What is the appropriate antibiotic choice for an infected orthopedic (ortho) surgical site wound?

From the Guidelines

For an infected orthopedic surgical site wound, a first-generation cephalosporin or an antistaphylococcal penicillin for methicillin-susceptible Staphylococcus aureus (MSSA) or vancomycin, linezolid, daptomycin, telavancin, or ceftaroline where risk factors for MRSA are high is recommended. This recommendation is based on the guidelines for the diagnosis and management of skin and soft tissue infections, including surgical site infections, as outlined by the Infectious Diseases Society of America 1.

When considering the appropriate antibiotic choice, several factors must be taken into account, including:

• The type of orthopedic surgery performed
• The presence of systemic signs of infection, such as erythema, induration, fever, or elevated white blood cell count
• The risk factors for methicillin-resistant Staphylococcus aureus (MRSA), such as nasal colonization, prior MRSA infection, recent hospitalization, or recent antibiotic use
• The need for coverage against gram-negative bacteria and anaerobes, depending on the location and type of surgery

Key considerations for antibiotic selection include:

• For MSSA, a first-generation cephalosporin or an antistaphylococcal penicillin is recommended
• For MRSA, vancomycin, linezolid, daptomycin, telavancin, or ceftaroline is recommended, particularly in cases with high risk factors for MRSA
• For infections following operations on the axilla, gastrointestinal tract, perineum, or female genital tract, agents active against gram-negative bacteria and anaerobes, such as a cephalosporin or fluoroquinolone in combination with metronidazole, are recommended 1.

It is essential to note that adjunctive systemic antimicrobial therapy is not routinely indicated but may be beneficial in conjunction with incision and drainage for surgical site infections associated with a significant systemic response. The duration of antibiotic therapy typically ranges from 4-6 weeks for deep infections involving bone or hardware, while superficial infections may require only 7-14 days. Surgical debridement is often necessary alongside antibiotic therapy, and monitoring for therapeutic drug levels, renal function, and clinical response is crucial throughout treatment.

From the FDA Drug Label

The prophylactic administration of Cefazolin for Injection, USP preoperatively, intraoperatively, and postoperatively may reduce the incidence of certain postoperative infections in patients undergoing surgical procedures which are classified as contaminated or potentially contaminated (e.g., vaginal hysterectomy and cholecystectomy in high-risk patients such as those older than 70 years, with acute cholecystitis, obstructive jaundice, or common duct bile stones). The prophylactic administration of Cefazolin for Injection, USP also may be effective in surgical patients in whom infection at the operative site would present a serious risk (e.g., during open-heart surgery and prosthetic arthroplasty). Bone and Joint Infections: Due to S. aureus.

The appropriate antibiotic choice for an infected orthopedic (ortho) surgical site wound is cefazolin.

• Key points:
  • Cefazolin is effective against S. aureus, a common cause of bone and joint infections.
  • It can be used for perioperative prophylaxis in surgical patients, including those undergoing prosthetic arthroplasty.
  • The dosage and administration of cefazolin should be based on the severity of the infection and the patient's renal function 2.

From the Research

Antibiotic Choice for Infected Orthopedic Surgical Site Wounds

• The choice of antibiotic for an infected orthopedic surgical site wound depends on various factors, including the type of bacteria causing the infection and the patient's medical history 3, 4, 5.
• Studies have shown that Staphylococcus aureus is a common cause of surgical site infections in orthopedic implants, and it is often resistant to multiple antibiotics 4, 5.
• Vancomycin and gentamicin have been shown to be effective against Staphylococcus aureus and other bacteria that cause surgical site infections in orthopedic implants 3, 4.
• Cefazolin is a commonly used antibiotic for surgical prophylaxis in orthopedic surgery, but it may not be effective against all types of bacteria, particularly methicillin-resistant Staphylococcus aureus (MRSA) 5, 6.
• Ceftriaxone has been used as an alternative to cefazolin in some cases, but it may not be as effective in preventing deep surgical site infections 6.
• Local intra-wound administration of powdered antibiotics, such as vancomycin, has been shown to be effective in reducing the risk of surgical site infections in orthopedic surgery 7.

Factors to Consider When Choosing an Antibiotic

• The type of bacteria causing the infection
• The patient's medical history and allergies
• The type of orthopedic implant used
• The location and severity of the infection
• The potential for antibiotic resistance

Common Antibiotics Used for Infected Orthopedic Surgical Site Wounds

• Vancomycin
• Gentamicin
• Cefazolin
• Ceftriaxone
• Linezolid
• Fusidic acid
• Cotrimoxazole
• Tetracycline
• Clindamycin