Joint Replacement Prophylaxis

All patients who receive and arthroplasty from the Shoulder and Elbow team are advised to take antibiotics prior to any procedure that may cause bacteremia. These procedures include dental work, sigmoidoscopy, proctoscopy, cystoscopy, or pretty much any procedure with the respiratory, digestive or urinary tract.

Patients should not have any procedures that may cause bacteremia for 2 weeks prior and 3 months post any arthroplasty surgery.

Members of the Arthritis Team (Shoulder, Elbow, Hip and Knees) should feel free to prescribe prophylactic antibiotics for joint replacement patients prior to a dental procedure. For dental procedures we follow the ADA and AAOS recommendations for antibiotics but extend use of them for life (as opposed to two years following arthroplasty and for high risk patients).

Since some of the choices for antibiotic include vancomycin and/or gentamicin, we reserve prescribing of these antibiotics to the surgeon doing the procedure - so that they can work up and follow the patient. If there are questions as what antibiotic course to take, we can give information about the AHA's recommendations for endocarditis prophylaxis and the AAOS' recommendations listed/linked below. It is also important to note that we consider all of our patients at high risk and recommend treatment for life, compared to the common practice of only provide prophylactic treatment for two years following arthroplasty surgery.

AHA Procedures for which endocarditis prophylaxis is recommended

Respiratory tract

Tonsillectomy and/or adenoidectomy

Surgical operations that involve respiratory mucosa

Bronchoscopy with a rigid bronchoscope

Gastrointestinal tract

Sclerotherapy for esophageal varices

Esophageal stricture dilation
Endoscopic retrograde cholangiography with biliary obstruction

Biliary tract surgery

Surgical operations that involve intestinal mucosa

Genitourinary tract

Prostatic surgery

Cystoscopy

Urethral dilation

Prophylactic Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures. (Follow-up dose no longer recommended.) Total children’s dose should not exceed adult dose.

I. Standard general prophylaxis for patients at risk:

Amoxicillin: Adults, 2.0 g (children, 50 mg/kg) given orally one hour before procedure.

II. Unable to take oral medications:

Ampicillin: Adults, 2.0 g (children 50 mg/kg) given IM or IV within 30 minutes before procedure.

III. Amoxicillin/ampicillin/penicillin allergic patients:

Clindamycin: Adults, 600 mg (children 20 mg/kg) given orally one hour before procedure. -OR-
Cephalexin* or Cefadroxil*: Adults, 2.0 g (children 50 mg/kg) orally one hour before procedure. -OR-
Azithromycin or Clarithromycin: Adults, 500 mg (children 15 mg/kg) orally one hour before procedure.

IV. Amoxicillin/ampicillin/penicillin allergic patients unable to take oral medications:

Clindamycin: Adults, 600 mg (children 20 mg/kg) IV within 30 minutes before procedure. -OR-
Cefazolin*: Adults, 1.0 g (children 25 mg/kg) IM or IV within 30 minutes before procedure.

*Cephalosporins should not be used in patients with immediate-type hypersensitivity reaction to penicillins.

Prophylactic Regimens for Genitourinary/Gastrointestinal Procedures: (Joint Replacement Patients should be considered High Risk for our purposes)

I. High-risk patients:

Ampicillin plus gentamicin: Ampicillin (adults, 2.0 g; children 50 mg/kg) plus gentamicin 1.5 mg/kg (for both adults and children, not to exceed 120 mg) IM or IV within 30 minutes before starting procedure. 6 hours later, ampicillin (adults, 1.0 g; children, 25 mg/kg) IM or IV, or amoxicillin (adults, 1.0 g; children, 25 mg/kg) orally.

II. High-risk patients allergic to ampicillin/amoxicillin:

Vancomycin plus gentamicin: Vancomycin (adults, 1.0 g; children, 20 mg/kg) IV over 1–2 hours plus gentamicin 1.5 mg/kg (for both adults and children, not to exceed 120 mg) IM or IV. Complete injection/infusion within 30 minutes before starting procedure.

III. Moderate-risk patients:

Amoxicillin: Adults, 2.0 g (children 50 mg/kg) orally one hour before procedure -OR-
Ampicillin: Adults, 2.0 g (children 50 mg/kg) IM or IV within 30 minutes before starting procedure.

IV. Moderate-risk patients allergic to ampicillin/amoxicillin:

Vancomycin: Adults, 1.0 g (children 20 mg/kg) IV over 1–2 hours. Complete infusion within 30 minutes of starting the procedure.

This Information Statement was developed as an educational tool based on the opinion of the authors. Readers are encouraged to consider the information presented and reach their own conclusions.

More than 1,000,000 total joint arthroplasties are performed annually in the United States, of which approximately 7 percent are revision procedures.¹ Deep infections of total joint replacements usually result in failure of the initial operation and the need for extensive revision, treatment and cost. Due to the use of perioperative antibiotic prophylaxis and other technical advances, deep infection occurring in the immediate postoperative period resulting from intraoperative contamination has been markedly reduced in the past 20 years.

Bacteremia from a variety of sources can cause hematogenous seeding of bacteria onto joint implants, both in the early postoperative period and for many years following implantation.² In addition, bacteremia may occur in the course of normal daily life^3-5 and concurrently with dental, urologic and other surgical and medical procedures.⁵ The analogy of late prosthetic joint infections with infective endocarditis is invalid as the anatomy, blood supply, microorganisms and mechanisms of infection are all different.⁶

It is likely that bacteremia associated with acute infection in the oral cavity,^7,8 skin, respiratory, gastrointestinal and urogenital systems and/or other sites can and do cause late implant infection.⁸ Practitioners should maintain a high index of suspicion for any change or unusual signs and symptoms (e.g. pain, swelling, fever, joint warm to touch) in patients with total joint prostheses. Any patient with an acute prosthetic joint infection should be vigorously treated with elimination of the source of the infection and appropriate therapeutic antibiotics.^8,9

Patients with joint replacements who are having invasive procedures or who have other infections are at increased risk of hematogenous seeding of their prosthesis. Antibiotic prophylaxis may be considered, for those patients who have had previous prosthetic joint infections, and for those with other conditions that may predispose the patient to infection (Table 1). ^8,10-16 There is evidence that some immunocompromised patients with total joint replacements may be at higher risk for hematogenous infections.^10-18 However, patients with pins, plates and screws, or other orthopaedic hardware that is not within a synovial joint are not at increased risk for hematogenous seeding by microorganisms.

Given the potential adverse outcomes and cost of treating an infected joint replacement, the AAOS recommends that clinicians consider antibiotic prophylaxis for all total joint replacement patients prior to any invasive procedure that may cause bacteremia. This is particularly important for those patients with one or more of the following risk factors.

Table 1. Patients at Potential Increased Risk of Hematogenous Total Joint Infection^8,10-16,18

Prophylactic antibiotics prior to any procedure that may cause bacteremia are chosen on the basis of its activity against endogenous flora that would likely to be encountered from any secondary other source of bacteremia, its toxicity, and its cost. In order to prevent bacteremia, an appropriate dose of a prophylactic antibiotic should be given prior to the procedure so that an effective tissue concentration is present at the time of instrumentation or incision in order to protect the patient’s prosthetic joint from a bacteremia induced periprosthetic sepsis. Current prophylactic antibiotic recommendations for these different procedures are listed in Table 2. ¹⁹

Occasionally, a patient with a joint prosthesis may present to a given clinician with a recommendation from his/her orthopaedic surgeon that is not consistent with these recommendations. This could be due to lack of familiarity with the recommendations or to special considerations about the patient's medical condition which are not known to either the clinician or orthopaedic surgeon. In this situation, the clinician is encouraged to consult with the orthopaedic surgeon to determine if there are any special considerations that might affect the clinician’s decision on whether or not to pre-medicate, and may wish to share a copy of these recommendations with the physician, if appropriate. After this consultation, the clinician may decide to follow the orthopaedic surgeon’s recommendation, or, if in the clinician’s professional judgment, antibiotic prophylaxis is not indicated, may decide to proceed without antibiotic prophylaxis.

† If a tourniquet is used the entire dose of antibiotic must be infused prior to its inflation

This statement provides recommendations to supplement practitioners in their clinical judgment regarding antibiotic prophylaxis for patients with a joint prosthesis. It is not intended as the standard of care nor as a substitute for clinical judgment as it is impossible to make recommendations for all conceivable clinical situations in which bacteremias may occur. The treating clinician is ultimately responsible for making treatment recommendations for his/her patients based on the clinician’s professional judgment.

Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known risks of antibiotic toxicity, allergy, and development, selection and transmission of microbial resistance. Practitioners must exercise their own clinical judgment in determining whether or not antibiotic prophylaxis is appropriate.

Procedure	Antimicrobial Agent	Dose	Timing	Duration
Dental	Cephalexin, cephradine, amoxicillin	2 gm PO	1 hour prior to procedure	Discontinued within 24 hours of the procedure. For most outpatient/office-based procedures a single pre-procedure dose is sufficient.
Ophthalmic	Gentamicin, tobramycin, ciprofloxacin, gatifloxacin, levofloxacin, moxifloxacin, ofloxacin, or meomycin-gramicidin-polymyxin B cefazolin	Multiple drops topically over 2 to 24 hours or 100 mg subconjunctivally	Consult ophthalmologist or pharmacist for dosing regimen
Orthopaedic†	CefazolinCefuroxime OR Vancomycin	1-2 g IV 1.5 g IV 1 g IV	Begin dose 60 minutes prior to procedure
Vascular	Cefazolin OR Vancomyin	1-2 g IV 1 g IV	Begin dose 60 minutes prior to procedure
Gastrointestinal
Esophageal, gastroduodenal	Cefazolin	1-2 g IV	Begin dose 60 minutes prior to procedure
Biliary tract	Cefazolin	1-2 g IV
Colorectal	Neomycin + erythromycin base (oral)	1 g	Dependent on time of procedure, consult with GI physician and/or pharmacist
Colorectal	OR metronidazole (oral)	1 g
Head and neck	Clindamycin + gentamicin OR cefazolin	600-900 mg IV 1.5 mg/kg IV 1-2 g IV	Begin dose 60 minutes prior to procedure
Obstetric and gynecological	Cefoxitin, cefazolin Ampicillin/sulbactam	1-2 g IV 3 g IV	Begin dose 60 minutes prior to procedure
Genitourinary	Ciprofloxacin	500 mg PO or 400 mg IV	1 hour prior to procedure Begin dose 60 minutes prior to procedure