You are on page 1of 4

CMED_Ortho_VA 7/30/07 10:52 AM Page 1

Antibiotic Prophylaxis
in Orthopedic Surgery
Translated from the original French version published November 2005

This guide is provided for information purposes and is not a substitute for clinical judgment.

GENERAL
• Most studies addressing antibiotic prophylaxis in orthopedic surgery have involved hip replacements or implantation
of internal fixation devices in hip fractures.
• Antibiotic prophylaxis in other types of orthopedic surgery involving implantation of internal fixation devices (prosthesis,
plates, nails etc.) is considered a standard of practice however based on empiric data.

TREATMENT GUIDELINES
• Antibiotic prophylaxis must be adapted to specific resistance patterns of each hospital environment.

Antibiotic prophylaxis
Prophylaxis NOT RECOMMENDED
Orthopedic surgery without implantation of internal fixation devices (e.g. arthroscopy, acromioplasty, soft tissue repair
with absorbable sutures)
Scientific evidence supporting antibiotic prophylaxis is insufficient to justify therapy.
Prophylaxis RECOMMENDED
Orthopedic surgery with implantation of internal fixation devices (prosthesis, nail, plate, screw, wire)
Recommended for all these types of orthopedic surgery because of the extensive morbidity associated with surgical
site infection.

First-line antibiotic prophylaxis
• Cefazolin (Ancef ®)
Second-line antibiotic prophylaxis
⇒ Indications
• Documented allergy to ß-lactams in patients:
• having shown signs of anaphylaxis, urticaria or rash, within 72 hours of administering a ß-lactam antimicrobial

or having had a serious adverse drug reaction such as, drug fever or toxic epidermal necrolysis.
• Patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) or with methicillin-resistant
coagulase-negative staphylococci.
REFERENCES
⇒ Vancomycin is considered an appropriate second-line choice by most authors because of its adequate coverage of pathogens American Society of Health-System Pharmacists. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. American Journal of Health-System Pharmacy 1999 ; 56 : 1839 - 88.
most likely to be encountered and because of its antibacterial effect. Vancomycin should be preferred unless clindamycin Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004 ; 38 : 1706 - 15.
offers better coverage against the pathogens encountered. Pickering LK (ed). Report of the Committee on Infectious Diseases, 26th edition, Red Book 2003. American Academy of Pediatrics, Elk Grove Village, 2003.
Scottish Intercollegiate Guidelines Network (SIGN). Antibiotic prophylaxis in surgery: a national clinical guideline. 2000 (45) : 1 - 36.
The Medical Letter. Antimicrobial prophylaxis for surgery. Treatment Guidelines from The Medical Letter 2004 ; 2(20) : 27- 32.

Antibiotic Prophylaxis in Orthopedic Surgery
This guide was developed in collaboration with professional corporations (CMQ, OPQ), the federations (FMOQ, FMSQ) and Québec associations of pharmacists and physicians.

plate. nail. † Two additional doses of 25 mg/kg IV every 8 hours may be required. • For practical purposes. Cost may vary with the region.ca CHILDREN ANTIBIOTIC PROPHYLAXIS* PROPHYLAXIS NOT RECOMMENDED FOR ORTHOPEDIC PROCEDURES WITHOUT IMPLANTATION OF FIXATION DEVICES Antibiotic administration Type First-line therapy Second-line therapy of surgery Antibiotic Dosage Cost per dose ‡§ Antibiotic Dosage Cost per dose ‡ § Cefazolin direct IV over 3-5 minutes OR IV infusion over 15–30 minutes Orthopedic Cefazolin (Ancef®) 25 mg/kg IV at induction † $1 Vancomycin 10 mg/kg IV infusion $1 procedures with Dose range: 20 .30 mg/kg (Vancocin®) over 60 min Vancomycin IV infusion over 60 minutes.cdm. Cost may vary with the region. Antibiotic prophylaxis for over 24 hours is not warranted. • A single dose of Vancomycin is sufficient because of its longer half-life. nail.CMED_Ortho_VA 7/30/07 10:52 AM Page 2 THERAPY ADULTS ANTIBIOTIC PROPHYLAXIS* Timing of preoperative antibiotic administration PROPHYLAXIS NOT RECOMMENDED FOR ORTHOPEDIC PROCEDURES WITHOUT IMPLANTATION OF FIXATION DEVICES Type First-line therapy Second-line therapy • At induction of anesthesia of surgery Antibiotic Dosage Cost per dose ‡ Antibiotic Dosage Cost per dose ‡ • Variable depending on the recommended agent Orthopedic Cefazolin (Ancef®) 1 g IV at induction † $1 Vancomycin 1 g IV infusion $7 • If a proximal tourniquet is required: procedures with (Vancocin®) over 60 min • The preoperative dose should be completely infused BEFORE applying the tourniquet. Characteristics of pediatric antibiotic prophylaxis • Pediatric dose: calculated in mg/kg with a maximum dose equivalent to the adult dose. www. internal fixation 2 g IV at induction † devices (prosthesis. wire) * Only one brand name product is listed although several manufacturers may market other brand names. screw. • Recommendations are based on adult population trials and may be adapted to local experience. ‡ Approximate cost negotiated for the healthcare facilities of the region of Québec (June 2005). Repeat dose during wire) procedure if it lasts > 3 hours or if blood loss exceeds 1500 mL Duration of antibiotic prophylaxis * Only one brand name product is listed although several manufacturers may market other brand names.qc. even in the presence of a drain or urinary catheter. Antibiotic Prophylaxis in Orthopedic Surgery . Start infusion 60-90 minutes before incision implantation of Maximal dose: 1 g Maximal dose: 1 g internal fixation devices (prosthesis.gouv. • A single preoperative dose is sufficient for most orthopedic surgeries. implantation of patient > 80 kg: • A minimum of 10 minutes is required before inflating the tourniquet. • Few studies have evaluated the efficacy of antibiotic prophylaxis in children undergoing orthopedic surgery. § Approximate cost for lowest dosage in a 20 kg-child. † Two additional doses of 1 g IV every 8 hours may be required. • The half-life of cefazolin may warrant the administration of a preoperative dose followed by two postoperative doses. plate. ‡ Approximate cost negotiated for the healthcare facilities of the region of Québec (June 2005). screw. a 24-hour prophylaxis may be justified because surgical site infections following contamination during orthopedic surgery are a major source of morbidity.

www. ‡ Approximate cost negotiated for the healthcare facilities of the region of Québec (June 2005). Repeat dose during wire) procedure if it lasts > 3 hours or if blood loss exceeds 1500 mL Duration of antibiotic prophylaxis * Only one brand name product is listed although several manufacturers may market other brand names. Start infusion 60-90 minutes before incision implantation of Maximal dose: 1 g Maximal dose: 1 g internal fixation devices (prosthesis. nail. plate. • For practical purposes. screw. • A single preoperative dose is sufficient for most orthopedic surgeries. Antibiotic prophylaxis for over 24 hours is not warranted. Cost may vary with the region.ca CHILDREN ANTIBIOTIC PROPHYLAXIS* PROPHYLAXIS NOT RECOMMENDED FOR ORTHOPEDIC PROCEDURES WITHOUT IMPLANTATION OF FIXATION DEVICES Antibiotic administration Type First-line therapy Second-line therapy of surgery Antibiotic Dosage Cost per dose ‡§ Antibiotic Dosage Cost per dose ‡ § Cefazolin direct IV over 3-5 minutes OR IV infusion over 15–30 minutes Orthopedic Cefazolin (Ancef®) 25 mg/kg IV at induction † $1 Vancomycin 10 mg/kg IV infusion $1 procedures with Dose range: 20 . Cost may vary with the region. Characteristics of pediatric antibiotic prophylaxis • Pediatric dose: calculated in mg/kg with a maximum dose equivalent to the adult dose. implantation of patient > 80 kg: • A minimum of 10 minutes is required before inflating the tourniquet. • The half-life of cefazolin may warrant the administration of a preoperative dose followed by two postoperative doses.30 mg/kg (Vancocin®) over 60 min Vancomycin IV infusion over 60 minutes. † Two additional doses of 1 g IV every 8 hours may be required. ‡ Approximate cost negotiated for the healthcare facilities of the region of Québec (June 2005). • Few studies have evaluated the efficacy of antibiotic prophylaxis in children undergoing orthopedic surgery. nail. plate. § Approximate cost for lowest dosage in a 20 kg-child.gouv. wire) * Only one brand name product is listed although several manufacturers may market other brand names.qc.cdm. Antibiotic Prophylaxis in Orthopedic Surgery . • Recommendations are based on adult population trials and may be adapted to local experience. screw. a 24-hour prophylaxis may be justified because surgical site infections following contamination during orthopedic surgery are a major source of morbidity. † Two additional doses of 25 mg/kg IV every 8 hours may be required. even in the presence of a drain or urinary catheter. • A single dose of Vancomycin is sufficient because of its longer half-life.CMED_Ortho_VA 7/30/07 10:52 AM Page 2 THERAPY ADULTS ANTIBIOTIC PROPHYLAXIS* Timing of preoperative antibiotic administration PROPHYLAXIS NOT RECOMMENDED FOR ORTHOPEDIC PROCEDURES WITHOUT IMPLANTATION OF FIXATION DEVICES Type First-line therapy Second-line therapy • At induction of anesthesia of surgery Antibiotic Dosage Cost per dose ‡ Antibiotic Dosage Cost per dose ‡ • Variable depending on the recommended agent Orthopedic Cefazolin (Ancef®) 1 g IV at induction † $1 Vancomycin 1 g IV infusion $7 • If a proximal tourniquet is required: procedures with (Vancocin®) over 60 min • The preoperative dose should be completely infused BEFORE applying the tourniquet. internal fixation 2 g IV at induction † devices (prosthesis.

TREATMENT GUIDELINES • Antibiotic prophylaxis must be adapted to specific resistance patterns of each hospital environment. drug fever or toxic epidermal necrolysis.g. Prophylaxis RECOMMENDED Orthopedic surgery with implantation of internal fixation devices (prosthesis. FMSQ) and Québec associations of pharmacists and physicians. nails etc. Pickering LK (ed).32. nail. REFERENCES ⇒ Vancomycin is considered an appropriate second-line choice by most authors because of its adequate coverage of pathogens American Society of Health-System Pharmacists. American Journal of Health-System Pharmacy 1999 . Clin Infect Dis 2004 . GENERAL • Most studies addressing antibiotic prophylaxis in orthopedic surgery have involved hip replacements or implantation of internal fixation devices in hip fractures.88. Elk Grove Village. First-line antibiotic prophylaxis • Cefazolin (Ancef ®) Second-line antibiotic prophylaxis ⇒ Indications • Documented allergy to ß-lactams in patients: • having shown signs of anaphylaxis. . arthroscopy.CMED_Ortho_VA 7/30/07 10:52 AM Page 1 Antibiotic Prophylaxis in Orthopedic Surgery Translated from the original French version published November 2005 This guide is provided for information purposes and is not a substitute for clinical judgment. Red Book 2003. Treatment Guidelines from The Medical Letter 2004 . urticaria or rash. Report of the Committee on Infectious Diseases. 2000 (45) : 1 . acromioplasty. Houck PM. Antibiotic Prophylaxis in Orthopedic Surgery This guide was developed in collaboration with professional corporations (CMQ. plate. the federations (FMOQ. Antibiotic prophylaxis in surgery: a national clinical guideline. screw. soft tissue repair with absorbable sutures) Scientific evidence supporting antibiotic prophylaxis is insufficient to justify therapy. 2(20) : 27. Vancomycin should be preferred unless clindamycin Bratzler DW. The Medical Letter. • Antibiotic prophylaxis in other types of orthopedic surgery involving implantation of internal fixation devices (prosthesis. most likely to be encountered and because of its antibacterial effect.) is considered a standard of practice however based on empiric data. 38 : 1706 . within 72 hours of administering a ß-lactam antimicrobial or having had a serious adverse drug reaction such as. offers better coverage against the pathogens encountered. American Academy of Pediatrics. 26th edition. wire) Recommended for all these types of orthopedic surgery because of the extensive morbidity associated with surgical site infection.36. 56 : 1839 . Antimicrobial prophylaxis for surgery. 2003. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. plates. OPQ). Antibiotic prophylaxis Prophylaxis NOT RECOMMENDED Orthopedic surgery without implantation of internal fixation devices (e. • Patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) or with methicillin-resistant coagulase-negative staphylococci. Scottish Intercollegiate Guidelines Network (SIGN).15.