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Prepare for More Antibiotics

Commentary on an article by Avinash Inabathula, MD, et al.: “Extended Oral Antibiotic Prophylaxis in High-Risk Patients Substantially Reduces Primary Total Hip and Knee Arthroplasty 90-Day Infection Rate”

Khatod, Monti, MD

doi: 10.2106/JBJS.18.00932
Commentary and Perspective
Related Article

Department of Orthopaedic Surgery, Kaiser Permanente West Los Angeles Medical Center, Los Angeles, California

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“Preparing for success” is a phrase used in modern arthroplasty practice to advocate for patient optimization prior to elective arthroplasty. In today’s practice, however, surgeons are faced with the challenge presented by patients with painful disability who are not optimized for a procedure that nonetheless offers substantial improvements in quality of life1. The authors attempted to address this conflict by using extended oral antibiotic prophylaxis for high-risk patients and found that this novel approach led to substantial improvements in the 90-day infection rate. High-risk patients who did not receive extended antibiotic prophylaxis were 4.9 times more likely to develop an infection after total knee arthroplasty (TKA) and 4.0 times more likely to develop an infection after total hip arthroplasty (THA) compared with their high-risk counterparts who received extended antibiotic prophylaxis. In fact, the infection rate for high-risk patients on extended antibiotics was lower than even that for standard-risk patients who did not receive extended antibiotic prophylaxis. These findings warrant consideration as periprosthetic joint infection results in substantial, costly, and dramatic morbidity.

At first glance, the adoption of extended antibiotic prophylaxis seems warranted. However, one must balance the desire to help patients suffering arthritic pain with the knowledge that “preparing for success” still deserves consideration. The authors included all patients with a BMI of ≥35 kg/m2 and all diabetics in their high-risk group, which continues to be debatable1,2. Furthermore, the authors’ definition of high-risk patients altered during the study period, with the addition of a positive nasal colonization as a risk. In fact, only 28.7% of the patients undergoing TKA and 37.6% undergoing THA were considered to be at normal risk, suggesting that this paper does not represent a standard community-based practice or that the definition of “high-risk” may be too broad (e.g., including all patients with the diagnosis of chronic kidney disease regardless of severity).

The arthroplasty surgeon is not merely a provider of new knees and hips. The surgeon’s goal is to provide improved health, independence, and mobility to a community. The surgeon must also be a steward of antibiotic usage. Arthroplasty surgeons have the power to motivate patients to make holistic improvements in their health rather than simply putting a prosthetic knee into, for example, a morbidly obese smoker with poorly controlled diabetes. Is there justification for a personalized risk stratification model or risk calculator that allows patients and surgeons to evaluate the risk of complications and understand how modifying those risks may improve outcome, not only for infection but for other outcomes? Care pathways that aim to improve modifiable risk factors should not be seen as obsolete based on the findings of this paper. Before there is wide adoption of extended prophylaxis, we need studies of larger data sets that allow for a more definitive identification of at-risk patients and implementation of an integrated care model in which the arthroplasty surgeon can help patients improve their health while providing new hips and knees with the lowest risks possible.

Disclosure: The author indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (

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1. Giori NJ, Amanatullah DF, Gupta S, Bowe T, Harris AHS. Risk reduction compared with access to care: quantifying the trade-off of enforcing a body mass index eligibility criterion for joint replacement. J Bone Joint Surg Am. 2018 Apr 4;100(7):539-45.
2. Adams AL, Paxton EW, Wang JQ, Johnson ES, Bayliss EA, Ferrara A, Nakasato C, Bini SA, Namba RS. Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001 to 2009. J Bone Joint Surg Am. 2013 Mar 20;95(6):481-7.

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