Updated: 3/10/2020

Prophylactic Antibiotics

Review Topic
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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) q
      • indicated in all splenectomized patients

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(SAE13BS.94) What is the recommended optimal timing of presurgical antibiotic administration to prevent infection in patients undergoing total joint replacement surgery? Review Topic | Tested Concept

QID: 8335

Within 1 hour before incision




Within 2 hours before incision




Immediately after incision




Within 1 hour after incision



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