. Current antibiotic prophylaxis regimens varied widely among surgeons, emphasising the controversy that exists regarding what constitutes best clinical practice. Opinions regarding use of perioperative antibiotic prophylaxis in sarcoma surgery vary widely among orthopaedic surgeons worldwide, illustrating the controversy as to what constitutes best clinical practice. This survey suggests the need for a randomised clinical trial to aid in the development of guidelines in this area

There is high morbidity and mortality associated with infection following orthopaedic procedures. In accordance to local guidelines, most hospitals follow a set protocol for surgical prophylaxis, which expects a compliance rate of 100%. A new protocol was introduced to the orthopaedic department of a teaching hospital in August 2013, changing from a cephalosporin, with potential C. difficile risk, to teicoplanin and gentamicin, within 30 minutes of incision. Our aim was to audit how well the protocol was followed across 3 different time periods. Data was collected for 3 different time periods following the introduction of the new protocol (August-November 2013, April-May 2014 & November 2014) on the choice of antibiotic. Both elective and trauma cases were included. After each cycle, the data was presented to the orthopaedic surgical and anaesthetic departments to raise awareness and draw attention to the antibiotic prophylaxis posters in theatre. The 1st audit cycle (n=30) indicated that there was 0% compliance with the current protocol and 100% compliance with the previous protocol. The 2nd audit cycle (n=27) indicated that 0% complied with the current protocol, 54% complied with the previous protocol and that there was a combination of both protocols being used in 46% of the patients. Finally the 3rd audit cycle (n=33) indicated a 100% compliance rate in terms of antibiotic choice. However, only 9% were given the appropriate dose according to body weight and within the appropriate time based on the documented evidence. This audit demonstrates the value of auditing and then disseminating the findings to relevant departments to influence practice. Each audit cycle demonstrated a progressive uptake in compliance with the hospital trust's antibiotic prophylaxis policy. The last audit cycle highlighted discrepancy in dosage based on weights; a further intervention will be to provide ideal body weight (IBW) vs dose tables in all orthopaedic theatres to ensure the correct antibiotic dosage is given

Gram-negative organisms are increasingly seen as causative pathogens in orthopaedic fracture surgery, which might necessitate a change in antibiotic prophylaxis protocols. A single-centre retrospective review of antibiogram results from all patients treated for fracture-related infection (FRI) was conducted. Subgroup analysis was undertaken to identify any host, injury or treatment variables predisposed to Gram-negative infection. The bacteriological results of 267 patients who underwent surgical treatment for FRI were analysed. Pathogens were isolated in 216 cases (81%), of which 118 (55%) were Gram-negative infections. Fractures involving the tibia and femur (p=0.007), the presence of soft tissue defect (p=0.003) and bone defects (p=0.001) were associated with an increased risk of developing a Gram- negative FRI. Gram-negative fracture-related infections were associated with injuries experiencing bone loss and those requiring soft tissue reconstruction. It is, therefore, prudent to consider extended Gram-negative directed antimicrobial prophylaxis in these cases to prevent the development of fracture-related infection

Background:. Antibiotic prophylaxis prior to dental and other procedures when patients have joint replacements in situ remains controversial. Recommendations seem to generally be intuitive and not based on any sound scientific evidence. Recently, the American Academy of Orthopaedic Surgeons altered their previous standpoint and suggested that orthopaedic surgeons review their current practice of routine prescription of antibiotic prophylaxis. Method:. We conducted an electronic survey of members of the South African Orthopaedic Association to determine the opinion of the average orthopaedic surgeon in South Africa in respect of this prophylaxis. 111 surgeons responded. Results:. 73% of respondents were of the opinion that patients with joint replacements in situ should take antibiotic prophylaxis prior to undergoing any dental procedure. 65% of surgeons were of the opinion that this prophylaxis should be life-long. 59% of surgeons recommended that prophylaxis start before the procedure, 24% at the same time as the procedure. 35% of surgeons recommended prophylaxis with every dental procedure, and 61% only with more invasive procedures. We also show that working in private practice and greater surgical experience increases the likelihood that surgeons will prescribe prophylactic antibiotics prior to dental procedures. Scientific evidence linking bacteraemia from dental procedures with infected prosthetic implants is limited, however 19% of surgeons reported managing an infected implant as a result of dental surgery. Conclusion:. We could find no evidence to substantiate the practice of using antibiotic prophylaxis prior to dental or any other procedures in those patients with joint replacements in situ. Practice in South Africa is at odds with world-wide trends and we would recommend that these patients do not use antibiotic prophylaxis prior to dental and other procedures, except possibly those that may be immune-compromised

Aim. Deep infection following endoprosthetic replacement (EPR) of long bones is a devastating complication occurring in 15% of musculoskeletal tumour patients. The recently published PARITY Trial demonstrated that extending antibiotic prophylaxis from 24 hours to 5 days does not reduce infection rates. However, questions remain about the optimal antibiotic choice and dose. Method. A 23-question multiple-choice questionnaire was designed and piloted through an iterative feedback process until the final version was agreed by all authors. Open and closed-ended questions were used to gather information on practice and Likert-type scale responses were used to grade responses to ascertain surgeon perceptions and preferences. The online survey was sent to all surgeon delegates of the 34th Annual Meeting of the European Musculo-Skeletal Oncology Society in London in October 2022. Results. Amongst 61 respondents, 43 were based in Europe and 18 outside of Europe. The majority (48/61) had been in clinical practice over 11 years. Antibiotic choice. 1st or 2nd generation cephalosporins were the first line choice practiced among 49 (80.3%) of respondents. Of these, 39 responded had a 2nd line protocol for beta-lactam allergy which was most commonly clindamycin (18), vancomycin (11) or a combination of a glycopeptide or clindamycin plus gentamicin (4). Respondents changed their first line regimen for radiotherapy in 6/61, chemotherapy in 8/61 and tumour site in 20/61. Re-dosing. Intraoperative re-dosing intervals of 1st and 2nd generation cephalosporins ranged from 2 to 8 hourly. Re-dosing for blood loss ranged from never to when 2 litres was lost. Of the 47 respondents, 24 said intraoperative re-dosing is always reliably administered. Duration. Six (10%) of 61 respondent routinely cover the intraoperative period only, whereas 30 (49%) give 24 hours, 16 (give 48 hours or longer and 8 continue until surgical drains are removed. 31 of 61 change duration depending on clinical situation. The most common reasons for changing were patient risk factors, soft tissue status and previous radiotherapy. 57/61 surgeons were aware of the PARITY Trial. When these respondents were asked whether they had changed practice based on PARITY, 12 said yes, 24 said no and 21 said they always give 24 hours anyway. Conclusions. Amongst an international cohort of orthopaedic oncology surgeons there was a wide variation in practice. Further research should focus on the optimum choice and re-dosing strategy, which have not been defined

Introduction: Deep infection remains a major complication of joint arthroplasty. Major randomised controlled trials to determine the most effective antibiotic prophylaxis are difficult to construct and interpret. In a conventional theatre most orthopaedic intraoperative wound contamination arrives by the airborne route. Aim: To use a unique method to compare antibiotics against these airborne bacteria. Method: Seven antibiotics were tested; Cephradine, Cefuroxime, Cefotaxime, Flucloxacillin, Amoxycillin, Co-amoxyclav and Imipenem. They were incorporated into blood agar at concentrations equivalent to serum levels. Plates were then inoculated with airborne theatre bacteria using a multiple synchronous collection technique. After incubation, the percentage kills were calculated for each antibiotic. Results: At concentrations equivalent to serum levels one hour following an intravenous dose all of the antibiotics proved highly effective, with kill rates greater than 95%. Imipenem and Co-amoxiclav significantly outperformed the other antibiotics with kill rates of 99.6% and 99.4% respectively. At trough levels the antibiotics achieved kill rates from 61% to 97.6%. Discussion: Future randomised controlled trials comparing antibiotics in the setting of an already low infection rate are inappropriate. This technique for comparing antibiotic prophylaxis is quick, inexpensive and repeatable. The superiority of Imipenem is not unexpected, given its broad spectrum against both gram positive and negative, aerobic and anaerobic bacteria. Of more interest is the effectiveness of Co-amoxiclav over the presently favoured Cefuroxime

Controversy exists surrounding best practice for antibiotic prophylaxis in TJR. Practicing orthopedic surgeons performing TJR in Canada were surveyed to inform regarding the most common antibiotic prophylaxis practice. Cross-sectional survey of five hundred and ninety practicing Canadian orthopaedic surgeons was conducted. Three orthopaedic surgeons, and one infectious disease specialist established face and content validity of the survey. The survey was mailed to surgeons, and re-mailed to non-responders at twelve-weeks. Survey included questions pertaining to prophylaxis indications, antibiotic choice, dosing, route and timing of administration in the primary and revision setting, as well as postoperative wound drainage investigation and management. Response rate after two mail-outs was 410/590 (69.5%). 96.6% indicated routine use of systemic prophylactic antibiotics for uncomplicated primary TJR. Cefazolin was most commonly prescribed (97.3 %), with 1gm Cefazolin the most common dosage (70.2%). Vancomycin was prescribed 26% of the time as first line. 48.5% administer the antibiotic in the operating suite, and 90% administer within < sixty minutes prior to skin incision. 47.8% routinely use antibiotics in acrylic cement, and 50% use it in a commercially prepared form. Postoperative prophylaxis duration varied widely with 42% preferring twenty-four hours. 33% routinely culture serous wound drainage within one-week postoperative in the absence of redness or fever. 19.8% prescribe antibiotics if wound drainage persists beyond hospital stay. 15.6% would conduct intraoperative wound exploration if drainage persists beyond postoperative day four. 63.9% stated they routinely withhold antibiotics until they have obtained a deep tissue culture specimen in revision TJR. 74% use the same antibiotic prophylaxis regimen for both primary and revision procedures. Of responding surgeons, 47/410 (11.8%) were categorised as high volume performing > two hundred TJR’s per year, and 40/410 (9.8%) were categorised as low volume performing < twenty-five per year. Comparative results to be discussed. Opinions vary widely amongst surgeons in Canada, illustrating the controversy in what constitutes ‘best practice’. Despite available published data, a large proportion of Canadian surgeons may fall short in meeting optimal standards of care in some domains such as the dose prescribed and timing of administration. This survey also illustrates the lack of available information to guide current management of postoperative wound drainage in the face of shorter patient hospital stays. Much work is needed in this area to determine risks and benefits of these costly tests and interventions in treating arthroplasty patients

Aim. Alongside debridement and irrigation, soft tissue coverage and osseous stabilization, systemic antibiotic prophylaxis is considered the gold standard in the management of open fractures and considerably reduces the risk of subsequent fracture-related Infections (FRI). The direct application of antibiotics into the surgical field (local antibiotics) has been used for decades as additional prophylaxis in open fractures, although definitive evidence confirming a beneficial effect is scarce. The purpose of the present study was to review the clinical evidence regarding the effect of prophylactic application of local antibiotics in open limb fractures. Method. A comprehensive literature search was performed in PubMed, Web-of- Science and Embase. Cohort studies investigating the effect of additional local antibiotic prophylaxis compared to systemic prophylaxis alone in the management of open fractures were included and the data were pooled in a meta-analysis. Results. Eight studies, with a total of 2738 patients were eligible for quantitative synthesis. Six of these studies investigated the effect of antibiotic loaded PMMA beads and two studies evaluated the effect of local antibiotics applied without a carrier. Meta-analysis showed a significantly lower infection rate when local antibiotics were applied (4.7%;94/1996) than in the control group receiving standard systemic prophylaxis alone (16.2%;129/797) (p-value < 0.001) (OR 0.30; 95%CI 0.22–0.40). Conclusions. This meta-analysis suggests a clear risk reduction in FRI if additional local antibiotics are given prophylactically for open limb fractures. However, due to limited quality, heterogeneity and considerable risk of bias, the pooling of data from primary studies has to be interpreted with caution

Purpose: To assess the infection rate following Lower Limb Arthroplasty using single dose gentamicin antibiotic prophylaxis compared to a traditional three doses of cephalosporin. Method: All patients undergoing Total Hip and Knee replacements over six months (October 2007 to March 2008) at three participating hospitals were prospectively followed to assess perioperative infection rates using Surgical Site Surveillance(SSI) criteria. All patients received single dose antibiotic prophylaxis using intravenous Gentamicin 4.5mg/kg. This was compared with previous data collected over a 6 month period (Jan to Mar 2007 and Oct to Dec 2005) from the same hospitals using 3 doses of Cefuroxime 750mg. Return to theatre data was collected independently after introduction of gentamicin to compare with previous data. The change in creatinine level postoperatively was also measured in a selected group of patients. Results: Four hundred and eight patients underwent Total Hip Replacements (THR) and 458 patients Total Knee Replacements (TKR) during the study period. This was compared with 414 and 421 patients who underwent THRs and TKRs respectively during a previous six month period. SSI was detected in 9 THRs(2.2%) and 2 TKRs(0.44%) in the study group as compared to 13 THRs(3.1%) and 12 TKRs(2.9%) in the control group. The infection rates in THRs were not significantly different between the 2 groups(p value−0.52) but were significantly reduced in the study group for TKRs(p value−0.005). The rate of Clostridium difficile infection was reduced within the hospital with the use of gentamicin, although other measures to reduce its incidence were also introduced. The return to theatre was 1.64%(23/1402) after introduction of Gentamicin as compared with 1.05%(21/2005) [p value−0.092] before this. This was a cause for concern although not significant. The day1 postoperative creatinine level increased by more than 30 units in 6% of patients on Gentamicin. Conclusion: This study shows that the use of single dose prophylaxis using Gentamicin is effective for Lower Limb Arthroplasty. However, be wary of increased rate of return to theatre and the rise in creatinine level following use of gentamicin. Further period of evaluation and study is needed before it is recommended for routine use in present or modified form