From the Department of Orthopaedic Surgery, Division of Musculoskeletal Oncology, Vanderbilt University Medical Center, Nashville, TN (Hajdu, Chenard, Quirion, Mika, Gilbert, Hefley, Johnson, Halpern, Schwartz, Holt, and Lawrenz), Department of Orthopaedic Surgery, Rochester Regional Health, Rochester, NY (Judice)Department of Medicine, Division of Infectious Disease, Vanderbilt University Medical Center, Nashville, TN (Wright)Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN (Kang).
J Am Acad Orthop Surg. 2024 Nov 15;32(22):e1166-e1175. doi: 10.5435/JAAOS-D-24-00211. Epub 2024 Jul 2.
Infection is a common mode of failure in lower extremity endoprostheses. The Prophylactic Antibiotic Regimens in Tumor Surgery trial reported that 5 days of cefazolin had no difference in surgical site infection compared with 24 hours of cefazolin. Our purpose was to evaluate infection rates of patients receiving perioperative cefazolin monotherapy, cefazolin-vancomycin dual therapy, or alternative antibiotic regimens.
A single-center retrospective review was conducted on patients who received lower extremity endoprostheses from 2008 to 2021 with minimum 1-year follow-up. Three prophylactic antibiotic regimen groups were compared: cefazolin monotherapy, cefazolin-vancomycin dual therapy, and alternative regimens. The primary outcome was deep infection, defined by a sinus tract, positive culture, or clinical diagnosis. Secondary outcomes were revision surgery, microorganisms isolated, and superficial wound issues.
The overall deep infection rate was 10% (30/294) at the median final follow-up of 3.0 years (IQR 1.7 to 5.4). The deep infection rates in the cefazolin, cefazolin-vancomycin, and alternative regimen groups were 8% (6/72), 10% (18/179), and 14% (6/43), respectively ( P = 0.625). Patients not receiving cefazolin had an 18% deep infection rate (6/34) and 21% revision surgery rate (7/34) compared with a 9% deep infection rate (24/260) ( P = 0.13) and 12% revision surgery rate (31/260) ( P = 0.17) in patients receiving cefazolin. In those not receiving cefazolin, 88% (30/34) were due to a documented penicillin allergy, only two being anaphylaxis. All six patients in the alternative regimen group who developed deep infections did not receive cefazolin secondary to nonanaphylactic penicillin allergy.
The addition of perioperative vancomycin to cefazolin in lower extremity endoprosthetic reconstructions was not associated with a lower deep infection rate. Patients who did not receive cefazolin trended toward higher rates of deep infection and revision surgery, although not statistically significant. The most common reason for not receiving cefazolin was a nonanaphylactic penicillin allergy, highlighting the continued practice of foregoing cefazolin unnecessarily.
感染是下肢假体失效的常见模式。肿瘤手术预防性抗生素方案试验报告称，头孢唑林使用 5 天与使用 24 小时头孢唑林在手术部位感染方面没有差异。我们的目的是评估接受围手术期头孢唑林单药治疗、头孢唑林-万古霉素双联治疗或替代抗生素方案的患者的感染率。
对 2008 年至 2021 年期间接受下肢假体的患者进行了单中心回顾性研究，这些患者的随访时间至少为 1 年。比较了三种预防性抗生素方案组：头孢唑林单药治疗、头孢唑林-万古霉素双联治疗和替代方案。主要结局是深部感染，定义为窦道、阳性培养或临床诊断。次要结局是翻修手术、分离的微生物和浅表伤口问题。
在中位随访 3.0 年（IQR 1.7 至 5.4）时，总体深部感染率为 10%（30/294）。头孢唑林、头孢唑林-万古霉素和替代方案组的深部感染率分别为 8%（6/72）、10%（18/179）和 14%（6/43）（ P = 0.625）。未接受头孢唑林治疗的患者深部感染率为 18%（6/34），翻修手术率为 21%（7/34），而接受头孢唑林治疗的患者深部感染率为 9%（24/260）（ P = 0.13），翻修手术率为 12%（31/260）（ P = 0.17）。在未接受头孢唑林治疗的患者中，88%（30/34）有明确的青霉素过敏史，仅有两例为过敏反应。在接受替代方案的 6 例深部感染患者中，均由于非过敏青霉素过敏而未接受头孢唑林治疗。
在下肢假体重建术中，头孢唑林加用万古霉素并不会降低深部感染率。未接受头孢唑林治疗的患者深部感染和翻修手术的发生率呈上升趋势，但无统计学意义。未接受头孢唑林治疗的最常见原因是非过敏青霉素过敏，这突显了不必要地避免使用头孢唑林的持续做法。
