CDC Guideline: Post-Operative Prophylactic AntibioticsPosition of the American Association of Hip and Knee Surgeons Position Statements
At this time, we do not agree with this recommendation vis a vis TJA in that it contradicts current international standards of care with limited evidence and study.
A recent TJA focused meta-analysis of this specific topic could only find four appropriate randomized control trials, two of which overlap with the citations given by the CDC. Again, the aggregate infection rate is higher than ones reported as ideal and expected in the literature. The authors showed non-superiority for the post-operative antibiotics. Their conclusion, however, carried significant caveats. The available literature was considered flawed: “both reviewers rated down the quality of evidence from the 4 trials from high to very low based on (a) unclear risk of bias, (b) imprecision due to few outcome events and (c) inconsistency due to residual unexplained heterogeneity.” The very low quality of evidence rating was based on the widely accepted Grade methodology. The authors recommended that more rigorous multicenter trials were needed.
As an organization we agree with that recommendation. The consequences of a TJA infection are devastating to the patient, hard to eradicate, and costs society hundreds of thousands of dollars per case. It is our recommendation that implementation of this recommendation be delayed. We further recommend that the CDC join AAHKS in calling for funding to more rigorously answer this question.
To that end, the 2017 Foundation for Arthroplasty Research and Education (FARE) grant recipient, Thorsten M. Seyler, MD, PhD of Duke University, is conducting a prospective, randomized study, “Perioperative Antibiotic Prophylaxis in Patients Undergoing Elective Total Knee Arthroplasty.” This study is aiming to provide Level I evidence for or against single-dose versus 24-hour antibiotic prophylaxis in primary total knee arthroplasty (TKA) and is based on the most recent release of the Centers for Medicare & Medicaid Service’s guideline for perioperative antibiotics, which is based on limited evidence.
 Gehrke T, Parvizi J. Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection. Rolle (Switzerland): European Federation of National Associations of Orthopaedics and Traumatology; 2013. Available: www.efort.org/wp-content/uploads/2013/10/Philadelphia_Consensus.pdf (accessed 2014July 03).
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Buckley R, Hughes GNF, Snodgrass T, Huchcroft SA. Perioperative cefazolin prophylaxis in hip fracture surgery. Can J Surg. Apr 1990;33(2):122-127.
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 Thornley P, Evaniew N, Riediger, Winemaker M, Bhandari M, Ghert M. Postoperative antibiotic prophylaxis in total hip and knee arthroplasty: a systematic review and meta-analysisof randomized controlled trialsCMAJ Open 2015. DOI:10.9778/cmajo.20150012
» AAHKS White Paper on Postoperative prophylactic antibiotics in total joint arthroplasty (Arthroplasty Today, 2018)
» Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection (2017)
» American Academy of Orthopaedic Surgeon (AAOS) 2014 Comment Letter on CDC Draft Guideline for the Prevention of Surgical Site Infections.
» American Academy of Orthopaedic Surgeon (AAOS) advisory opinion passed jointly by the Board of Councilors and Board of Specialty Societies in May of 2017, and then adapted by the AAOS Board in June of 2017 calling for further research on this issue.