Antibiotic Stewardship in

Orthopedics
Antimicrobial resistance
• Globally, more than 700,000 people die each year of antibiotic-
resistant infections
• By the year 2050, AMR infections are predicted to be a larger
killer than cancer and heart disease
• The primary drivers for resistance are overuse and
inappropriate use of antimicrobials
Antimicrobial Stewardship
• a coordinated set of interventions designed to promote the
appropriate use of antimicrobials
• The goal is to improve patient outcomes, reduce microbial resistance,
and decrease the spread of drug-resistant infections
Antimicrobial Stewardship Concepts
• Two core strategies of antimicrobial stewardship are prior
authorization and prospective audit/feedback
• Prior authorization occurs when certain antibiotics must go through an
approval process before they can be prescribed
• Audits reduce nonoptimal antimicrobial therapy through direct feedback to
the prescriber
• Supplemental strategies include education, guidelines, clinical
pathways, automatic substitutions, and intravenous-to-oral
conversion protocols.
Antibiotic Time-out
• The provider and team members purposefully review the patient’s
antimicrobial therapy for appropriateness
• The surgeon reviews each antibiotic order for indication and escalation
or de-escalation opportunities, plans duration of therapy, and makes
any necessary changes
• This approach accommodates the need to initiate broad therapy during times of
uncertain diagnosis, while encouraging transition to more targeted therapy as
additional clinical information becomes available
• Antibiotic time-outs can be performed informally or in a more
documented manner, depending on provider and institution
preferences
Opportunities for the Orthopaedic Surgeon
1. De-escalate empiric antimicrobial therapy appropriately when culture sensitivities demonstrate
susceptibility to more narrow agents, such as with methicillin-susceptible Staphylococcus aureus (S.
aureus) (MSSA)
• Vancomycin often is used empirically to treat surgical site infections (SSIs) and osteomyelitis, due to its activity
against methicillin-resistant S. aureus (MRSA)
• However, when culture results demonstrate MSSA, vancomycin sometimes is continued inappropriately—when a
narrower spectrum beta-lactam agent would be more appropriate.
• This practice can adversely affect patient outcomes because vancomycin has been shown to be inferior to beta-
lactam agents as definitive therapy for certain MSSA infections
• Studies have demonstrated higher recurrence rates, treatment failures, and even deaths
• Because vancomycin is less efficacious than standard prophylaxis in a non-MRSA setting, its generic use
for prophylaxis when concerns for MRSA are high might leave a patient relatively unprotected against
some MSSA strains
• Unless a patient has an allergy, orthopaedic surgeons should strive to utilize beta-lactam therapy for
MSSA infections to maximize treatment efficacy and to minimize resistance development and adverse
medication effects
Opportunities for the Orthopaedic Surgeon
2. Avoid overly broad antimicrobial coverage for skin and soft-tissue
infections
• Such infections are caused by a variety of microbes, including streptococci, MSSA,
and MRSA
• With the frequency of community-acquired strains of MRSA increasing,
orthopaedic surgeons must identify patient risk factors in order to
prescribe the most appropriate therapies and minimize the increased
resistance and adverse effects associated with overly broad therapy
• Adverse effects include Clostridium difficile infection (CDI) and increased
nephrotoxicity associated with concomitant vancomycin and
piperacillin/tazobactam
Opportunities for the Orthopaedic Surgeon
• Purulent soft tissue infections, including abscesses, warrant empiric
MRSA coverage, as do severe nonpurulent infections, although such
coverage should be de-escalated once culture results are available
• Empiric MRSA coverage also is warranted if a patient demonstrates
systemic signs of toxicity, prior MRSA infection or colonization,
presence of MRSA risk factors, or proximity of a lesion to an
indwelling medical device
• Mild to moderate nonpurulent infections should be treated
empirically with a beta-lactam agent or clindamycin
Opportunities for the Orthopaedic Surgeon
3. Optimizing the duration and dosing of perioperative surgical
prophylaxis
• Significant controversy exists regarding the recommended duration of
prophylaxis in routine orthopaedic cases
• CDC guidelines released in 2017 recommend administration of
preoperative antibiotics before skin incision
• The guidelines also state that no further additional antibiotic doses need to
be given after a surgical incision is closed in all clean and clean-contaminated
procedures, including joint arthroplasties
• In addition, many institutions use initial dosing that is weight dependent and
use re-dosing for longer procedures.
Opportunities for the Orthopaedic Surgeon
• Shorter postoperative prophylaxis is supported by data recently
presented from a study that sought to characterize the relationship
between duration of antibiotic prophylaxis and important outcomes
• Using a large, multicenter national cohort of total joint, cardiac, vascular, and
colorectal procedures, investigators found that increasing duration of
postoperative antimicrobial prophylaxis was associated with higher odds of
acute kidney injury and CDI
• Additional days of routine antibiotic administration were not associated
with reduced odds of SSI
• AAOS disagrees with a shortened postoperative course and instead
recommends that prophylaxis be continued for 24 hours postoperatively
 Opportunities for the Orthopaedic Surgeon
• Unfortunately, sufficient data are not yet available regarding the
optimal duration of antimicrobial prophylaxis
• Several orthopaedic centers successfully follow the CDC recommendations of
administering only single-dose prophylaxis*
• Those institutions are encouraged to review and publish data on infection
rates to help elucidate the best course of action, because the risk of infection
needs to be carefully balanced with the risks that additional antibiotic doses
confer, including CDI, which can occur after a single dose
• We must seek the answer to the optimal duration of prophylaxis to
minimize infection risk while avoiding significant adverse reactions

*“Meta-analysis Evaluates CDC’s Recommendation of a Single, Preoperative Dose of

Antibiotics,” AAOS Now, October 2018
Antimicrobial Stewardship
Program Guidelines
Antibiotic Stewardship in Orthopaedic Surgery: Principles and Practice, Campbell
2014
Antibiotic Dosage
Recommendations
Reference
• Antibiotic Stewardship in Orthopaedic Surgery: Principles and
Practice, Campbell 2014