What is the recommended pre-surgical antibiotic protocol for hip replacement surgery?

Pre-Surgical Antibiotic Protocol for Hip Replacement

For hip replacement surgery, cefazolin 2g IV should be administered within 60 minutes before skin incision as the standard prophylactic antibiotic regimen, with a single dose being sufficient for most procedures. 1

First-Line Antibiotic Selection

• Cefazolin 2g IV slow infusion is the recommended first-line agent for antibiotic prophylaxis in hip replacement surgery 1, 2
• Timing: Administer within 60 minutes prior to skin incision (ideally 30-60 minutes before) 3, 1
• Duration: A single preoperative dose is adequate for most procedures 3
• Re-dosing: If surgery exceeds 4 hours or if blood loss exceeds 1.5L, administer an additional 1g dose 3, 2

Alternative Options for Penicillin-Allergic Patients

• Clindamycin 900mg IV slow infusion for patients with true penicillin allergy 3, 1
• Vancomycin 30mg/kg IV (infused over 120 minutes) for patients with MRSA colonization or at facilities with high MRSA rates 1
  • Vancomycin infusion should end no later than the start of surgery 1

Evidence Supporting Recommendations

Cefazolin is the preferred agent because it achieves the highest bone tissue concentrations (30 μg/g) compared to other cephalosporins, with peak levels reached 25-40 minutes after injection 4. These levels are approximately 60 times higher than the minimum inhibitory concentration for penicillin-resistant staphylococci 4.

Randomized controlled trials have demonstrated that cefazolin prophylaxis significantly reduces hip infection rates from 3.3% (placebo) to 0.9% 5. Even short-course prophylaxis has been shown to be as effective as longer regimens in preventing infection 6.

Important Considerations

• Timing is critical: Preoperative dose must be given 30-60 minutes before initial surgical incision to ensure adequate antibiotic levels in serum and tissues 3, 2
• Dosage adjustment for obesity: For patients ≥120 kg, consider higher doses of antibiotics 3
• Renal function: Adjust dosing for patients with reduced renal function 2:
  • Creatinine clearance 35-54 mL/min: Full dose but at 8-hour intervals
  • Creatinine clearance 11-34 mL/min: Half dose every 12 hours
  • Creatinine clearance ≤10 mL/min: Half dose every 18-24 hours

Duration of Prophylaxis

• Single preoperative dose is generally sufficient 3, 1
• Extended prophylaxis (up to 24 hours) may be considered for specific circumstances such as certain cardiac and vascular surgeries 3
• There is no evidence supporting the use of postoperative antibiotic prophylaxis beyond 24 hours 3, 1

Additional Infection Prevention Measures

• Implement proper infection prevention and control strategies, including correct hand hygiene practices 3
• Ensure meticulous surgical techniques and minimize tissue trauma 3
• Maintain appropriate perioperative temperature, fluid, and oxygenation management 3
• Use active warming strategies during and after surgery to prevent hypothermia 3
• Consider thromboembolism prophylaxis with appropriate timing to minimize bleeding risk during surgery 3

Remember that antibiotics alone cannot prevent surgical site infections. A comprehensive approach including proper surgical technique, sterile environment, and patient optimization is essential for successful infection prevention in hip replacement surgery.