Substantiation of antibiotic prophylaxis of infectious complications in surgery of large joints

The increase in the number of operations on large joints, the lack of sufficient material support for clinics, admission to interventions of under-trained personnel do not allow for today to exclude the development of the most formidable postoperative complication - peri-implant infection. One of the most important factors is drug prevention.

Numerous publications in recent years show that even the systematic use of antibacterial drugs and the flawless technique of surgery in some cases do not prevent the development of postoperative infectious complications. Thus, the incidence of deep infections with total hip arthroplasty reached previously 50%, and now, according to foreign and domestic publications, 2.5%. Treatment of patients with such complications involves repeated surgical interventions, the appointment of repeated antibacterial, immunocorrective therapy, not to mention a significant lengthening of hospitalization and possible disability of the patient.

The classical scheme of perioperative prophylaxis, set forth in most guidelines on antibiotic chemotherapy in orthopedics, assumes the use of cephalosporins of I-II generation (CS I-II) during routine operations. The choice of these drugs is caused, as is known, by the fact that with microbial contamination of the wound surface, the main causative agent of postoperative infection is S. Aureus. However, as practice shows, the use of CS I-II does not always allow for a smooth postoperative period and prevent the development of postoperative infectious complications. The reasons for such failures are an inadequate assessment of risk factors, which, in addition to key provisions common to all surgical interventions, in skeletal surgery have a number of principal features. The latter can be formulated as follows:

• First, a special feature is the presence of an additional substrate for the adhesion of potential pathogenic pathogens - the implant. The use of the said antibacterial drugs in this case does not ensure the complete elimination of the adherent bacteria. With this circumstance, the possibility of a delayed manifestation of infection after operative intervention in terms ranging from several days to two years or more is directly related;
• secondly, the proposed scheme does not take into account the possibility of hematogenous dissemination of pathogens from distant foci of infection. This issue has recently received special attention, since numerous confirmations of the possibility of development of postoperative complications in the presence of an infectious process in the oral cavity, respiratory tract or urinary tract have been obtained;
• an additional risk factor is the presence of an undiagnosed intraarticular infection in the patient;
• a significant increase in the frequency of superficial and deep infectious complications in total hip replacement is also observed in patients with diabetes mellitus, rheumatoid arthritis, with terminal renal failure.

Finally, the unified appointment for perioperative prevention of CI I-II completely disregards the heterogeneity of the group of patients entering surgical treatment. Even with a superficial analysis, it is clear that patients entering such operations need to be ranked at least into several groups. The first should include patients who are operated for the first time, to the second - patients who enter for repeated operations after the removal of insolvent structures. The third and fourth, respectively, should include patients with septic complications in the history and patients who received antibiotic therapy previously. Protocols of antibiotic prophylaxis in patients of different groups can not be identical.

When planning the tactics of antibacterial prophylaxis, the attending physician, in addition to taking into account all possible risk factors for the development of infectious complications in his patient, should possess reliable and timely information about the specific weight of pathogens in the structure of postoperative infectious complications in the department. In this respect, irreplaceable methods of investigation are a correctly performed microbiological or PCR study. The material, depending on the clinical situation, can be obtained intraoperatively, when performing joint puncture, when examining fragments of a prosthesis, cement or detachable from a wound (fistula).

It should also be taken into account that the causative agent of postoperative wound complications may be microbial associations, which, according to our data, account for up to 7% of all the results of the microbiological study. These results were obtained from a bacteriological study of the material in more than a thousand patients during a 10-year monitoring. With a qualitative assessment of the etiologic significance of the causative agents of wound infection, a predominant composition of the "participants" of associations was established: Staph. Aureus in combination with Ps. Aeruginosa - 42.27%, Staph. Aureus with Pr. Vulgaris - 9.7%, Staph. Aureus with Pr. Mirabilis - 8.96%, Staph. Aureus with E. Coli - 5.97%, Staph. Aureus with Str. Haemolyticus and Ps. Aeruginosa with Pr. Vulgaris - no 5.22%.

One of the problems of antibacterial pharmacotherapy is the increasing resistance of hospital strains. When determining the sensitivity of these strains to the first-generation cephalosporins, we obtained results indicating high resistance to these antibacterial drugs. So, Staph. Aureus, considered the main "culprit" of such complications, was sensitive to cephalosporins of the first generation in only 29.77% of cases.

The question arises: are there methods for today that allow in all cases to achieve the absence of postoperative infectious complications during interventions on the musculoskeletal system? Of course, in addition to adequate / inadequate antibiotic prophylaxis, the outcome of the operation is determined by preoperative preparation, observance of aseptic rules, peculiarities of surgical intervention and even the operating state. At the same time, an adequate use of antibiotics can play a key role during the postoperative period.

Based on the results of ten years of bacteriological monitoring, we proposed a perioperative prevention of wound infection in hip replacement, including the parenteral administration of cefalosporin of the second generation of cefuroxime and a drug from the group of fluorinated quinolones, ciprofloxacin.

Cefuroxime was given at a dose of 1.5 g 30 minutes prior to surgery, then 0.75 g three times a day for 48 hours after the operation. Ciprofloxacin was administered at a dose of 0.4 g twice daily for 3-5 days. In this combination, cefuroxime provides sufficient activity against staphylococci and enterobacteria, and ciprofloxacin - against gram-negative microorganisms. The use of such a scheme has made it possible to nullify the number of postoperative complications associated with the development of wound infection after the installation of the hip joint prosthesis. Currently, the incidence of such cases in the orthopedic traumatology department of KKB does not exceed 5.6%.

The development of a prosthetic-associated staphylococcal infection can be overcome with the administration of rifampicin.

However, it must be remembered that with monotherapy with this drug, resistance develops rapidly. Zimmerii et. Al. (1994), taking into account the latter feature, proposed the use as a prophylaxis of postoperative complications associated with implant-associated staphylococcal infection, a combination of two antibacterial drugs: rifampicin in combination with oral administration of ciprofloxacin.

We believe that the antibiotic prophylaxis strategy in each specific case can be defined as follows:

• the appointment of cefazolin or cefuroxime for perioperative prophylaxis is indicated for patients who have been operated for the first time, in the absence of risk factors, who have not (rehabilitated) distant foci of infection who have not received antibacterial therapy before;
• in all other cases it is advisable to consider the appointment of two antibacterial drugs or an ultra-wide-dose preparation that overlap the entire spectrum of potential pathogens. If suspected for the presence of methicillin-resistant strains, the drugs of choice will be vancomycin in combination with rifampicin, with anaerobic infection - clindamycin. When identifying Ps. Aeruginosa preference should be given to ceftazidime or cefepime, and a mixed flora will require the administration of antibacterial drugs from the carbapenem group.

Active use of combined use of two types of antibiotics for the prevention of paraprotease infection has made it possible to reduce the number of such complications in the orthopedic department No. 2 of the GAZU RKB MZ RT to 0.2% in the last three years. The active use of quality implants, antibiotic prophylaxis, reduction of the duration of the operation, adequate drainage are the basis of successful work.

Thus, the approach to perioperative antibiotic prophylaxis should not be uniform. The treatment regimen should be developed individually for each patient, taking into account all the anamnestic features and possible risk factors, features of pharmacokinetics and the spectrum of antimicrobial activity of antibacterial drugs in a particular patient. It seems to us that in this case the best result can be given by the joint work of the attending physician and the clinical pharmacologist, since it is the competent selection of antibacterial therapy that can play a key role in the successful outcome of the treatment.

Doctor of Medical Sciences, Professor Bogdanov Enver Ibragimovich. Substantiation of antibiotic prophylaxis of infectious complications in surgery of large joints // Practical medicine. 8 (64) December 2012 / volume 1

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