Rationale of antibiotic prophylaxis of infectious complications in surgery of large joints

The growing number of operations on large joints, the lack of sufficient material support for clinics, and the admission of insufficiently trained personnel to interventions do not allow us to exclude the development of the most formidable postoperative complication - peri-implant infection. One of the most important factors in this case remains drug prophylaxis.

Numerous publications of recent years indicate that even the systematic use of antibacterial drugs and impeccable surgical technique in some cases do not prevent the development of postoperative infectious complications. Thus, the incidence of deep infections in total hip arthroplasty previously reached 50%, and currently, according to foreign and domestic publications, 2.5%. Treatment of patients with such complications involves multiple surgical interventions, the appointment of repeated antibacterial, immunocorrective therapy, not to mention a significant extension of the hospitalization period and possible disability of the patient.

The classic perioperative prophylaxis scheme, described in most guidelines on antibacterial chemotherapy in orthopedics, suggests the use of cephalosporins of the first and second generations (CS I-II) during elective surgeries. The choice of these drugs is due, as is known, to the fact that in case of microbial contamination of the wound surface, the main causative agent of postoperative infection is considered to be S. aureus. However, as practice shows, the use of CS I-II does not always ensure a smooth course of the postoperative period and prevent the development of postoperative infectious complications. The reasons for such failures are an inadequate assessment of risk factors, which, in addition to the key provisions common to all surgical interventions, have a number of fundamental features in skeletal surgery. The latter can be formulated as follows:

• Firstly, the peculiarity is the presence of an additional substrate for adhesion of potential pathogenic agents - the implant. The use of the mentioned antibacterial drugs in this case does not ensure complete elimination of adhered bacteria. This circumstance is directly related to the possibility of delayed manifestation of infection after surgical intervention in periods varying from several days to two years or more;
• secondly, the proposed scheme does not take into account the possibility of hematogenous dissemination of pathogens from distant foci of infection. This issue has recently received particularly close attention, since numerous confirmations have been received of the possibility of developing postoperative complications in the presence of an infectious process in the oral cavity, respiratory tract or urinary tract;
• an additional risk factor is the presence of an undiagnosed intra-articular infection in the patient;
• A significant increase in the frequency of superficial and deep infectious complications in total hip arthroplasty is also observed in patients with diabetes mellitus, rheumatoid arthritis, and terminal renal failure.

Finally, the unified prescription for perioperative prophylaxis of CS I-II does not take into account the heterogeneity of the group of patients admitted for surgical treatment. Even a superficial analysis shows that patients admitted for such operations should be ranked into at least several groups. The first group should include patients who are being operated on for the first time, the second group should include patients admitted for repeated operations after removal of incompetent structures. The third and fourth groups, respectively, should include patients with a history of septic complications and patients who have previously received antibacterial therapy. Antibiotic prophylaxis protocols for patients in different groups cannot be identical.

When planning antibacterial prophylaxis tactics, the attending physician, in addition to taking into account all possible risk factors for the development of infectious complications in his patient, must have reliable and up-to-date information on the proportion of pathogens in the structure of postoperative infectious complications in the department. In this regard, correctly performed microbiological or PCR research is an indispensable research method. Depending on the clinical situation, the material can be obtained intraoperatively, during joint puncture, during examination of prosthesis fragments, cement or discharge from the wound (fistula).

It is also necessary to take into account that the causative agent of postoperative wound complications can be microbial associations, which, according to our data, account for up to 7% of all microbiological study results. These results were obtained during bacteriological examination of material from more than a thousand patients during 10-year monitoring. During a qualitative assessment of the etiological significance of wound infection pathogens, the predominant composition of the "participants" of the associations was established: Staph. aureus in combination with Ps. aeruginosa - 42.27%, Staph. aureus with Pr. vulgaris - 9.7%, Staph. aureus with Pr. mirabilis - 8.96%, Staph. aureus with E. coli - 5.97%, Staph. aureus with Str. haemolyticus and Ps. aeruginosa with Pr. vulgaris - no 5.22%.

One of the problems of antibacterial pharmacotherapy is the increasing resistance of hospital strains. When determining the sensitivity of the said strains to first-generation cephalosporins, we obtained results indicating high resistance to these antibacterial drugs. Thus, Staph. aureus, considered the main "culprit" of such complications, was sensitive to first-generation cephalosporins only in 29.77% of cases.

The question arises: are there any methods today that allow in all cases to achieve the absence of postoperative infectious complications during interventions on the musculoskeletal system? Of course, in addition to adequate/inadequate antibiotic prophylaxis, the outcome of the operation is determined by preoperative preparation, compliance with aseptic rules, the characteristics of the surgical intervention and even the state of the operating room. At the same time, adequate use of antibiotics can play a key role during the postoperative period.

Based on the results of ten-year bacteriological monitoring, we proposed a regimen for perioperative prevention of wound infection in hip arthroplasty, including parenteral administration of the second-generation cephalosporin cefuroxime and a drug from the fluorinated quinolone group, ciprofloxacin.

Cefuroxime was administered at a dose of 1.5 g 30 minutes before surgery, then 0.75 g three times a day for 48 hours after surgery. Ciprofloxacin was administered at a dose of 0.4 g twice a day for 3-5 days. In this combination, cefuroxime provides sufficient activity against staphylococci and enterobacteria, and ciprofloxacin against gram-negative microorganisms. The use of such a scheme made it possible to reduce to zero the number of postoperative complications associated with the development of wound infection after the installation of a hip prosthesis. Currently, the frequency of such cases in the orthopedic traumatology department of the Krasnoyarsk Clinical Hospital does not exceed 5.6%.

The development of prosthesis-associated staphylococcal infection can also be overcome by prescribing rifampicin.

However, it should be remembered that resistance to this drug develops quickly when used as a monotherapy. Zimmerii et al. (1994), taking into account the latter feature, suggested using a combination of two antibacterial drugs as a preventive measure against postoperative complications associated with implant-associated staphylococcal infection: rifampicin in combination with oral ciprofloxacin.

We believe that the antibiotic prophylaxis strategy in each specific case can be determined as follows:

• the use of cefazolin or cefuroxime for perioperative prophylaxis is indicated for patients undergoing surgery for the first time, in the absence of risk factors, who do not have (have undergone treatment for) distant foci of infection, and who have not previously received antibacterial therapy;
• In all other cases, it is advisable to consider prescribing two antibacterial drugs or an ultra-broad-spectrum drug that covers the entire spectrum of potential pathogens. If methicillin-resistant strains are suspected, the drugs of choice will be vancomycin in combination with rifampicin, and in anaerobic infections, clindamycin. When identifying Ps. aeruginosa, preference should be given to ceftazidime or cefepime, and mixed flora will require the use of antibacterial drugs from the carbapenem group.

Active use of combined administration of two types of antibiotics for the prevention of paraprosthetic infection has allowed to reduce the number of such complications in the orthopedic department No. 2 of the Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan to 0.2% over the past three years. Active use of high-quality implants, antibiotic prophylaxis, reduction of the duration of surgery, adequate drainage are the basis for successful work.

Thus, the approach to perioperative antibiotic prophylaxis should not be unified. The treatment regimen should be developed individually for each patient, taking into account all anamnestic features and possible risk factors, pharmacokinetic features and the spectrum of antimicrobial activity of antibacterial drugs in a particular patient. We believe that in this case, the best result can be achieved by joint work of the attending physician and clinical pharmacologist, since it is the competent selection of antibacterial therapy that can play a key role in the successful outcome of treatment.

Doctor of Medical Sciences, Professor Bogdanov Enver Ibrahimovic. Justification of antibiotic prophylaxis of infectious complications in surgery of large joints // Practical Medicine. 8 (64) December 2012 / Volume 1

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