What is the recommended antibiotic prophylaxis for hip replacement (arthroplasty)?

From the Guidelines

Antibiotic prophylaxis is strongly recommended for all patients undergoing hip replacement surgery to prevent surgical site infections, with the standard regimen being cefazolin 2g IV (or 3g for patients weighing >120kg) administered within 60 minutes before surgical incision, as supported by the most recent and highest quality study 1. The use of antibiotic prophylaxis in hip replacement surgery is crucial in preventing surgical site infections, which can lead to devastating complications such as prosthetic joint infections requiring extensive revision surgeries.

• The recommended antibiotic regimen is cefazolin 2g IV (or 3g for patients weighing >120kg) administered within 60 minutes before surgical incision, as stated in the study 1.
• For patients with beta-lactam allergies, alternatives include clindamycin 900mg IV or vancomycin 15mg/kg IV (started 60-120 minutes before incision due to longer infusion time), as mentioned in the study 1.
• If MRSA colonization is known or suspected, vancomycin should be used, as recommended in the study 1.
• The prophylactic antibiotics should be discontinued within 24 hours after surgery, as longer durations do not provide additional benefit and may contribute to antibiotic resistance, as stated in the study 1.
• For prolonged procedures (>4 hours) or cases with significant blood loss (>1500mL), an additional intraoperative dose of cefazolin should be administered, as recommended in the study 1. The antibiotics target the most common pathogens in orthopedic infections, including Staphylococcus aureus, coagulase-negative staphylococci, and streptococci, as mentioned in the study 1. Proper timing ensures peak antibiotic tissue concentrations during the procedure when contamination risk is highest, as stated in the study 1. It is essential to follow the recommended guidelines for antibiotic prophylaxis in hip replacement surgery to minimize the risk of surgical site infections and ensure the best possible outcomes for patients, as supported by the study 1.

From the FDA Drug Label

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)

Antibiotic prophylaxis for hip replacement is supported by the FDA drug label, which mentions that cefazolin may be effective in surgical patients in whom infection at the operative site would present a serious risk, including prosthetic arthroplasty.

• The use of cefazolin as prophylaxis in hip replacement surgery may reduce the incidence of certain postoperative infections.
• The prophylactic administration of cefazolin should usually be discontinued within a 24-hour period after the surgical procedure, but may be continued for 3 to 5 days following the completion of surgery in cases where the occurrence of infection may be particularly devastating 2.

From the Research

Antibiotic Prophylaxis for Hip Replacement

• The use of antibiotic prophylaxis in hip replacement surgery is a widely accepted practice to prevent surgical site infections (SSIs) 3, 4, 5, 6, 7.
• Studies have shown that cephalosporins are effective antibiotics for prophylaxis in hip replacement surgery, with cefazolin being a commonly recommended choice 3, 4, 5, 7.
• The timing and dosage of antibiotic prophylaxis are crucial, with recommendations suggesting that the initial dose should be given 15 minutes prior to incision, and a second dose should be given one hour after the first dose if necessary 3, 4.
• Some studies have suggested that expanded gram-negative antimicrobial prophylaxis (EGNAP) may be beneficial in reducing SSIs in hip arthroplasty, particularly in cases where gram-negative pathogens are a concern 7.
• The choice of antibiotic prophylaxis may depend on various factors, including the patient's allergy status, the type of surgery, and the local microbiological environment 4, 5, 6.
• Vancomycin is sometimes used as an alternative to cephalosporins, particularly in cases of penicillin allergy, but its effectiveness may depend on the dosage used 5.
• The overall goal of antibiotic prophylaxis in hip replacement surgery is to reduce the risk of SSIs and improve patient outcomes, while also minimizing the risk of antibiotic resistance and other adverse effects 3, 4, 5, 6, 7.

Key Findings

• A study published in 1983 found that cefamandole maintained consistently higher levels in all tissues and penetrated bone and deep tissues better than cephalothin 3.
• A study published in 2001 recommended that antimicrobial prophylaxis should begin just before the operation and that a single-dose prophylaxis after the induction of anesthesia is sufficient 4.
• A study published in 2014 found that the overall thirty-day SSI rate was 1.4%, and that vancomycin only had a higher SSI rate compared to cefazolin only or clindamycin 5.
• A study published in 2008 found that methicillin-resistant Staphylococcus aureus (MRSA) was successfully eradicated in all patients after a mean follow-up of 53.6 months, but that deep infections required multiple operative debridements 6.
• A study published in 2016 found that the addition of EGNAP to hip arthroplasty patients reduced the SSI rate from 1.19% to 0.55% 7.