Is 21-day postoperative prophylaxis with ciprofloxacin (Cipro) and doxycycline indicated after orthopedic endoprosthetic reconstruction?

From the Guidelines

I strongly advise against the use of 21-day postoperative prophylaxis with ciprofloxacin and doxycycline after orthopedic endoprosthetic reconstruction. The most recent and highest quality study, published in 2019 in the journal Anaesthesia 1, recommends limited antibiotic prophylaxis to the operative period, typically not exceeding 24 hours, for orthopedic surgery involving joint prosthesis. This guideline suggests the use of cefazolin, cefamadole, or cefuroxime as the preferred antibiotics for prophylaxis in orthopedic surgery, with clindamycin or vancomycin as alternatives in cases of allergy.

Key points to consider include:

• The recommended duration of antibiotic prophylaxis is limited to the operative period, with a maximum of 24 hours 1.
• The use of ciprofloxacin and doxycycline is not recommended for routine prophylaxis in orthopedic endoprosthetic reconstruction.
• Extended prophylaxis beyond 24-48 hours has not been shown to provide additional benefit in preventing surgical site infections and may contribute to antibiotic resistance, Clostridioides difficile infections, and other adverse effects.
• Prolonged antibiotic exposure can disrupt normal flora, select for resistant organisms, and increase the risk of tendinopathy with fluoroquinolones like ciprofloxacin.

In terms of specific antibiotic selection, the guidelines recommend:

• Cefazolin as the first-line choice for orthopedic surgery involving joint prosthesis 1.
• Cefamadole or cefuroxime as alternative options 1.
• Clindamycin or vancomycin for patients with allergies to beta-lactams or suspected/confirmed colonization with methicillin-resistant Staphylococcus aureus 1.

From the Research

Orthopedic Endoprosthetic Reconstruction and Antibiotic Prophylaxis

• The use of antibiotic prophylaxis after orthopedic endoprosthetic reconstruction is a common practice to reduce the risk of surgical site infections (SSIs) 2, 3, 4, 5, 6.
• However, the optimal duration of antibiotic prophylaxis for this patient population remains unknown 2, 6.

Duration of Antibiotic Prophylaxis

• A study published in 2015 found that extended postoperative antibiotic prophylaxis may reduce the risk of periprosthetic joint infection (PJI) in patients undergoing tumor resection and endoprosthetic replacement for metastatic bone disease 2.
• Another study published in 2023 found that hospital length of stay (LOS) was an independent risk factor for SSI, and that streamlined discharge plans may potentially reduce the risk of SSI 4.
• A randomized clinical trial published in 2022 found that a 5-day regimen of postoperative intravenous antibiotics did not confirm the superiority of a 5-day regimen over a 1-day regimen in preventing SSIs after surgery for lower extremity bone tumors that required an endoprosthesis 6.

Specific Antibiotic Regimens

• A study published in 2024 compared the infection rates of patients receiving perioperative cefazolin monotherapy, cefazolin-vancomycin dual therapy, or alternative antibiotic regimens, and found that the addition of perioperative vancomycin to cefazolin was not associated with a lower deep infection rate 3.
• The use of ciprofloxacin and doxycycline as a prophylactic antibiotic regimen is not specifically mentioned in the provided studies.

Risk Factors for Surgical Site Infections

• Several studies have identified risk factors for SSIs after orthopedic endoprosthetic reconstruction, including operative time, volume of muscle excised, and hospital LOS 4, 5.
• Increased surgical duration was found to be an independent risk factor for SSI, but extended postoperative antibiotic therapy did not appear to mitigate this risk 5.