Guideline for antimicrobial use in the orthopaedic and trauma department

GUIDELINE FOR ANTIMICROBIAL USE IN
THE ORTHOPAEDIC AND TRAUMA
DEPARTMENT
Dr Ken. N. Agwuh, Consultant Microbiologist Mr Roger Helm, Consultant Orthopaedic Surgeon Mr T Kumar, Consultant Orthopaedic Surgeon The Drugs & Therapeutics Committee This document is part of antibiotic formulary guidance Formulary guidance holds the same status as Trust policy GUIDANCE ON MANAGEMENT
AMENDMENT FORM
Version Date
Brief Summary of Changes
November Complete review of prophylaxis table Mr Roger Helm, & Mr T Kumar Complete update of guidelines Mr Roger Helm, & Mr T Kumar Antibiotic prophylaxis added for fractured neck of femur Mr Z Abiddin, & Mr T Kumar May 2011 New policy Dr Ken Agwuh & Mr Z Abiddin
BACKGROUND:
The aim of this guideline is to provide basic information on prophylactic and
therapeutic antimicrobial use in orthopaedic and trauma patients.
Prophylactic use of antimicrobials aims at inhibition of growth of contaminating
bacteria, mainly skin flora organisms, and their adherence to prosthetic
devices or implants, thereby reducing the risk of infection, also to reduce the
incidence of surgical site infection.
Therapeutic antimicrobial treatment on the other hand, is used to clear
infection by an organism.
The goals of prophylactic or therapeutic administration of antibiotics to
surgical patients should also include antibiotic use in a manner that is
supported by evidence of effectiveness, minimise the effect of antibiotics on
the patient's normal bacterial flora, minimise adverse effects and cause
minimal change to the patient's host defences.
ORTHOPAEDIC SURGICAL PROPHYLAXIS:
Routine antibiotic Penicil in al ergy Special instruction procedure
Primary
iv Flucloxacillin 2gm + iv Teicoplanin 600mg iv Gentamicin at least single single dose + 10 minutes before dose at induction, then Gentamicin* single iv Flucloxacil in 1gm 6 dose tourniquet if to be used hourly x 2 doses iv Flucloxacillin 2gm + iv Teicoplanin 600mg iv Gentamicin at least single single dose + 10 minutes before dose at induction, then Gentamicin* single iv Flucloxacil in 1gm 6 dose tourniquet if to be used hourly x 2 doses instrumentation Other orthopaedic iv Flucloxacillin 2gm iv Teicoplanin 600mg Gentamicin* As above single single dose dose at induction Open surgery for iv Flucloxacillin 2gm iv Teicoplanin 600mg Gentamicin* As above Gentamicin* single single dose dose at induction or iv co-amoxiclav 1.2gm iv Cefuroxime 1.5gm ** See below iv Teicoplanin 600mg + Gentamicin* single iv Gentamicin at least Fractures
dose at induction. Consider Copal G+C 10 minutes before tourniquet if to be used NOTES: **Principal recommendations for open or compound fractures: • Antibiotics should be administered as soon as possible after the injury, and certainly within three hours. • The antibiotic should be continued until first debridement (excision) and continued until soft tissue closure or for a maximum of 72 hours, whichever is sooner. * Gentamicin 2mg/kg should be administered on induction of anaesthesia at the time of skeletal stabilisation and definitive soft tissue closure. The Gentamicin should not be continued post-operatively. + MRSA Risk include Patient >65 years old trauma patients, who do not have any MRSA screen result within the last one month prior to surgery. Also, patients of ALL age group from a residential home, who do not have any MRSA screen result within the last one month prior to surgery. All patients with recent positive MRSA screen results should receive same antibiotic prophylaxis regime on the table above as for Anaphylactic Penicil in al ergy. Special Note on revision Arthroplasty: In patients with suspected Periprosthetic Joint Infection (PJI), antibiotic prophylaxis should be withheld until after cultures from the joint have been obtained. At surgeons discretion if operative findings suggestive of infection or initial Gram stain positive. Antibiotic can be continued until initial/direct culture results on deep samples reported as negative. Antibiotic-loaded cement is recommended in addition to intravenous antibiotic (SIGN guidelines, April 2014). Gentamicin dose calculation (iv) for prophylaxis 50-69kg 120mg 70-89kg 160mg (Dose should approximate to 2mg/kg. If weight unknown use 120mg) THERAPEUTIC ANTIMICROBIAL USE:

1. CELLULITIS: Refer to Trust guideline
2. ANIMAL BITES: Refer to Trust guideline
3. BURSITIS: more than 80% are caused by Staph. aureus (Ohl CA,2010), complete drainage is essential, aspirates should be sent for culture/sensitivities.
IV Flucloxacillin 1 - 2gm 6hrly
OR
IV Clindamycin 600mg – 1.2gm 6hrly (if rash or anaphylactic
reaction to Penicillin)
(Can switch to oral Flucloxacillin 500mg – 1gm qds or
Clindamycin 450mg qds if patient improved and ready for
discharge, treat for 10-14 days or other appropriate
antibiotic as reported).

4. SEPTIC ARTHRITIS: between 37-65% are caused by Staph. aureus (Ohl, CA, 2010). Arthrocentesis should be performed on all patients
with suspected septic joint, and sample sent for URGENT Gram stain,
culture and sensitivities. Duration of treatment is usually 4 weeks of
iv/oral antimicrobial.

IV Flucloxacillin 1 - 2gm 6hrly
OR
IV Cefuroxime 1.5gm 8hrly (if history of rash to Penicillin allergy)
(May
result/culture/sensitivities, or history of severe Penicillin allergy, or if diagnosis suggestive of reactive arthritis. Discuss with microbiologist if concerned). 5. POSTOPERATIVE WOUND INFECTION: mainly caused by Staph aureus. Send deep swab for culture/sensitivities. IV Flucloxacillin 1g – 2gm 6hrly (or oral at 500mg – 1gm qds if
mild to moderate infection) +/- Metronidazole if infection around
the hip region
OR
IV Clindamycin 600mg 6hrly (or oral Clindamycin 450mg qds if
mild to moderate infection) *No need to add Metronidazole with
Clindamycin.
6. POSTOPERATIVE CHEST INFECTION: Refer to Trust guidelines.

7. CATHETERISATION POST JOINT REPLACEMENT: antibiotics NOT
indicated, as no evidence of benefit (IDSA, 2010). 8. PAEDIATRIC ANTIBIOTIC PRESCRIBING: a. Osteomyelitis: Acute haematogenous osteomyelitis. The most common
organism isolated is Staph aureus, then Strep pneumoniae,
in neonates organisms that cause neonatal sepsis such as
Group B Streptococcus and E coli are common (Berbari EF
et al 2010). Blood cultures is essential to isolate the
organism, this will assist in targeted antimicrobial therapy.
Children 1 month to 5 years:
iv Cefuroxime at 50-60mg/kg (Max. 1.5g) 8hrly
Children >5 years to 16 years:
iv Flucloxacillin at 50mg/kg (Max. 2g) 6hrly
add iv Cefotaxime in severe sepsis or if history of sickle
cell anaemia at 50mg/kg (Max 12g daily) 6hrly
Duration of treatment in children is 3 – 4 weeks, oral switch
can be done when patient able to tolerate orals, and has
remained afebrile for >72hrs or once daily iv Ceftriaxone at
50mg/kg (Review options with culture results).
b. Septic Arthritis:
Children 1 month to 5 years:
iv Cefuroxime at 50-60mg/kg (Max. 1.5g) 8hrly
Children >5 years to 16 years:
iv Flucloxacillin at 50mg/kg (Max. 2g) 6hrly
Duration of treatment 2 – 3 weeks with good response.
Discuss with microbiologist if history suggestive of
meningococcal sepsis, or history of Penicillin allergy
(Berbari EF et al. 2010).
9. Management of sterile pyuria / asymptomatic bacteriuria in patients undergoing lower limb arthroplasty: The Doncaster Bacteriuria Chart (Based on audit by Wong A, Hari-Kumar PN, with in put from Agwuh,KN). Leucocytes on urine culture & sensitivity >10 WBC/HPF on -Trimethoprim or microscopy (sterile pyuria) At induction, Gentamicin as per prophylactic guideline At 48 hours post-op, Culture negative Culture positive urine. urine. No antibiotic treatment but may bacteriuria, treat with need to investigate targeted antibiotic. 3 cause of sterile pyuria days in females and 5 days in male patients.
++ Will be preferable to use Trimethoprim or Nitrofurantoin as first line.


Reference:

American Academy of Orthopaedic Surgeons (AAOS), 2010. Diagnosis of Periprosthetic
Joint Infections of the hip and knee. Guideline and evidence report:

Berbari EF, Steckelberg JM, Osmon DR, Osteomyelitis. In Mandell, Douglas, and Bennett's
Principles and Practice of Infectious Diseases, Churchill Livingston Elsevier, 7th Ed, 2010, pp
1457-1467.
British Orthopaedic Association and British Association of Plastic Reconstructive and
Aesthetic Surgeons guideline 2009.
Brown EM, Pople IK, de Louvois J, Hedges A, Bayston R, Eisenstein SM, et al.: Spine
update: prevention of postoperative infection in patients undergoing spinal surgery. Spine.
2004 Apr 15;29(8):938-45.
Hauser CJ, Adams CA Jr, Eachempati SR, Council of the Surgical Infection Society. Surg
Infect (Larchmt). 2006 Aug; 7(4):379-405
IDSA: Urinary catheter guidelines (CID) 2010:50(1 March) 625-63.
NICE: Surgical site infection: Prevention and treatment of surgical site infection. NICE
Guidelines [CG74], published October 2008.
Ohl, CA: Infectious Arthritis of Native Joints. In Mandell, Douglas, and Bennett's Principles
and Practice of Infectious Diseases, Churchill Livingston Elsevier, 7th Ed, 2010, pp 1443-
1456.
Parvizi J and Gehrke T: Proceedings of the International Consensus Meeting on Periprosthetic
Joint Infection:

SIGN: Antibiotic Prophylaxis in surgery, Scottish Intercollegiate Guideline Network
Publication Number 104, Edinburgh, April 2014.

Source: http://www.antimicrobialguide.co.uk/resources/GUIDELINE%20FOR%20ANTIMICROBIAL%20USE%20IN%20THE%20ORTHOPAEDIC%20AND%20TRAUMA%20DEPARTMENT.pdf