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Year : 2013  |  Volume : 3  |  Issue : 2  |  Page : 87-91

Rational antimicrobial prophylaxis in orthopedics and trauma surgical practice

Department of Orthopaedics and Trauma Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria

Date of Web Publication13-Dec-2013

Correspondence Address:
Kenneth E Amaefule
Department of Orthopaedics and Trauma Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2278-9596.122924

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Background : Antimicrobial prophylaxis in surgical practice is a concept that has been in practice for over 3 decades. The aim is to prevent surgical site infection (SSI), a menace acknowledged as the most common nosocomial infection in surgical patients. Over the years, several international guidelines have been published in the literature to guide the practice. Yet some surgeons still practice outside these guidelines especially in orthopedics and trauma surgical practice. This has led to emergence of resistant strains of bacteria and increased cost of healthcare. The only option left to check this problem therefore lies in the proper use of available antibiotics. The objective of this study was to review the current literature on the guidelines and practice of antibiotic prophylaxis in orthopedics and trauma surgery.
Materials and Methods : A review of the literature on this subject was done on Medline, EBSCOhost database, and recent articles from relevant journals and texts. The database was searched using the keywords; antibiotic prophylaxis; orthopedic and trauma surgery.
Results: There are several guidelines and protocols that were established from evidence based information. However, compliance to these guidelines amongst surgeons and health institutions is suboptimal for various reasons. This is associated with increased morbidity and cost of treatment.
Conclusion : There is a need to be guided by evidence based guidelines in our antimicrobial prophylaxis practice; as surgery is both a science and an art.

Keywords: Antimicrobial prophylaxis, orthopedics, trauma surgical practice

How to cite this article:
Amaefule KE, Dahiru IL. Rational antimicrobial prophylaxis in orthopedics and trauma surgical practice. Arch Int Surg 2013;3:87-91

How to cite this URL:
Amaefule KE, Dahiru IL. Rational antimicrobial prophylaxis in orthopedics and trauma surgical practice. Arch Int Surg [serial online] 2013 [cited 2024 Mar 1];3:87-91. Available from:

  Introduction Top

Surgical site infections (SSIs) according to the center for disease control and prevention criteria include infections that result in cellulitis, osteomyelitis, and abscesses complicating surgical wounds. [1] SSIs are the most common nosocomial infections amongst surgical patients. [2] In the USA, SSIs are the second most common nosocomial infection after urinary tract infection. [3],[4],[5] A study by the Harvard School of Public Health revealed that SSIs accounted for the second largest number of adverse events, second only to medication errors. [6] The national health care associated infections prevalence survey done in Scotland between October 2005 and October 2006 also showed that SSIs were the second commonest healthcare associated infections, accounting for 15.9%. [7] A UK survey reported a SSIs rate of 2-15% depending on the type of operation. [8] SSIs results in significant morbidity, mortality, and cost. A cohort study revealed that patients who developed SSIs spent 60% more time in the intensive care unit, were over five times more likely to be rehospitalized and had a doubled mortality rate. [9]

Antimicrobial prophylaxis is one of the measures of preventing SSIs. This is achieved with a brief course of antimicrobials given just before surgery, and based on effectiveness, minimizing possible alteration in the patient's normal bacterial flora, adverse effects, and change to the patients host defences. [10] The aim of antimicrobial prophylaxis is to have optimal serum and tissue level of administered antimicrobials that exceed the minimum inhibitory concentration for organisms likely to be encountered during surgery all through the surgical procedure and for up to 24 h. [11],[12]

Over the years, inappropriate widespread use of newer and broad-spectrum antimicrobials has led to the emergence of resistant bacteria strains and super infection. [13],[14],[15] Guidelines have been published in the literature to guide the rational use of antimicrobials in the various surgical procedures with only slight differences amongst them. [2],[10],[16 ],[17],[18],[19],[20],[21],[22],[23] In spite of these, many orthopedic surgeons still practice outside the guidelines, either due to what may be best described as personal preference for a particular practice, influence of training, lack of awareness of any of these published evidence-based guidelines, or lack of existing local hospital antimicrobial protocol. [24],[25] Also use of antimicrobials in open fractures is another area of trauma surgery where antimicrobial use has been grossly abused.

This review article, therefore, aims to offer a concise discussion on the rational use of antimicrobial prophylaxis in orthopedics and trauma surgical practice, with emphasis on identification of patients at risk of SSIs and the principle guiding prophylactic antimicrobial administration in such cases.

  Identification of Patients at Risk of Surgical Site Infections Top

General surgical procedures may be classified according to the chances of the wound becoming contaminated and hence the amount of the bacterial inoculum entering the wound. [26] Other factors that may increase the chances of SSI are: The virulence of the contaminating bacteria, prolonged preoperative hospital stay, and alterations in systemic and local resistance. Systemic resistance being largely determined by the patients characteristics and his or her disease state such as diabetes mellitus and sickle cell disease amongst others. [27] Local resistance is lowered by factors such as hematoma, foreign bodies such as implants, ischemia, and necrotic tissue. [27],[28] This makes the achievement of optimal local resistance largely dependent on the surgeon. [28] Antimicrobial prophylaxis is recommended for operations with a high risk of postoperative wound infection or with a low risk of infection, but significant consequences if infection occurs. [28]

Clean procedures

Antimicrobial prophylaxis is indicated only in those clean orthopedic and musculoskeletal trauma surgical procedures where there is suboptimal systemic or local resistance to infections. These are the aforementioned instances of systemic immune compromise and implantation procedures like replacement arthroplasties and open reduction and internal fixation for closed fractures or corrective realignment osteotomies where an implant will be used for internal fixation. [11],[16 ],[17],[18],[19],[20],[21],[22],[23]

Clean-contaminated procedures

There is no controversy amongst surgeons on the use of antimicrobial prophylaxis in these cases as these procedures have high risk of postoperative wound infections. [16],[17],[18],[19],[20],[21],[22],[23] In orthopedics and musculoskeletal trauma surgical practice, these include clean orthopedic procedures done in operating rooms where orthopedic surgeons

share operating room with gastrointestinal tract surgeons or where infected cases are also done as seen in some developing countries; as well as most pelvic surgeries, because of their proximity to the perineum. Also included here are clean prolonged procedures lasting more than 4 h especially in operating rooms without ultra-clean systems.

Contaminated procedures

A good example here is an open extremity fracture. These classes of wounds are usually contaminated with organisms from the environment where the fracture occurred, as well as the patient's skin and clothing. In addition, some foreign bodies may be lodged in the wound and all these make open fractures highly prone to infection. [20]

  Principle of Prophylactic Antimicrobial Administration Top

Prophylactic antimicrobial administration over the years has witnessed varied practices amongst surgeons for various reasons. The misconception has largely been in the choice of antimicrobials and duration of admistration. [29],[30]

Choice of antimicrobials

A review of the literature shows different choices for different surgeons. In the past 3 decades, the choices have varied from the use of multidrug regimen such as first generation cephalosporin like cefazolin and aminoglycoside like gentamycin to cover for both gram positive and gram negative organisms, respectively, with the addition of metronidazole for anaerobic cover. [11] With the introduction of broad spectrum third generation cephalosporins, the preference of some surgeons shifted to this class of drugs for almost all types of procedures. This has contributed to the emergence of drug resistant bacterial strains. Generally, the guidelines advocate that the choice of antimicrobials should be based on the common organisms likely to cause SSI in such procedures or be guided by the local hospital bacteriology pattern. [2],[10],[16],[17],[18],[19],[20],[21],[22],[23] The second consideration in the choice of antibiotics should be the serum half-life. An antimicrobial with a longer serum half-life to cover for the duration of the surgical procedure should be chosen, especially if single dose prophylaxis is opted for. In light of these, recent guidelines advocate the choice of potent anti-staphylococcus first or second generation cephalosporin such as cefazolin, cefuroxime, or ceftazidim only for most clean and clean-contaminated orthopedic and trauma procedures requiring antimicrobials prophylaxis. [2],[10],[16],[17],[18],[19] For contaminated procedures, like open extremity fractures which is one class of wounds that have witnessed antimicrobial abuse over the years because of the high incidence of infection, antimicrobial therapy in addition to proper surgical wound care management has for long been the standard of care. [20],[31],[32],[33],[34] Some surgeons have advocated covering all open fractures with a combination of a first generation cephalosporin and aminoglycoside, while others have opted for the use of newer broad spectrum third generation cephalosporin.

The Eastern Association for the Surgery of Trauma (EAST) practice guideline appears to be a popular and rational guideline on antimicrobial therapy in this class of wounds. [20] It advices that the choice be based on the severity of the open fracture according to the Gustilo and Anderson classification [Table 1]. [35] It advocates the use of monotherapy using first generation cephalosporin with activity against gram-positive organisms exclusively for types I and II open fractures and coverage for both gram positive and gram negative organisms with first generation cephalosporin and aminoglycoside for type III fractures, with the addition of anaerobic coverage if fecal or clostridia contamination is suspected. [20],[36],[37],[38]
Table 1: Gustilo and Anderson classifi cation of open fractures

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There is a consensus in all the reviewed literature that intravenous route is the best route to achieve a fast optimal tissue level of the antimicrobials. [2],[10],[16],[17],[18],[19],[20],[21],[22],[23]


There is also a consensus here for therapeutic doses to be administered during prophylaxis. [2],[10],[16],[17],[18],[19],[20],[21],[22],[23] This dose gives a serum and tissue level of the antimicrobial above the minimum inhibitory concentration for the sensitive organisms.


This is another area of controversy in antimicrobial prophylaxis. In clean procedures requiring antimicrobial prophylaxis and all clean-contaminated procedures, some surgeons advocate the use of multiple dose regimen, given up to a time that ranges from 48-72 h from the end of surgery, arguing that this is necessary when drains and catheters remain in situ for some days after operation. [28] Other surgeons and indeed most evidence based guidelines on this issue, advocate single dose using antimicrobial with a long half-life that covers the duration of the surgery, except in special circumstances like a prolonged procedure lasting longer than the half-life of the antimicrobials used or in major blood loss. [2],[17],[18],[19] However, the popular practice here appears to be the administration of the chosen antimicrobial to have optimal tissue levels for up to 24 h only as studies have shown that short course prophylaxis is equally as effective as longer courses in preventing SSI. [2],[17] Also prolonged use of antimicrobials prophylaxis can lead to the emergence of resistant bacterial strain. [14],[15]

In open fractures with its usual gross contamination and high risk of infection, the concept is actually "antimicrobial therapy", the duration of which has witnessed diverse practices and controversy. While some authors recommended a 3-day course of antimicrobial therapy for all patients, regardless of the type of open fracture, others recommend ending antimicrobial coverage within 24 h of wound closure. [1],[31] The EAST guideline, recommend no more than 24 h coverage after definitive wound closure for type I and II open fractures, and not more than 72 h of coverage for type III fractures. [20]

Many orthopedic surgeons have shown some reluctance to this guideline especially in type III open fractures because of the high risk of infection in these patients, hence the unwillingness to give up some common antimicrobial practices in open fractures like prolonged courses, repeated short courses, use of broad spectrum antimicrobials to cover gram positive, gram negative and clostridium species, and the use of local antimicrobial beads.


The efficacy of antimicrobial therapy depends on the timing of the drug administration to give optimum bactericidal concentration in serum and tissues at skin incision. To achieve this, evidence based guidelines advocate administering the antimicrobials within 30-60 min before skin incision. [2],[10],[16],[17],[18],[19],[20],[22] It has been shown that delay of initial antimicrobial dose until after the skin incision, or administration too long before the skin incision is associated with increased rate of SSI compared to when the antimicrobial was given within 2 h of skin incision. [39] This becomes significant when antimicrobials with short serum half-life are used or the operation is prolonged or both. In these instances a second dose should be administered during the operation to maintain the optimum tissue level of the drug.

  Conclusion Top

Antimicrobials prophylaxis in orthopedics and trauma surgical practice has over the last 3 decades been practiced differently by different orthopedic surgeons. In the 21 st century, it will be wise that surgeons adopt published evidence-based guidelines in their practice. This also calls for a survey of the local hospital bacteriology and antimicrobial susceptibility pattern in our health institutions to guide our antimicrobial prophylaxis practice.

  References Top

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  [Table 1]

This article has been cited by
1 Enhancing Surgical Outcomes: A Critical Review of Antibiotic Prophylaxis in Orthopedic Surgery
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Cureus. 2023;
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