CANADIAN ORTHOPAEDIC SURGEON SURVEY: ANTIBIOTIC PROPHYLAXIS FOR TJR SURGERY1

Abstract

Controversy exists surrounding best practice for antibiotic prophylaxis in TJR. Practicing orthopedic surgeons performing TJR in Canada were surveyed to inform regarding the most common antibiotic prophylaxis practice.

Cross-sectional survey of five hundred and ninety practicing Canadian orthopaedic surgeons was conducted. Three orthopaedic surgeons, and one infectious disease specialist established face and content validity of the survey. The survey was mailed to surgeons, and re-mailed to non-responders at twelve-weeks. Survey included questions pertaining to prophylaxis indications, antibiotic choice, dosing, route and timing of administration in the primary and revision setting, as well as postoperative wound drainage investigation and management.

Response rate after two mail-outs was 410/590 (69.5%). 96.6% indicated routine use of systemic prophylactic antibiotics for uncomplicated primary TJR. Cefazolin was most commonly prescribed (97.3 %), with 1gm Cefazolin the most common dosage (70.2%). Vancomycin was prescribed 26% of the time as first line. 48.5% administer the antibiotic in the operating suite, and 90% administer within < sixty minutes prior to skin incision. 47.8% routinely use antibiotics in acrylic cement, and 50% use it in a commercially prepared form. Postoperative prophylaxis duration varied widely with 42% preferring twenty-four hours. 33% routinely culture serous wound drainage within one-week postoperative in the absence of redness or fever. 19.8% prescribe antibiotics if wound drainage persists beyond hospital stay. 15.6% would conduct intraoperative wound exploration if drainage persists beyond postoperative day four. 63.9% stated they routinely withhold antibiotics until they have obtained a deep tissue culture specimen in revision TJR. 74% use the same antibiotic prophylaxis regimen for both primary and revision procedures. Of responding surgeons, 47/410 (11.8%) were categorised as high volume performing > two hundred TJR’s per year, and 40/410 (9.8%) were categorised as low volume performing < twenty-five per year. Comparative results to be discussed.

Opinions vary widely amongst surgeons in Canada, illustrating the controversy in what constitutes ‘best practice’. Despite available published data, a large proportion of Canadian surgeons may fall short in meeting optimal standards of care in some domains such as the dose prescribed and timing of administration. This survey also illustrates the lack of available information to guide current management of postoperative wound drainage in the face of shorter patient hospital stays. Much work is needed in this area to determine risks and benefits of these costly tests and interventions in treating arthroplasty patients.