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Updated: Jun 17 2021

Prophylactic Antibiotics

  • Perioperative Abx Overview
    • Includes preoperative and postoperative antibiotics
      • 25-50% of all antibiotics used are for prophylaxis
    • Indications
      • routine adminstration of prophylactic antibiotics is accepted in
        • patients who will have a foreign body implanted
        • bone grafting procedures
        • large dissection resulting in significant dead space or hematoma
        • expecting significant blood loss
      • orthopaedics procedures that do not require prophylactic antibiotics
        • carpal tunnel surgery
        • diagnostic arthroscopy is more controversial
    • Most likely pathogens to cause infection in orthopaedic procedures includes
      • S aureus
      • S epidermidis
      • aerobic streptococci
      • anaerobic cocci
  • Perioperative Prophylaxis in Total Joint Replacement  (AAOS Recommendations)
    • Choice of antibiotics
      • if no beta-lactam allergy
        • cefazolin or
        • cefuroxime
      • if beta-lactam allergy
        • vancomycin or
        • clindamycin
      • if history of MRSA infection or in areas with high prevelance of MRSA
        • vancomycin in addition to cefazolin
          • use judiciously - increased risk of vancomycin-resistant enterococcus (VRE)
    • Administration
      • always administer abx prior to tourniquet inflation
      • cefazolin
        • administer within 1 hour of incision
        • double amount of cefazolin administered if above 80kg
      • vancomycin
        • administer within 2 hours of incision
    • Duration
      • prophylactic antibiotics should NOT exceed 24 hours after surgery
      • In clean and clean-contaminated procedures, do not administer additional doses of antibiotics after incision is closed in the operating room, even in the presence of a drain.
  • Dental Procedure Abx Prophylaxis in TJR Patients (AAOS & ADA)
    • Indications
      • TJA patients at increased risk of hematogenous seeding should be given prophylactic antibiotics prior to dental procedures. This includes
        • all patients for the first two years after TJA
        • immunocompromised patients
        • drug induced immunosuppression
        • radiation induced immunosuppression
        • inflammatory arthropathies including SLE and RA
        • comorbidities including
          • previous prosthetic joint infection
          • Type I (insulin-dependent) diabetes
          • malnourishment
          • hemophilia
          • HIV
          • malignancy
      • evidence to support recommendations
        • AAOS and ADA recognizes there is limited or inconclusive evidence to support the recommendations above and practitioners should use clinical judgment
    • Administration
      • antibiotics is given 1 hour before dental procedure
      • patients NOT allergic to penicillin should be given
        • amoxicillin or cephalexin 2 grams orally
        • if unable to take oral medications than 1 gram cefazolin or 2 gram ampicillin IV or IM
      • if allergic to penicillin
        • clindamycin 600 mg orally
        • if unable to take oral medications than clindamycin 600 mg IV
  • Splenectomy Patients Prophylaxis
    • Indications in splenectomized patients
      • pneumococcal immunization
        • indicated in all splenectomized patients and those with functional hyposplenism
      • haemophilus influenza type B vaccine
        • indicated in all patients not previously immunized
      • meningococcal group C conjugate vaccine
        • indicated in all patients not previously immunized
      • influenza immunization
        • should be given annually
      • lifelong prophylactic antibiotics (oral phenoxymethylpenicillin or erythromycin)
        • indicated in all splenectomized patients
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