faut-il faire une antibioprophylaxie dans les reprises de ... · fiables (ponction), ......
TRANSCRIPT
Faut-il faire une antibioprophylaxie dans les
reprises de prothegraveses infecteacutees
Eric Bonnet12 Geacuterard Giordano1
1 Uniteacute Mobile drsquoInfectiologie et Service de Chirurgie Orthopeacutedique Hocircpital Joseph Ducuing
2 Uniteacute Mobile drsquoInfectiologie Clinique Pasteur
Toulouse
Background-Recommandations (1)
bull Le but de lrsquoantibioprophylaxie en chirurgie est de srsquoopposer agrave la prolifeacuteration bacteacuterienne au niveau du site opeacuteratoire afin drsquoen diminuer le risque drsquoinfection
bull LrsquoABP diminue drsquoenviron 50le risque drsquoinfection du site opeacuteratoire
bull Lrsquoantibioprophylaxie (ABP) est une prescription drsquoantibiotique qui srsquoapplique agrave certaines chirurgies ldquopropresrdquo ou ldquopropre-contamineacuteesrdquo
bull La cible bacteacuterienne doit ecirctre identifieacutee et deacutepend du type de chirurgie de la flore endogegravene du patient et de lrsquoeacutecologie de lrsquouniteacute drsquohospitalisation
bull Lrsquoadministration doit preacuteceacuteder le deacutebut de lrsquointervention drsquoenviron 30minutes
bull La dureacutee de la prescription doit ecirctre la plus courte possible Lrsquoinjection drsquoune dose unique est recommandeacutee et la prescription au-delagrave de 48 heures est interdite
bull Les patients preacutesentant un risque particulier peuvent beacuteneacuteficier drsquoune ABP laquo agrave la carte raquohellip(Sujets potentiellement coloniseacutes par une flore bacteacuterienne nosocomialehellip)
Recommandations SFAR 2010
Background-Recommandations (2)
Recommandations SFAR 2010
Background-Recommandations (3)
Recommandations SFAR 2010
Background-Recommandations (4)
La prescription de vancomycine doit ecirctre argumenteacutee - allergie aux becircta-lactamines - colonisation suspecteacutee ou prouveacutee par du staphylocoque meacuteticilline-reacutesistant reacute-intervention chez un malade hospitaliseacute dans une uniteacute avec une eacutecologie agrave staphylocoque meacuteticilline-reacutesistant antibiotheacuterapie anteacuterieure Lrsquoinjection dure 60 minutes et doit se terminer au plus tard lors du deacutebut de lrsquointervention
Recommandations SFAR 2010
Background-Recommandations (5)
Recommandations SFAR 2010
Background-Recommandations (6)
bull Lrsquoadministration drsquoantibiotiques avant la reacutealisation des preacutelegravevements agrave viseacutee microbiologiques est deacuteconseilleacutee
bull Afin de diminuer le risque drsquoobtenir des preacutelegravevements faussement neacutegatifs il est recommandeacute de respecter un deacutelai minimal de 15 jours par rapport agrave toute antibiotheacuterapie (sauf en cas de sepsis et apregraves eacutevaluation du risque drsquoinfection disseacutemineacutee) (avis drsquoexpert) Conf consensus Infection os sur mateacuteriel2009
bull 321233 Modaliteacutes de la chirurgie en deux temps Elles consistent agrave deacuteposer la prothegravese agrave reacutealiser les preacutelegravevements microbiologiques en lrsquoabsence de toute antibioprophylaxiehellipConf consensus Infection os sur mateacuteriel2009
Background-Recommandations (7)
Que deacutecider en pratique (1)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Lavage-synovectomie
bull Pas drsquoantibioprophylaxie puisque bull pas drsquoimplantation de nouveau mateacuteriel protheacutetique
bull et antibiotheacuterapie probabiliste agrave large spectre deacutebuteacutee en peropeacuteratoire ou en post-opeacuteratoire immeacutediat selon les recommandations de lrsquoHAS
bull Toutefois mecircme si la prothegravese est conserveacutee il est conseilleacute de reacutealiser un changement des piegraveces modulaires si possible et ainsi du nouveau mateacuteriel est inseacutereacute ce qui pourrait justifier une antibioprophylaxiehellip
Que deacutecider en pratique (2)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Deacutepose-repose de prothegravese en un temps
bull Antibioprophylaxie ouihellip possiblehellipcar bull mise en place drsquoune nouvelle prothegravese
bull crainte que le moment de lrsquoinitiation des antibiotiques en peropeacuteratoire ou post-opeacuteratoire immeacutediat soit trop tardif et donc non efficace
bull crainte que les antibiotiques donneacutes en prophylaxie srsquoils ne sont pas agrave large spectre mais cibleacutes uniquement sur la ou les bacteacuteries identifieacutee(s) sur des preacutelegravevements preacute-opeacuteratoires fiables (ponction) ne permettent pas drsquoeacuteviter le prolifeacuteration de nouvelles bacteacuteries au niveau du site opeacuteratoire
bull Mais si administration drsquoantibiotiques avant la reacutealisation des preacutelegravevements =gt risque theacuteorique de laquo neacutegativer raquo ces preacutelegravevements de ne pas pouvoir mettre en eacutevidence la (ou les) bacteacuterie(s) responsable(s) de lrsquoinfection
que dit la litteacuterature
Que deacutecider en pratique (3)
bull Infection chronique bull Deacutepose-repose de prothegravese en un temps
bull Deacutepose-repose de prothegravese en 2 temps bull Lors du premier temps une antibioprophylaxie ne parait pas neacutecessaire puisque
la prothegravese est deacuteposeacutee et qursquoun espaceur souvent impreacutegneacutee drsquoantibiotiques est mis en place
bull Lors du deuxiegraveme temps bull srsquoil srsquoagit drsquoun laquo deux temps long raquo avec fenecirctre antibiotique de 2 semaines une
antibioprophylaxie est bull possible (cf changement en un temps) srsquoil y reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou
post-opeacuteratoire immeacutediat probablement pas neacutecessaire si cette antibiotheacuterapie est agrave large spectre
bull indiqueacutee srsquoil nrsquoy a pas de reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou post-opeacuteratoire immeacutediat
bull srsquoil srsquoagitlaquo deux temps court raquo ougrave la repose se fait alors que le patient est encore sous antibiotique une antibioprophylaxie agrave large spectre pour eacuteviter la prolifeacuteration de nouvelles bacteacuteries est possible agrave discuter en reacuteunion de concertation pluridisciplinaire
Quid du timing de lrsquoantibioprophylaxie
Timing of antimicrobial prophylaxis and the risk of surgical site infections results from the Trial to Reduce Antimicrobial
Prophylaxis Errors
Steinberg JP1 et al Ann Surg 2009
OBJECTIVE The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP)
SUMMARY BACKGROUND DATA National AMP guidelines should be supported by evidence from large contemporary data sets
METHODS Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac hipknee
arthroplasty and hysterectomy cases Surgical site infections (SSIs) were ascertained through routine surveillance using National
Nosocomial Infections Surveillance system methodology The association between the prophylaxis timing and the occurrence of
SSI was assessed using conditional logistic regression (conditioning on hospital)
RESULTS One-hundred thirteen SSI were detected in 109 patients SSI risk increased incrementally as the interval of time
between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 004) When
antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded the infection risk following
administration of antibiotic within 30 minutes prior to incision was 16 compared with 24 associated with administration of
antibiotic between 31 to 60 minutes prior to surgery (OR 174 95 confidence interval 098-304) The infection risk increased
as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision
(ORthinsp=thinsp220 95 CI 103-466) but not prior to 60 minutes Intraoperative redosing (performed in only 21 of long operations)
appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 308 with no redosing 95 confidence interval 074-
1290) but only when the preoperative dose was given correctly
CONCLUSIONS These data from a large multicenter collaborative study confirm and extend previous observations and show a
consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with
cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision
bull laquo Timing of surgical antibiotic prophylaxis and the risk of surgical site infection raquo Hawn MT et al JAMA Surg 2013
bull Patients et meacutethode bull Etude reacutetrospective bull Registre national des Veacuteteacuterans 2005-2009 bull Chirurgie orthopeacutedique (arthroplastie de hanche et de genou) colorectale vasculaire
gyneacutecologique
bull Reacutesultats bull Plus de 32 000 interventions avec antibioprophylaxie (plus de 20 000 = chirurgie orthopeacutedique) bull Taux global plus eacuteleveacute drsquoISO si antibioprophylaxie administreacutee plus de 60 minutes avant lrsquoincision
dans un modegravele avant ajustement bull Apregraves ajustement sur le type de patient de proceacutedure et lrsquoantibiotique utiliseacute aucune diffeacuterence
significative du taux drsquoISO selon le deacutelai de lrsquoadministration des antibiotiques par rapport au moment de lrsquoincision que lrsquoantibioprophylaxie ait eacuteteacute administreacutee avant ou apregraves lrsquointervention
bull Vancomycine seule utiliseacutee en antibioprophylaxie en chirurgie orthopeacutedique associeacutee agrave un taux drsquoISO plus eacuteleveacutee
Date of download 932015 Copyright copy 2015 American Medical
Association All rights reserved
From Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
JAMA Surg 2013148(7)649-657 doi101001jamasurg2013134
Association Between Timing of Prophylactic Antibiotics and Surgical Site InfectionUnadjusted (A) and adjusted (B) odds ratios (ORs)
for the association between timing of prophylactic antibiotics and surgical site infection with P values representing the significance
of the associationSolid line indicates the OR estimate for surgical site infection shaded area 95 CI dashed vertical line incision
time and dashed horizontal line an OR estimate of 10 Because spline fits for timing in the adjusted overall and vascular models
were nearly linear (dfthinspltthinsp11) final models considered timing as a linear effect
Figure Legend
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull ldquoPrior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infectionrdquo Davud Malekzadeh et al Clin Orthop Relat Res 2010
bull laquo Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprothetic joint infection raquo
Shahi A et al Clin Orthop Relat Res 2015
bull laquo Patients in the antibiotic group had higher rates of negative cultures raquo (264 vs 129)
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Background-Recommandations (1)
bull Le but de lrsquoantibioprophylaxie en chirurgie est de srsquoopposer agrave la prolifeacuteration bacteacuterienne au niveau du site opeacuteratoire afin drsquoen diminuer le risque drsquoinfection
bull LrsquoABP diminue drsquoenviron 50le risque drsquoinfection du site opeacuteratoire
bull Lrsquoantibioprophylaxie (ABP) est une prescription drsquoantibiotique qui srsquoapplique agrave certaines chirurgies ldquopropresrdquo ou ldquopropre-contamineacuteesrdquo
bull La cible bacteacuterienne doit ecirctre identifieacutee et deacutepend du type de chirurgie de la flore endogegravene du patient et de lrsquoeacutecologie de lrsquouniteacute drsquohospitalisation
bull Lrsquoadministration doit preacuteceacuteder le deacutebut de lrsquointervention drsquoenviron 30minutes
bull La dureacutee de la prescription doit ecirctre la plus courte possible Lrsquoinjection drsquoune dose unique est recommandeacutee et la prescription au-delagrave de 48 heures est interdite
bull Les patients preacutesentant un risque particulier peuvent beacuteneacuteficier drsquoune ABP laquo agrave la carte raquohellip(Sujets potentiellement coloniseacutes par une flore bacteacuterienne nosocomialehellip)
Recommandations SFAR 2010
Background-Recommandations (2)
Recommandations SFAR 2010
Background-Recommandations (3)
Recommandations SFAR 2010
Background-Recommandations (4)
La prescription de vancomycine doit ecirctre argumenteacutee - allergie aux becircta-lactamines - colonisation suspecteacutee ou prouveacutee par du staphylocoque meacuteticilline-reacutesistant reacute-intervention chez un malade hospitaliseacute dans une uniteacute avec une eacutecologie agrave staphylocoque meacuteticilline-reacutesistant antibiotheacuterapie anteacuterieure Lrsquoinjection dure 60 minutes et doit se terminer au plus tard lors du deacutebut de lrsquointervention
Recommandations SFAR 2010
Background-Recommandations (5)
Recommandations SFAR 2010
Background-Recommandations (6)
bull Lrsquoadministration drsquoantibiotiques avant la reacutealisation des preacutelegravevements agrave viseacutee microbiologiques est deacuteconseilleacutee
bull Afin de diminuer le risque drsquoobtenir des preacutelegravevements faussement neacutegatifs il est recommandeacute de respecter un deacutelai minimal de 15 jours par rapport agrave toute antibiotheacuterapie (sauf en cas de sepsis et apregraves eacutevaluation du risque drsquoinfection disseacutemineacutee) (avis drsquoexpert) Conf consensus Infection os sur mateacuteriel2009
bull 321233 Modaliteacutes de la chirurgie en deux temps Elles consistent agrave deacuteposer la prothegravese agrave reacutealiser les preacutelegravevements microbiologiques en lrsquoabsence de toute antibioprophylaxiehellipConf consensus Infection os sur mateacuteriel2009
Background-Recommandations (7)
Que deacutecider en pratique (1)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Lavage-synovectomie
bull Pas drsquoantibioprophylaxie puisque bull pas drsquoimplantation de nouveau mateacuteriel protheacutetique
bull et antibiotheacuterapie probabiliste agrave large spectre deacutebuteacutee en peropeacuteratoire ou en post-opeacuteratoire immeacutediat selon les recommandations de lrsquoHAS
bull Toutefois mecircme si la prothegravese est conserveacutee il est conseilleacute de reacutealiser un changement des piegraveces modulaires si possible et ainsi du nouveau mateacuteriel est inseacutereacute ce qui pourrait justifier une antibioprophylaxiehellip
Que deacutecider en pratique (2)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Deacutepose-repose de prothegravese en un temps
bull Antibioprophylaxie ouihellip possiblehellipcar bull mise en place drsquoune nouvelle prothegravese
bull crainte que le moment de lrsquoinitiation des antibiotiques en peropeacuteratoire ou post-opeacuteratoire immeacutediat soit trop tardif et donc non efficace
bull crainte que les antibiotiques donneacutes en prophylaxie srsquoils ne sont pas agrave large spectre mais cibleacutes uniquement sur la ou les bacteacuteries identifieacutee(s) sur des preacutelegravevements preacute-opeacuteratoires fiables (ponction) ne permettent pas drsquoeacuteviter le prolifeacuteration de nouvelles bacteacuteries au niveau du site opeacuteratoire
bull Mais si administration drsquoantibiotiques avant la reacutealisation des preacutelegravevements =gt risque theacuteorique de laquo neacutegativer raquo ces preacutelegravevements de ne pas pouvoir mettre en eacutevidence la (ou les) bacteacuterie(s) responsable(s) de lrsquoinfection
que dit la litteacuterature
Que deacutecider en pratique (3)
bull Infection chronique bull Deacutepose-repose de prothegravese en un temps
bull Deacutepose-repose de prothegravese en 2 temps bull Lors du premier temps une antibioprophylaxie ne parait pas neacutecessaire puisque
la prothegravese est deacuteposeacutee et qursquoun espaceur souvent impreacutegneacutee drsquoantibiotiques est mis en place
bull Lors du deuxiegraveme temps bull srsquoil srsquoagit drsquoun laquo deux temps long raquo avec fenecirctre antibiotique de 2 semaines une
antibioprophylaxie est bull possible (cf changement en un temps) srsquoil y reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou
post-opeacuteratoire immeacutediat probablement pas neacutecessaire si cette antibiotheacuterapie est agrave large spectre
bull indiqueacutee srsquoil nrsquoy a pas de reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou post-opeacuteratoire immeacutediat
bull srsquoil srsquoagitlaquo deux temps court raquo ougrave la repose se fait alors que le patient est encore sous antibiotique une antibioprophylaxie agrave large spectre pour eacuteviter la prolifeacuteration de nouvelles bacteacuteries est possible agrave discuter en reacuteunion de concertation pluridisciplinaire
Quid du timing de lrsquoantibioprophylaxie
Timing of antimicrobial prophylaxis and the risk of surgical site infections results from the Trial to Reduce Antimicrobial
Prophylaxis Errors
Steinberg JP1 et al Ann Surg 2009
OBJECTIVE The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP)
SUMMARY BACKGROUND DATA National AMP guidelines should be supported by evidence from large contemporary data sets
METHODS Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac hipknee
arthroplasty and hysterectomy cases Surgical site infections (SSIs) were ascertained through routine surveillance using National
Nosocomial Infections Surveillance system methodology The association between the prophylaxis timing and the occurrence of
SSI was assessed using conditional logistic regression (conditioning on hospital)
RESULTS One-hundred thirteen SSI were detected in 109 patients SSI risk increased incrementally as the interval of time
between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 004) When
antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded the infection risk following
administration of antibiotic within 30 minutes prior to incision was 16 compared with 24 associated with administration of
antibiotic between 31 to 60 minutes prior to surgery (OR 174 95 confidence interval 098-304) The infection risk increased
as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision
(ORthinsp=thinsp220 95 CI 103-466) but not prior to 60 minutes Intraoperative redosing (performed in only 21 of long operations)
appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 308 with no redosing 95 confidence interval 074-
1290) but only when the preoperative dose was given correctly
CONCLUSIONS These data from a large multicenter collaborative study confirm and extend previous observations and show a
consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with
cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision
bull laquo Timing of surgical antibiotic prophylaxis and the risk of surgical site infection raquo Hawn MT et al JAMA Surg 2013
bull Patients et meacutethode bull Etude reacutetrospective bull Registre national des Veacuteteacuterans 2005-2009 bull Chirurgie orthopeacutedique (arthroplastie de hanche et de genou) colorectale vasculaire
gyneacutecologique
bull Reacutesultats bull Plus de 32 000 interventions avec antibioprophylaxie (plus de 20 000 = chirurgie orthopeacutedique) bull Taux global plus eacuteleveacute drsquoISO si antibioprophylaxie administreacutee plus de 60 minutes avant lrsquoincision
dans un modegravele avant ajustement bull Apregraves ajustement sur le type de patient de proceacutedure et lrsquoantibiotique utiliseacute aucune diffeacuterence
significative du taux drsquoISO selon le deacutelai de lrsquoadministration des antibiotiques par rapport au moment de lrsquoincision que lrsquoantibioprophylaxie ait eacuteteacute administreacutee avant ou apregraves lrsquointervention
bull Vancomycine seule utiliseacutee en antibioprophylaxie en chirurgie orthopeacutedique associeacutee agrave un taux drsquoISO plus eacuteleveacutee
Date of download 932015 Copyright copy 2015 American Medical
Association All rights reserved
From Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
JAMA Surg 2013148(7)649-657 doi101001jamasurg2013134
Association Between Timing of Prophylactic Antibiotics and Surgical Site InfectionUnadjusted (A) and adjusted (B) odds ratios (ORs)
for the association between timing of prophylactic antibiotics and surgical site infection with P values representing the significance
of the associationSolid line indicates the OR estimate for surgical site infection shaded area 95 CI dashed vertical line incision
time and dashed horizontal line an OR estimate of 10 Because spline fits for timing in the adjusted overall and vascular models
were nearly linear (dfthinspltthinsp11) final models considered timing as a linear effect
Figure Legend
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull ldquoPrior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infectionrdquo Davud Malekzadeh et al Clin Orthop Relat Res 2010
bull laquo Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprothetic joint infection raquo
Shahi A et al Clin Orthop Relat Res 2015
bull laquo Patients in the antibiotic group had higher rates of negative cultures raquo (264 vs 129)
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Background-Recommandations (2)
Recommandations SFAR 2010
Background-Recommandations (3)
Recommandations SFAR 2010
Background-Recommandations (4)
La prescription de vancomycine doit ecirctre argumenteacutee - allergie aux becircta-lactamines - colonisation suspecteacutee ou prouveacutee par du staphylocoque meacuteticilline-reacutesistant reacute-intervention chez un malade hospitaliseacute dans une uniteacute avec une eacutecologie agrave staphylocoque meacuteticilline-reacutesistant antibiotheacuterapie anteacuterieure Lrsquoinjection dure 60 minutes et doit se terminer au plus tard lors du deacutebut de lrsquointervention
Recommandations SFAR 2010
Background-Recommandations (5)
Recommandations SFAR 2010
Background-Recommandations (6)
bull Lrsquoadministration drsquoantibiotiques avant la reacutealisation des preacutelegravevements agrave viseacutee microbiologiques est deacuteconseilleacutee
bull Afin de diminuer le risque drsquoobtenir des preacutelegravevements faussement neacutegatifs il est recommandeacute de respecter un deacutelai minimal de 15 jours par rapport agrave toute antibiotheacuterapie (sauf en cas de sepsis et apregraves eacutevaluation du risque drsquoinfection disseacutemineacutee) (avis drsquoexpert) Conf consensus Infection os sur mateacuteriel2009
bull 321233 Modaliteacutes de la chirurgie en deux temps Elles consistent agrave deacuteposer la prothegravese agrave reacutealiser les preacutelegravevements microbiologiques en lrsquoabsence de toute antibioprophylaxiehellipConf consensus Infection os sur mateacuteriel2009
Background-Recommandations (7)
Que deacutecider en pratique (1)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Lavage-synovectomie
bull Pas drsquoantibioprophylaxie puisque bull pas drsquoimplantation de nouveau mateacuteriel protheacutetique
bull et antibiotheacuterapie probabiliste agrave large spectre deacutebuteacutee en peropeacuteratoire ou en post-opeacuteratoire immeacutediat selon les recommandations de lrsquoHAS
bull Toutefois mecircme si la prothegravese est conserveacutee il est conseilleacute de reacutealiser un changement des piegraveces modulaires si possible et ainsi du nouveau mateacuteriel est inseacutereacute ce qui pourrait justifier une antibioprophylaxiehellip
Que deacutecider en pratique (2)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Deacutepose-repose de prothegravese en un temps
bull Antibioprophylaxie ouihellip possiblehellipcar bull mise en place drsquoune nouvelle prothegravese
bull crainte que le moment de lrsquoinitiation des antibiotiques en peropeacuteratoire ou post-opeacuteratoire immeacutediat soit trop tardif et donc non efficace
bull crainte que les antibiotiques donneacutes en prophylaxie srsquoils ne sont pas agrave large spectre mais cibleacutes uniquement sur la ou les bacteacuteries identifieacutee(s) sur des preacutelegravevements preacute-opeacuteratoires fiables (ponction) ne permettent pas drsquoeacuteviter le prolifeacuteration de nouvelles bacteacuteries au niveau du site opeacuteratoire
bull Mais si administration drsquoantibiotiques avant la reacutealisation des preacutelegravevements =gt risque theacuteorique de laquo neacutegativer raquo ces preacutelegravevements de ne pas pouvoir mettre en eacutevidence la (ou les) bacteacuterie(s) responsable(s) de lrsquoinfection
que dit la litteacuterature
Que deacutecider en pratique (3)
bull Infection chronique bull Deacutepose-repose de prothegravese en un temps
bull Deacutepose-repose de prothegravese en 2 temps bull Lors du premier temps une antibioprophylaxie ne parait pas neacutecessaire puisque
la prothegravese est deacuteposeacutee et qursquoun espaceur souvent impreacutegneacutee drsquoantibiotiques est mis en place
bull Lors du deuxiegraveme temps bull srsquoil srsquoagit drsquoun laquo deux temps long raquo avec fenecirctre antibiotique de 2 semaines une
antibioprophylaxie est bull possible (cf changement en un temps) srsquoil y reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou
post-opeacuteratoire immeacutediat probablement pas neacutecessaire si cette antibiotheacuterapie est agrave large spectre
bull indiqueacutee srsquoil nrsquoy a pas de reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou post-opeacuteratoire immeacutediat
bull srsquoil srsquoagitlaquo deux temps court raquo ougrave la repose se fait alors que le patient est encore sous antibiotique une antibioprophylaxie agrave large spectre pour eacuteviter la prolifeacuteration de nouvelles bacteacuteries est possible agrave discuter en reacuteunion de concertation pluridisciplinaire
Quid du timing de lrsquoantibioprophylaxie
Timing of antimicrobial prophylaxis and the risk of surgical site infections results from the Trial to Reduce Antimicrobial
Prophylaxis Errors
Steinberg JP1 et al Ann Surg 2009
OBJECTIVE The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP)
SUMMARY BACKGROUND DATA National AMP guidelines should be supported by evidence from large contemporary data sets
METHODS Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac hipknee
arthroplasty and hysterectomy cases Surgical site infections (SSIs) were ascertained through routine surveillance using National
Nosocomial Infections Surveillance system methodology The association between the prophylaxis timing and the occurrence of
SSI was assessed using conditional logistic regression (conditioning on hospital)
RESULTS One-hundred thirteen SSI were detected in 109 patients SSI risk increased incrementally as the interval of time
between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 004) When
antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded the infection risk following
administration of antibiotic within 30 minutes prior to incision was 16 compared with 24 associated with administration of
antibiotic between 31 to 60 minutes prior to surgery (OR 174 95 confidence interval 098-304) The infection risk increased
as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision
(ORthinsp=thinsp220 95 CI 103-466) but not prior to 60 minutes Intraoperative redosing (performed in only 21 of long operations)
appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 308 with no redosing 95 confidence interval 074-
1290) but only when the preoperative dose was given correctly
CONCLUSIONS These data from a large multicenter collaborative study confirm and extend previous observations and show a
consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with
cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision
bull laquo Timing of surgical antibiotic prophylaxis and the risk of surgical site infection raquo Hawn MT et al JAMA Surg 2013
bull Patients et meacutethode bull Etude reacutetrospective bull Registre national des Veacuteteacuterans 2005-2009 bull Chirurgie orthopeacutedique (arthroplastie de hanche et de genou) colorectale vasculaire
gyneacutecologique
bull Reacutesultats bull Plus de 32 000 interventions avec antibioprophylaxie (plus de 20 000 = chirurgie orthopeacutedique) bull Taux global plus eacuteleveacute drsquoISO si antibioprophylaxie administreacutee plus de 60 minutes avant lrsquoincision
dans un modegravele avant ajustement bull Apregraves ajustement sur le type de patient de proceacutedure et lrsquoantibiotique utiliseacute aucune diffeacuterence
significative du taux drsquoISO selon le deacutelai de lrsquoadministration des antibiotiques par rapport au moment de lrsquoincision que lrsquoantibioprophylaxie ait eacuteteacute administreacutee avant ou apregraves lrsquointervention
bull Vancomycine seule utiliseacutee en antibioprophylaxie en chirurgie orthopeacutedique associeacutee agrave un taux drsquoISO plus eacuteleveacutee
Date of download 932015 Copyright copy 2015 American Medical
Association All rights reserved
From Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
JAMA Surg 2013148(7)649-657 doi101001jamasurg2013134
Association Between Timing of Prophylactic Antibiotics and Surgical Site InfectionUnadjusted (A) and adjusted (B) odds ratios (ORs)
for the association between timing of prophylactic antibiotics and surgical site infection with P values representing the significance
of the associationSolid line indicates the OR estimate for surgical site infection shaded area 95 CI dashed vertical line incision
time and dashed horizontal line an OR estimate of 10 Because spline fits for timing in the adjusted overall and vascular models
were nearly linear (dfthinspltthinsp11) final models considered timing as a linear effect
Figure Legend
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull ldquoPrior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infectionrdquo Davud Malekzadeh et al Clin Orthop Relat Res 2010
bull laquo Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprothetic joint infection raquo
Shahi A et al Clin Orthop Relat Res 2015
bull laquo Patients in the antibiotic group had higher rates of negative cultures raquo (264 vs 129)
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Background-Recommandations (3)
Recommandations SFAR 2010
Background-Recommandations (4)
La prescription de vancomycine doit ecirctre argumenteacutee - allergie aux becircta-lactamines - colonisation suspecteacutee ou prouveacutee par du staphylocoque meacuteticilline-reacutesistant reacute-intervention chez un malade hospitaliseacute dans une uniteacute avec une eacutecologie agrave staphylocoque meacuteticilline-reacutesistant antibiotheacuterapie anteacuterieure Lrsquoinjection dure 60 minutes et doit se terminer au plus tard lors du deacutebut de lrsquointervention
Recommandations SFAR 2010
Background-Recommandations (5)
Recommandations SFAR 2010
Background-Recommandations (6)
bull Lrsquoadministration drsquoantibiotiques avant la reacutealisation des preacutelegravevements agrave viseacutee microbiologiques est deacuteconseilleacutee
bull Afin de diminuer le risque drsquoobtenir des preacutelegravevements faussement neacutegatifs il est recommandeacute de respecter un deacutelai minimal de 15 jours par rapport agrave toute antibiotheacuterapie (sauf en cas de sepsis et apregraves eacutevaluation du risque drsquoinfection disseacutemineacutee) (avis drsquoexpert) Conf consensus Infection os sur mateacuteriel2009
bull 321233 Modaliteacutes de la chirurgie en deux temps Elles consistent agrave deacuteposer la prothegravese agrave reacutealiser les preacutelegravevements microbiologiques en lrsquoabsence de toute antibioprophylaxiehellipConf consensus Infection os sur mateacuteriel2009
Background-Recommandations (7)
Que deacutecider en pratique (1)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Lavage-synovectomie
bull Pas drsquoantibioprophylaxie puisque bull pas drsquoimplantation de nouveau mateacuteriel protheacutetique
bull et antibiotheacuterapie probabiliste agrave large spectre deacutebuteacutee en peropeacuteratoire ou en post-opeacuteratoire immeacutediat selon les recommandations de lrsquoHAS
bull Toutefois mecircme si la prothegravese est conserveacutee il est conseilleacute de reacutealiser un changement des piegraveces modulaires si possible et ainsi du nouveau mateacuteriel est inseacutereacute ce qui pourrait justifier une antibioprophylaxiehellip
Que deacutecider en pratique (2)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Deacutepose-repose de prothegravese en un temps
bull Antibioprophylaxie ouihellip possiblehellipcar bull mise en place drsquoune nouvelle prothegravese
bull crainte que le moment de lrsquoinitiation des antibiotiques en peropeacuteratoire ou post-opeacuteratoire immeacutediat soit trop tardif et donc non efficace
bull crainte que les antibiotiques donneacutes en prophylaxie srsquoils ne sont pas agrave large spectre mais cibleacutes uniquement sur la ou les bacteacuteries identifieacutee(s) sur des preacutelegravevements preacute-opeacuteratoires fiables (ponction) ne permettent pas drsquoeacuteviter le prolifeacuteration de nouvelles bacteacuteries au niveau du site opeacuteratoire
bull Mais si administration drsquoantibiotiques avant la reacutealisation des preacutelegravevements =gt risque theacuteorique de laquo neacutegativer raquo ces preacutelegravevements de ne pas pouvoir mettre en eacutevidence la (ou les) bacteacuterie(s) responsable(s) de lrsquoinfection
que dit la litteacuterature
Que deacutecider en pratique (3)
bull Infection chronique bull Deacutepose-repose de prothegravese en un temps
bull Deacutepose-repose de prothegravese en 2 temps bull Lors du premier temps une antibioprophylaxie ne parait pas neacutecessaire puisque
la prothegravese est deacuteposeacutee et qursquoun espaceur souvent impreacutegneacutee drsquoantibiotiques est mis en place
bull Lors du deuxiegraveme temps bull srsquoil srsquoagit drsquoun laquo deux temps long raquo avec fenecirctre antibiotique de 2 semaines une
antibioprophylaxie est bull possible (cf changement en un temps) srsquoil y reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou
post-opeacuteratoire immeacutediat probablement pas neacutecessaire si cette antibiotheacuterapie est agrave large spectre
bull indiqueacutee srsquoil nrsquoy a pas de reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou post-opeacuteratoire immeacutediat
bull srsquoil srsquoagitlaquo deux temps court raquo ougrave la repose se fait alors que le patient est encore sous antibiotique une antibioprophylaxie agrave large spectre pour eacuteviter la prolifeacuteration de nouvelles bacteacuteries est possible agrave discuter en reacuteunion de concertation pluridisciplinaire
Quid du timing de lrsquoantibioprophylaxie
Timing of antimicrobial prophylaxis and the risk of surgical site infections results from the Trial to Reduce Antimicrobial
Prophylaxis Errors
Steinberg JP1 et al Ann Surg 2009
OBJECTIVE The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP)
SUMMARY BACKGROUND DATA National AMP guidelines should be supported by evidence from large contemporary data sets
METHODS Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac hipknee
arthroplasty and hysterectomy cases Surgical site infections (SSIs) were ascertained through routine surveillance using National
Nosocomial Infections Surveillance system methodology The association between the prophylaxis timing and the occurrence of
SSI was assessed using conditional logistic regression (conditioning on hospital)
RESULTS One-hundred thirteen SSI were detected in 109 patients SSI risk increased incrementally as the interval of time
between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 004) When
antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded the infection risk following
administration of antibiotic within 30 minutes prior to incision was 16 compared with 24 associated with administration of
antibiotic between 31 to 60 minutes prior to surgery (OR 174 95 confidence interval 098-304) The infection risk increased
as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision
(ORthinsp=thinsp220 95 CI 103-466) but not prior to 60 minutes Intraoperative redosing (performed in only 21 of long operations)
appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 308 with no redosing 95 confidence interval 074-
1290) but only when the preoperative dose was given correctly
CONCLUSIONS These data from a large multicenter collaborative study confirm and extend previous observations and show a
consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with
cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision
bull laquo Timing of surgical antibiotic prophylaxis and the risk of surgical site infection raquo Hawn MT et al JAMA Surg 2013
bull Patients et meacutethode bull Etude reacutetrospective bull Registre national des Veacuteteacuterans 2005-2009 bull Chirurgie orthopeacutedique (arthroplastie de hanche et de genou) colorectale vasculaire
gyneacutecologique
bull Reacutesultats bull Plus de 32 000 interventions avec antibioprophylaxie (plus de 20 000 = chirurgie orthopeacutedique) bull Taux global plus eacuteleveacute drsquoISO si antibioprophylaxie administreacutee plus de 60 minutes avant lrsquoincision
dans un modegravele avant ajustement bull Apregraves ajustement sur le type de patient de proceacutedure et lrsquoantibiotique utiliseacute aucune diffeacuterence
significative du taux drsquoISO selon le deacutelai de lrsquoadministration des antibiotiques par rapport au moment de lrsquoincision que lrsquoantibioprophylaxie ait eacuteteacute administreacutee avant ou apregraves lrsquointervention
bull Vancomycine seule utiliseacutee en antibioprophylaxie en chirurgie orthopeacutedique associeacutee agrave un taux drsquoISO plus eacuteleveacutee
Date of download 932015 Copyright copy 2015 American Medical
Association All rights reserved
From Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
JAMA Surg 2013148(7)649-657 doi101001jamasurg2013134
Association Between Timing of Prophylactic Antibiotics and Surgical Site InfectionUnadjusted (A) and adjusted (B) odds ratios (ORs)
for the association between timing of prophylactic antibiotics and surgical site infection with P values representing the significance
of the associationSolid line indicates the OR estimate for surgical site infection shaded area 95 CI dashed vertical line incision
time and dashed horizontal line an OR estimate of 10 Because spline fits for timing in the adjusted overall and vascular models
were nearly linear (dfthinspltthinsp11) final models considered timing as a linear effect
Figure Legend
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull ldquoPrior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infectionrdquo Davud Malekzadeh et al Clin Orthop Relat Res 2010
bull laquo Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprothetic joint infection raquo
Shahi A et al Clin Orthop Relat Res 2015
bull laquo Patients in the antibiotic group had higher rates of negative cultures raquo (264 vs 129)
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Background-Recommandations (4)
La prescription de vancomycine doit ecirctre argumenteacutee - allergie aux becircta-lactamines - colonisation suspecteacutee ou prouveacutee par du staphylocoque meacuteticilline-reacutesistant reacute-intervention chez un malade hospitaliseacute dans une uniteacute avec une eacutecologie agrave staphylocoque meacuteticilline-reacutesistant antibiotheacuterapie anteacuterieure Lrsquoinjection dure 60 minutes et doit se terminer au plus tard lors du deacutebut de lrsquointervention
Recommandations SFAR 2010
Background-Recommandations (5)
Recommandations SFAR 2010
Background-Recommandations (6)
bull Lrsquoadministration drsquoantibiotiques avant la reacutealisation des preacutelegravevements agrave viseacutee microbiologiques est deacuteconseilleacutee
bull Afin de diminuer le risque drsquoobtenir des preacutelegravevements faussement neacutegatifs il est recommandeacute de respecter un deacutelai minimal de 15 jours par rapport agrave toute antibiotheacuterapie (sauf en cas de sepsis et apregraves eacutevaluation du risque drsquoinfection disseacutemineacutee) (avis drsquoexpert) Conf consensus Infection os sur mateacuteriel2009
bull 321233 Modaliteacutes de la chirurgie en deux temps Elles consistent agrave deacuteposer la prothegravese agrave reacutealiser les preacutelegravevements microbiologiques en lrsquoabsence de toute antibioprophylaxiehellipConf consensus Infection os sur mateacuteriel2009
Background-Recommandations (7)
Que deacutecider en pratique (1)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Lavage-synovectomie
bull Pas drsquoantibioprophylaxie puisque bull pas drsquoimplantation de nouveau mateacuteriel protheacutetique
bull et antibiotheacuterapie probabiliste agrave large spectre deacutebuteacutee en peropeacuteratoire ou en post-opeacuteratoire immeacutediat selon les recommandations de lrsquoHAS
bull Toutefois mecircme si la prothegravese est conserveacutee il est conseilleacute de reacutealiser un changement des piegraveces modulaires si possible et ainsi du nouveau mateacuteriel est inseacutereacute ce qui pourrait justifier une antibioprophylaxiehellip
Que deacutecider en pratique (2)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Deacutepose-repose de prothegravese en un temps
bull Antibioprophylaxie ouihellip possiblehellipcar bull mise en place drsquoune nouvelle prothegravese
bull crainte que le moment de lrsquoinitiation des antibiotiques en peropeacuteratoire ou post-opeacuteratoire immeacutediat soit trop tardif et donc non efficace
bull crainte que les antibiotiques donneacutes en prophylaxie srsquoils ne sont pas agrave large spectre mais cibleacutes uniquement sur la ou les bacteacuteries identifieacutee(s) sur des preacutelegravevements preacute-opeacuteratoires fiables (ponction) ne permettent pas drsquoeacuteviter le prolifeacuteration de nouvelles bacteacuteries au niveau du site opeacuteratoire
bull Mais si administration drsquoantibiotiques avant la reacutealisation des preacutelegravevements =gt risque theacuteorique de laquo neacutegativer raquo ces preacutelegravevements de ne pas pouvoir mettre en eacutevidence la (ou les) bacteacuterie(s) responsable(s) de lrsquoinfection
que dit la litteacuterature
Que deacutecider en pratique (3)
bull Infection chronique bull Deacutepose-repose de prothegravese en un temps
bull Deacutepose-repose de prothegravese en 2 temps bull Lors du premier temps une antibioprophylaxie ne parait pas neacutecessaire puisque
la prothegravese est deacuteposeacutee et qursquoun espaceur souvent impreacutegneacutee drsquoantibiotiques est mis en place
bull Lors du deuxiegraveme temps bull srsquoil srsquoagit drsquoun laquo deux temps long raquo avec fenecirctre antibiotique de 2 semaines une
antibioprophylaxie est bull possible (cf changement en un temps) srsquoil y reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou
post-opeacuteratoire immeacutediat probablement pas neacutecessaire si cette antibiotheacuterapie est agrave large spectre
bull indiqueacutee srsquoil nrsquoy a pas de reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou post-opeacuteratoire immeacutediat
bull srsquoil srsquoagitlaquo deux temps court raquo ougrave la repose se fait alors que le patient est encore sous antibiotique une antibioprophylaxie agrave large spectre pour eacuteviter la prolifeacuteration de nouvelles bacteacuteries est possible agrave discuter en reacuteunion de concertation pluridisciplinaire
Quid du timing de lrsquoantibioprophylaxie
Timing of antimicrobial prophylaxis and the risk of surgical site infections results from the Trial to Reduce Antimicrobial
Prophylaxis Errors
Steinberg JP1 et al Ann Surg 2009
OBJECTIVE The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP)
SUMMARY BACKGROUND DATA National AMP guidelines should be supported by evidence from large contemporary data sets
METHODS Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac hipknee
arthroplasty and hysterectomy cases Surgical site infections (SSIs) were ascertained through routine surveillance using National
Nosocomial Infections Surveillance system methodology The association between the prophylaxis timing and the occurrence of
SSI was assessed using conditional logistic regression (conditioning on hospital)
RESULTS One-hundred thirteen SSI were detected in 109 patients SSI risk increased incrementally as the interval of time
between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 004) When
antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded the infection risk following
administration of antibiotic within 30 minutes prior to incision was 16 compared with 24 associated with administration of
antibiotic between 31 to 60 minutes prior to surgery (OR 174 95 confidence interval 098-304) The infection risk increased
as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision
(ORthinsp=thinsp220 95 CI 103-466) but not prior to 60 minutes Intraoperative redosing (performed in only 21 of long operations)
appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 308 with no redosing 95 confidence interval 074-
1290) but only when the preoperative dose was given correctly
CONCLUSIONS These data from a large multicenter collaborative study confirm and extend previous observations and show a
consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with
cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision
bull laquo Timing of surgical antibiotic prophylaxis and the risk of surgical site infection raquo Hawn MT et al JAMA Surg 2013
bull Patients et meacutethode bull Etude reacutetrospective bull Registre national des Veacuteteacuterans 2005-2009 bull Chirurgie orthopeacutedique (arthroplastie de hanche et de genou) colorectale vasculaire
gyneacutecologique
bull Reacutesultats bull Plus de 32 000 interventions avec antibioprophylaxie (plus de 20 000 = chirurgie orthopeacutedique) bull Taux global plus eacuteleveacute drsquoISO si antibioprophylaxie administreacutee plus de 60 minutes avant lrsquoincision
dans un modegravele avant ajustement bull Apregraves ajustement sur le type de patient de proceacutedure et lrsquoantibiotique utiliseacute aucune diffeacuterence
significative du taux drsquoISO selon le deacutelai de lrsquoadministration des antibiotiques par rapport au moment de lrsquoincision que lrsquoantibioprophylaxie ait eacuteteacute administreacutee avant ou apregraves lrsquointervention
bull Vancomycine seule utiliseacutee en antibioprophylaxie en chirurgie orthopeacutedique associeacutee agrave un taux drsquoISO plus eacuteleveacutee
Date of download 932015 Copyright copy 2015 American Medical
Association All rights reserved
From Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
JAMA Surg 2013148(7)649-657 doi101001jamasurg2013134
Association Between Timing of Prophylactic Antibiotics and Surgical Site InfectionUnadjusted (A) and adjusted (B) odds ratios (ORs)
for the association between timing of prophylactic antibiotics and surgical site infection with P values representing the significance
of the associationSolid line indicates the OR estimate for surgical site infection shaded area 95 CI dashed vertical line incision
time and dashed horizontal line an OR estimate of 10 Because spline fits for timing in the adjusted overall and vascular models
were nearly linear (dfthinspltthinsp11) final models considered timing as a linear effect
Figure Legend
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull ldquoPrior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infectionrdquo Davud Malekzadeh et al Clin Orthop Relat Res 2010
bull laquo Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprothetic joint infection raquo
Shahi A et al Clin Orthop Relat Res 2015
bull laquo Patients in the antibiotic group had higher rates of negative cultures raquo (264 vs 129)
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Background-Recommandations (5)
Recommandations SFAR 2010
Background-Recommandations (6)
bull Lrsquoadministration drsquoantibiotiques avant la reacutealisation des preacutelegravevements agrave viseacutee microbiologiques est deacuteconseilleacutee
bull Afin de diminuer le risque drsquoobtenir des preacutelegravevements faussement neacutegatifs il est recommandeacute de respecter un deacutelai minimal de 15 jours par rapport agrave toute antibiotheacuterapie (sauf en cas de sepsis et apregraves eacutevaluation du risque drsquoinfection disseacutemineacutee) (avis drsquoexpert) Conf consensus Infection os sur mateacuteriel2009
bull 321233 Modaliteacutes de la chirurgie en deux temps Elles consistent agrave deacuteposer la prothegravese agrave reacutealiser les preacutelegravevements microbiologiques en lrsquoabsence de toute antibioprophylaxiehellipConf consensus Infection os sur mateacuteriel2009
Background-Recommandations (7)
Que deacutecider en pratique (1)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Lavage-synovectomie
bull Pas drsquoantibioprophylaxie puisque bull pas drsquoimplantation de nouveau mateacuteriel protheacutetique
bull et antibiotheacuterapie probabiliste agrave large spectre deacutebuteacutee en peropeacuteratoire ou en post-opeacuteratoire immeacutediat selon les recommandations de lrsquoHAS
bull Toutefois mecircme si la prothegravese est conserveacutee il est conseilleacute de reacutealiser un changement des piegraveces modulaires si possible et ainsi du nouveau mateacuteriel est inseacutereacute ce qui pourrait justifier une antibioprophylaxiehellip
Que deacutecider en pratique (2)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Deacutepose-repose de prothegravese en un temps
bull Antibioprophylaxie ouihellip possiblehellipcar bull mise en place drsquoune nouvelle prothegravese
bull crainte que le moment de lrsquoinitiation des antibiotiques en peropeacuteratoire ou post-opeacuteratoire immeacutediat soit trop tardif et donc non efficace
bull crainte que les antibiotiques donneacutes en prophylaxie srsquoils ne sont pas agrave large spectre mais cibleacutes uniquement sur la ou les bacteacuteries identifieacutee(s) sur des preacutelegravevements preacute-opeacuteratoires fiables (ponction) ne permettent pas drsquoeacuteviter le prolifeacuteration de nouvelles bacteacuteries au niveau du site opeacuteratoire
bull Mais si administration drsquoantibiotiques avant la reacutealisation des preacutelegravevements =gt risque theacuteorique de laquo neacutegativer raquo ces preacutelegravevements de ne pas pouvoir mettre en eacutevidence la (ou les) bacteacuterie(s) responsable(s) de lrsquoinfection
que dit la litteacuterature
Que deacutecider en pratique (3)
bull Infection chronique bull Deacutepose-repose de prothegravese en un temps
bull Deacutepose-repose de prothegravese en 2 temps bull Lors du premier temps une antibioprophylaxie ne parait pas neacutecessaire puisque
la prothegravese est deacuteposeacutee et qursquoun espaceur souvent impreacutegneacutee drsquoantibiotiques est mis en place
bull Lors du deuxiegraveme temps bull srsquoil srsquoagit drsquoun laquo deux temps long raquo avec fenecirctre antibiotique de 2 semaines une
antibioprophylaxie est bull possible (cf changement en un temps) srsquoil y reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou
post-opeacuteratoire immeacutediat probablement pas neacutecessaire si cette antibiotheacuterapie est agrave large spectre
bull indiqueacutee srsquoil nrsquoy a pas de reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou post-opeacuteratoire immeacutediat
bull srsquoil srsquoagitlaquo deux temps court raquo ougrave la repose se fait alors que le patient est encore sous antibiotique une antibioprophylaxie agrave large spectre pour eacuteviter la prolifeacuteration de nouvelles bacteacuteries est possible agrave discuter en reacuteunion de concertation pluridisciplinaire
Quid du timing de lrsquoantibioprophylaxie
Timing of antimicrobial prophylaxis and the risk of surgical site infections results from the Trial to Reduce Antimicrobial
Prophylaxis Errors
Steinberg JP1 et al Ann Surg 2009
OBJECTIVE The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP)
SUMMARY BACKGROUND DATA National AMP guidelines should be supported by evidence from large contemporary data sets
METHODS Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac hipknee
arthroplasty and hysterectomy cases Surgical site infections (SSIs) were ascertained through routine surveillance using National
Nosocomial Infections Surveillance system methodology The association between the prophylaxis timing and the occurrence of
SSI was assessed using conditional logistic regression (conditioning on hospital)
RESULTS One-hundred thirteen SSI were detected in 109 patients SSI risk increased incrementally as the interval of time
between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 004) When
antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded the infection risk following
administration of antibiotic within 30 minutes prior to incision was 16 compared with 24 associated with administration of
antibiotic between 31 to 60 minutes prior to surgery (OR 174 95 confidence interval 098-304) The infection risk increased
as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision
(ORthinsp=thinsp220 95 CI 103-466) but not prior to 60 minutes Intraoperative redosing (performed in only 21 of long operations)
appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 308 with no redosing 95 confidence interval 074-
1290) but only when the preoperative dose was given correctly
CONCLUSIONS These data from a large multicenter collaborative study confirm and extend previous observations and show a
consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with
cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision
bull laquo Timing of surgical antibiotic prophylaxis and the risk of surgical site infection raquo Hawn MT et al JAMA Surg 2013
bull Patients et meacutethode bull Etude reacutetrospective bull Registre national des Veacuteteacuterans 2005-2009 bull Chirurgie orthopeacutedique (arthroplastie de hanche et de genou) colorectale vasculaire
gyneacutecologique
bull Reacutesultats bull Plus de 32 000 interventions avec antibioprophylaxie (plus de 20 000 = chirurgie orthopeacutedique) bull Taux global plus eacuteleveacute drsquoISO si antibioprophylaxie administreacutee plus de 60 minutes avant lrsquoincision
dans un modegravele avant ajustement bull Apregraves ajustement sur le type de patient de proceacutedure et lrsquoantibiotique utiliseacute aucune diffeacuterence
significative du taux drsquoISO selon le deacutelai de lrsquoadministration des antibiotiques par rapport au moment de lrsquoincision que lrsquoantibioprophylaxie ait eacuteteacute administreacutee avant ou apregraves lrsquointervention
bull Vancomycine seule utiliseacutee en antibioprophylaxie en chirurgie orthopeacutedique associeacutee agrave un taux drsquoISO plus eacuteleveacutee
Date of download 932015 Copyright copy 2015 American Medical
Association All rights reserved
From Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
JAMA Surg 2013148(7)649-657 doi101001jamasurg2013134
Association Between Timing of Prophylactic Antibiotics and Surgical Site InfectionUnadjusted (A) and adjusted (B) odds ratios (ORs)
for the association between timing of prophylactic antibiotics and surgical site infection with P values representing the significance
of the associationSolid line indicates the OR estimate for surgical site infection shaded area 95 CI dashed vertical line incision
time and dashed horizontal line an OR estimate of 10 Because spline fits for timing in the adjusted overall and vascular models
were nearly linear (dfthinspltthinsp11) final models considered timing as a linear effect
Figure Legend
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull ldquoPrior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infectionrdquo Davud Malekzadeh et al Clin Orthop Relat Res 2010
bull laquo Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprothetic joint infection raquo
Shahi A et al Clin Orthop Relat Res 2015
bull laquo Patients in the antibiotic group had higher rates of negative cultures raquo (264 vs 129)
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Background-Recommandations (6)
bull Lrsquoadministration drsquoantibiotiques avant la reacutealisation des preacutelegravevements agrave viseacutee microbiologiques est deacuteconseilleacutee
bull Afin de diminuer le risque drsquoobtenir des preacutelegravevements faussement neacutegatifs il est recommandeacute de respecter un deacutelai minimal de 15 jours par rapport agrave toute antibiotheacuterapie (sauf en cas de sepsis et apregraves eacutevaluation du risque drsquoinfection disseacutemineacutee) (avis drsquoexpert) Conf consensus Infection os sur mateacuteriel2009
bull 321233 Modaliteacutes de la chirurgie en deux temps Elles consistent agrave deacuteposer la prothegravese agrave reacutealiser les preacutelegravevements microbiologiques en lrsquoabsence de toute antibioprophylaxiehellipConf consensus Infection os sur mateacuteriel2009
Background-Recommandations (7)
Que deacutecider en pratique (1)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Lavage-synovectomie
bull Pas drsquoantibioprophylaxie puisque bull pas drsquoimplantation de nouveau mateacuteriel protheacutetique
bull et antibiotheacuterapie probabiliste agrave large spectre deacutebuteacutee en peropeacuteratoire ou en post-opeacuteratoire immeacutediat selon les recommandations de lrsquoHAS
bull Toutefois mecircme si la prothegravese est conserveacutee il est conseilleacute de reacutealiser un changement des piegraveces modulaires si possible et ainsi du nouveau mateacuteriel est inseacutereacute ce qui pourrait justifier une antibioprophylaxiehellip
Que deacutecider en pratique (2)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Deacutepose-repose de prothegravese en un temps
bull Antibioprophylaxie ouihellip possiblehellipcar bull mise en place drsquoune nouvelle prothegravese
bull crainte que le moment de lrsquoinitiation des antibiotiques en peropeacuteratoire ou post-opeacuteratoire immeacutediat soit trop tardif et donc non efficace
bull crainte que les antibiotiques donneacutes en prophylaxie srsquoils ne sont pas agrave large spectre mais cibleacutes uniquement sur la ou les bacteacuteries identifieacutee(s) sur des preacutelegravevements preacute-opeacuteratoires fiables (ponction) ne permettent pas drsquoeacuteviter le prolifeacuteration de nouvelles bacteacuteries au niveau du site opeacuteratoire
bull Mais si administration drsquoantibiotiques avant la reacutealisation des preacutelegravevements =gt risque theacuteorique de laquo neacutegativer raquo ces preacutelegravevements de ne pas pouvoir mettre en eacutevidence la (ou les) bacteacuterie(s) responsable(s) de lrsquoinfection
que dit la litteacuterature
Que deacutecider en pratique (3)
bull Infection chronique bull Deacutepose-repose de prothegravese en un temps
bull Deacutepose-repose de prothegravese en 2 temps bull Lors du premier temps une antibioprophylaxie ne parait pas neacutecessaire puisque
la prothegravese est deacuteposeacutee et qursquoun espaceur souvent impreacutegneacutee drsquoantibiotiques est mis en place
bull Lors du deuxiegraveme temps bull srsquoil srsquoagit drsquoun laquo deux temps long raquo avec fenecirctre antibiotique de 2 semaines une
antibioprophylaxie est bull possible (cf changement en un temps) srsquoil y reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou
post-opeacuteratoire immeacutediat probablement pas neacutecessaire si cette antibiotheacuterapie est agrave large spectre
bull indiqueacutee srsquoil nrsquoy a pas de reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou post-opeacuteratoire immeacutediat
bull srsquoil srsquoagitlaquo deux temps court raquo ougrave la repose se fait alors que le patient est encore sous antibiotique une antibioprophylaxie agrave large spectre pour eacuteviter la prolifeacuteration de nouvelles bacteacuteries est possible agrave discuter en reacuteunion de concertation pluridisciplinaire
Quid du timing de lrsquoantibioprophylaxie
Timing of antimicrobial prophylaxis and the risk of surgical site infections results from the Trial to Reduce Antimicrobial
Prophylaxis Errors
Steinberg JP1 et al Ann Surg 2009
OBJECTIVE The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP)
SUMMARY BACKGROUND DATA National AMP guidelines should be supported by evidence from large contemporary data sets
METHODS Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac hipknee
arthroplasty and hysterectomy cases Surgical site infections (SSIs) were ascertained through routine surveillance using National
Nosocomial Infections Surveillance system methodology The association between the prophylaxis timing and the occurrence of
SSI was assessed using conditional logistic regression (conditioning on hospital)
RESULTS One-hundred thirteen SSI were detected in 109 patients SSI risk increased incrementally as the interval of time
between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 004) When
antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded the infection risk following
administration of antibiotic within 30 minutes prior to incision was 16 compared with 24 associated with administration of
antibiotic between 31 to 60 minutes prior to surgery (OR 174 95 confidence interval 098-304) The infection risk increased
as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision
(ORthinsp=thinsp220 95 CI 103-466) but not prior to 60 minutes Intraoperative redosing (performed in only 21 of long operations)
appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 308 with no redosing 95 confidence interval 074-
1290) but only when the preoperative dose was given correctly
CONCLUSIONS These data from a large multicenter collaborative study confirm and extend previous observations and show a
consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with
cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision
bull laquo Timing of surgical antibiotic prophylaxis and the risk of surgical site infection raquo Hawn MT et al JAMA Surg 2013
bull Patients et meacutethode bull Etude reacutetrospective bull Registre national des Veacuteteacuterans 2005-2009 bull Chirurgie orthopeacutedique (arthroplastie de hanche et de genou) colorectale vasculaire
gyneacutecologique
bull Reacutesultats bull Plus de 32 000 interventions avec antibioprophylaxie (plus de 20 000 = chirurgie orthopeacutedique) bull Taux global plus eacuteleveacute drsquoISO si antibioprophylaxie administreacutee plus de 60 minutes avant lrsquoincision
dans un modegravele avant ajustement bull Apregraves ajustement sur le type de patient de proceacutedure et lrsquoantibiotique utiliseacute aucune diffeacuterence
significative du taux drsquoISO selon le deacutelai de lrsquoadministration des antibiotiques par rapport au moment de lrsquoincision que lrsquoantibioprophylaxie ait eacuteteacute administreacutee avant ou apregraves lrsquointervention
bull Vancomycine seule utiliseacutee en antibioprophylaxie en chirurgie orthopeacutedique associeacutee agrave un taux drsquoISO plus eacuteleveacutee
Date of download 932015 Copyright copy 2015 American Medical
Association All rights reserved
From Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
JAMA Surg 2013148(7)649-657 doi101001jamasurg2013134
Association Between Timing of Prophylactic Antibiotics and Surgical Site InfectionUnadjusted (A) and adjusted (B) odds ratios (ORs)
for the association between timing of prophylactic antibiotics and surgical site infection with P values representing the significance
of the associationSolid line indicates the OR estimate for surgical site infection shaded area 95 CI dashed vertical line incision
time and dashed horizontal line an OR estimate of 10 Because spline fits for timing in the adjusted overall and vascular models
were nearly linear (dfthinspltthinsp11) final models considered timing as a linear effect
Figure Legend
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull ldquoPrior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infectionrdquo Davud Malekzadeh et al Clin Orthop Relat Res 2010
bull laquo Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprothetic joint infection raquo
Shahi A et al Clin Orthop Relat Res 2015
bull laquo Patients in the antibiotic group had higher rates of negative cultures raquo (264 vs 129)
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Background-Recommandations (7)
Que deacutecider en pratique (1)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Lavage-synovectomie
bull Pas drsquoantibioprophylaxie puisque bull pas drsquoimplantation de nouveau mateacuteriel protheacutetique
bull et antibiotheacuterapie probabiliste agrave large spectre deacutebuteacutee en peropeacuteratoire ou en post-opeacuteratoire immeacutediat selon les recommandations de lrsquoHAS
bull Toutefois mecircme si la prothegravese est conserveacutee il est conseilleacute de reacutealiser un changement des piegraveces modulaires si possible et ainsi du nouveau mateacuteriel est inseacutereacute ce qui pourrait justifier une antibioprophylaxiehellip
Que deacutecider en pratique (2)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Deacutepose-repose de prothegravese en un temps
bull Antibioprophylaxie ouihellip possiblehellipcar bull mise en place drsquoune nouvelle prothegravese
bull crainte que le moment de lrsquoinitiation des antibiotiques en peropeacuteratoire ou post-opeacuteratoire immeacutediat soit trop tardif et donc non efficace
bull crainte que les antibiotiques donneacutes en prophylaxie srsquoils ne sont pas agrave large spectre mais cibleacutes uniquement sur la ou les bacteacuteries identifieacutee(s) sur des preacutelegravevements preacute-opeacuteratoires fiables (ponction) ne permettent pas drsquoeacuteviter le prolifeacuteration de nouvelles bacteacuteries au niveau du site opeacuteratoire
bull Mais si administration drsquoantibiotiques avant la reacutealisation des preacutelegravevements =gt risque theacuteorique de laquo neacutegativer raquo ces preacutelegravevements de ne pas pouvoir mettre en eacutevidence la (ou les) bacteacuterie(s) responsable(s) de lrsquoinfection
que dit la litteacuterature
Que deacutecider en pratique (3)
bull Infection chronique bull Deacutepose-repose de prothegravese en un temps
bull Deacutepose-repose de prothegravese en 2 temps bull Lors du premier temps une antibioprophylaxie ne parait pas neacutecessaire puisque
la prothegravese est deacuteposeacutee et qursquoun espaceur souvent impreacutegneacutee drsquoantibiotiques est mis en place
bull Lors du deuxiegraveme temps bull srsquoil srsquoagit drsquoun laquo deux temps long raquo avec fenecirctre antibiotique de 2 semaines une
antibioprophylaxie est bull possible (cf changement en un temps) srsquoil y reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou
post-opeacuteratoire immeacutediat probablement pas neacutecessaire si cette antibiotheacuterapie est agrave large spectre
bull indiqueacutee srsquoil nrsquoy a pas de reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou post-opeacuteratoire immeacutediat
bull srsquoil srsquoagitlaquo deux temps court raquo ougrave la repose se fait alors que le patient est encore sous antibiotique une antibioprophylaxie agrave large spectre pour eacuteviter la prolifeacuteration de nouvelles bacteacuteries est possible agrave discuter en reacuteunion de concertation pluridisciplinaire
Quid du timing de lrsquoantibioprophylaxie
Timing of antimicrobial prophylaxis and the risk of surgical site infections results from the Trial to Reduce Antimicrobial
Prophylaxis Errors
Steinberg JP1 et al Ann Surg 2009
OBJECTIVE The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP)
SUMMARY BACKGROUND DATA National AMP guidelines should be supported by evidence from large contemporary data sets
METHODS Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac hipknee
arthroplasty and hysterectomy cases Surgical site infections (SSIs) were ascertained through routine surveillance using National
Nosocomial Infections Surveillance system methodology The association between the prophylaxis timing and the occurrence of
SSI was assessed using conditional logistic regression (conditioning on hospital)
RESULTS One-hundred thirteen SSI were detected in 109 patients SSI risk increased incrementally as the interval of time
between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 004) When
antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded the infection risk following
administration of antibiotic within 30 minutes prior to incision was 16 compared with 24 associated with administration of
antibiotic between 31 to 60 minutes prior to surgery (OR 174 95 confidence interval 098-304) The infection risk increased
as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision
(ORthinsp=thinsp220 95 CI 103-466) but not prior to 60 minutes Intraoperative redosing (performed in only 21 of long operations)
appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 308 with no redosing 95 confidence interval 074-
1290) but only when the preoperative dose was given correctly
CONCLUSIONS These data from a large multicenter collaborative study confirm and extend previous observations and show a
consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with
cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision
bull laquo Timing of surgical antibiotic prophylaxis and the risk of surgical site infection raquo Hawn MT et al JAMA Surg 2013
bull Patients et meacutethode bull Etude reacutetrospective bull Registre national des Veacuteteacuterans 2005-2009 bull Chirurgie orthopeacutedique (arthroplastie de hanche et de genou) colorectale vasculaire
gyneacutecologique
bull Reacutesultats bull Plus de 32 000 interventions avec antibioprophylaxie (plus de 20 000 = chirurgie orthopeacutedique) bull Taux global plus eacuteleveacute drsquoISO si antibioprophylaxie administreacutee plus de 60 minutes avant lrsquoincision
dans un modegravele avant ajustement bull Apregraves ajustement sur le type de patient de proceacutedure et lrsquoantibiotique utiliseacute aucune diffeacuterence
significative du taux drsquoISO selon le deacutelai de lrsquoadministration des antibiotiques par rapport au moment de lrsquoincision que lrsquoantibioprophylaxie ait eacuteteacute administreacutee avant ou apregraves lrsquointervention
bull Vancomycine seule utiliseacutee en antibioprophylaxie en chirurgie orthopeacutedique associeacutee agrave un taux drsquoISO plus eacuteleveacutee
Date of download 932015 Copyright copy 2015 American Medical
Association All rights reserved
From Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
JAMA Surg 2013148(7)649-657 doi101001jamasurg2013134
Association Between Timing of Prophylactic Antibiotics and Surgical Site InfectionUnadjusted (A) and adjusted (B) odds ratios (ORs)
for the association between timing of prophylactic antibiotics and surgical site infection with P values representing the significance
of the associationSolid line indicates the OR estimate for surgical site infection shaded area 95 CI dashed vertical line incision
time and dashed horizontal line an OR estimate of 10 Because spline fits for timing in the adjusted overall and vascular models
were nearly linear (dfthinspltthinsp11) final models considered timing as a linear effect
Figure Legend
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull ldquoPrior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infectionrdquo Davud Malekzadeh et al Clin Orthop Relat Res 2010
bull laquo Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprothetic joint infection raquo
Shahi A et al Clin Orthop Relat Res 2015
bull laquo Patients in the antibiotic group had higher rates of negative cultures raquo (264 vs 129)
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Que deacutecider en pratique (1)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Lavage-synovectomie
bull Pas drsquoantibioprophylaxie puisque bull pas drsquoimplantation de nouveau mateacuteriel protheacutetique
bull et antibiotheacuterapie probabiliste agrave large spectre deacutebuteacutee en peropeacuteratoire ou en post-opeacuteratoire immeacutediat selon les recommandations de lrsquoHAS
bull Toutefois mecircme si la prothegravese est conserveacutee il est conseilleacute de reacutealiser un changement des piegraveces modulaires si possible et ainsi du nouveau mateacuteriel est inseacutereacute ce qui pourrait justifier une antibioprophylaxiehellip
Que deacutecider en pratique (2)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Deacutepose-repose de prothegravese en un temps
bull Antibioprophylaxie ouihellip possiblehellipcar bull mise en place drsquoune nouvelle prothegravese
bull crainte que le moment de lrsquoinitiation des antibiotiques en peropeacuteratoire ou post-opeacuteratoire immeacutediat soit trop tardif et donc non efficace
bull crainte que les antibiotiques donneacutes en prophylaxie srsquoils ne sont pas agrave large spectre mais cibleacutes uniquement sur la ou les bacteacuteries identifieacutee(s) sur des preacutelegravevements preacute-opeacuteratoires fiables (ponction) ne permettent pas drsquoeacuteviter le prolifeacuteration de nouvelles bacteacuteries au niveau du site opeacuteratoire
bull Mais si administration drsquoantibiotiques avant la reacutealisation des preacutelegravevements =gt risque theacuteorique de laquo neacutegativer raquo ces preacutelegravevements de ne pas pouvoir mettre en eacutevidence la (ou les) bacteacuterie(s) responsable(s) de lrsquoinfection
que dit la litteacuterature
Que deacutecider en pratique (3)
bull Infection chronique bull Deacutepose-repose de prothegravese en un temps
bull Deacutepose-repose de prothegravese en 2 temps bull Lors du premier temps une antibioprophylaxie ne parait pas neacutecessaire puisque
la prothegravese est deacuteposeacutee et qursquoun espaceur souvent impreacutegneacutee drsquoantibiotiques est mis en place
bull Lors du deuxiegraveme temps bull srsquoil srsquoagit drsquoun laquo deux temps long raquo avec fenecirctre antibiotique de 2 semaines une
antibioprophylaxie est bull possible (cf changement en un temps) srsquoil y reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou
post-opeacuteratoire immeacutediat probablement pas neacutecessaire si cette antibiotheacuterapie est agrave large spectre
bull indiqueacutee srsquoil nrsquoy a pas de reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou post-opeacuteratoire immeacutediat
bull srsquoil srsquoagitlaquo deux temps court raquo ougrave la repose se fait alors que le patient est encore sous antibiotique une antibioprophylaxie agrave large spectre pour eacuteviter la prolifeacuteration de nouvelles bacteacuteries est possible agrave discuter en reacuteunion de concertation pluridisciplinaire
Quid du timing de lrsquoantibioprophylaxie
Timing of antimicrobial prophylaxis and the risk of surgical site infections results from the Trial to Reduce Antimicrobial
Prophylaxis Errors
Steinberg JP1 et al Ann Surg 2009
OBJECTIVE The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP)
SUMMARY BACKGROUND DATA National AMP guidelines should be supported by evidence from large contemporary data sets
METHODS Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac hipknee
arthroplasty and hysterectomy cases Surgical site infections (SSIs) were ascertained through routine surveillance using National
Nosocomial Infections Surveillance system methodology The association between the prophylaxis timing and the occurrence of
SSI was assessed using conditional logistic regression (conditioning on hospital)
RESULTS One-hundred thirteen SSI were detected in 109 patients SSI risk increased incrementally as the interval of time
between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 004) When
antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded the infection risk following
administration of antibiotic within 30 minutes prior to incision was 16 compared with 24 associated with administration of
antibiotic between 31 to 60 minutes prior to surgery (OR 174 95 confidence interval 098-304) The infection risk increased
as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision
(ORthinsp=thinsp220 95 CI 103-466) but not prior to 60 minutes Intraoperative redosing (performed in only 21 of long operations)
appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 308 with no redosing 95 confidence interval 074-
1290) but only when the preoperative dose was given correctly
CONCLUSIONS These data from a large multicenter collaborative study confirm and extend previous observations and show a
consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with
cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision
bull laquo Timing of surgical antibiotic prophylaxis and the risk of surgical site infection raquo Hawn MT et al JAMA Surg 2013
bull Patients et meacutethode bull Etude reacutetrospective bull Registre national des Veacuteteacuterans 2005-2009 bull Chirurgie orthopeacutedique (arthroplastie de hanche et de genou) colorectale vasculaire
gyneacutecologique
bull Reacutesultats bull Plus de 32 000 interventions avec antibioprophylaxie (plus de 20 000 = chirurgie orthopeacutedique) bull Taux global plus eacuteleveacute drsquoISO si antibioprophylaxie administreacutee plus de 60 minutes avant lrsquoincision
dans un modegravele avant ajustement bull Apregraves ajustement sur le type de patient de proceacutedure et lrsquoantibiotique utiliseacute aucune diffeacuterence
significative du taux drsquoISO selon le deacutelai de lrsquoadministration des antibiotiques par rapport au moment de lrsquoincision que lrsquoantibioprophylaxie ait eacuteteacute administreacutee avant ou apregraves lrsquointervention
bull Vancomycine seule utiliseacutee en antibioprophylaxie en chirurgie orthopeacutedique associeacutee agrave un taux drsquoISO plus eacuteleveacutee
Date of download 932015 Copyright copy 2015 American Medical
Association All rights reserved
From Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
JAMA Surg 2013148(7)649-657 doi101001jamasurg2013134
Association Between Timing of Prophylactic Antibiotics and Surgical Site InfectionUnadjusted (A) and adjusted (B) odds ratios (ORs)
for the association between timing of prophylactic antibiotics and surgical site infection with P values representing the significance
of the associationSolid line indicates the OR estimate for surgical site infection shaded area 95 CI dashed vertical line incision
time and dashed horizontal line an OR estimate of 10 Because spline fits for timing in the adjusted overall and vascular models
were nearly linear (dfthinspltthinsp11) final models considered timing as a linear effect
Figure Legend
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull ldquoPrior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infectionrdquo Davud Malekzadeh et al Clin Orthop Relat Res 2010
bull laquo Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprothetic joint infection raquo
Shahi A et al Clin Orthop Relat Res 2015
bull laquo Patients in the antibiotic group had higher rates of negative cultures raquo (264 vs 129)
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Que deacutecider en pratique (2)
bull Infection reacutecente (eacutevoluant depuis moins drsquoun mois) bull Deacutepose-repose de prothegravese en un temps
bull Antibioprophylaxie ouihellip possiblehellipcar bull mise en place drsquoune nouvelle prothegravese
bull crainte que le moment de lrsquoinitiation des antibiotiques en peropeacuteratoire ou post-opeacuteratoire immeacutediat soit trop tardif et donc non efficace
bull crainte que les antibiotiques donneacutes en prophylaxie srsquoils ne sont pas agrave large spectre mais cibleacutes uniquement sur la ou les bacteacuteries identifieacutee(s) sur des preacutelegravevements preacute-opeacuteratoires fiables (ponction) ne permettent pas drsquoeacuteviter le prolifeacuteration de nouvelles bacteacuteries au niveau du site opeacuteratoire
bull Mais si administration drsquoantibiotiques avant la reacutealisation des preacutelegravevements =gt risque theacuteorique de laquo neacutegativer raquo ces preacutelegravevements de ne pas pouvoir mettre en eacutevidence la (ou les) bacteacuterie(s) responsable(s) de lrsquoinfection
que dit la litteacuterature
Que deacutecider en pratique (3)
bull Infection chronique bull Deacutepose-repose de prothegravese en un temps
bull Deacutepose-repose de prothegravese en 2 temps bull Lors du premier temps une antibioprophylaxie ne parait pas neacutecessaire puisque
la prothegravese est deacuteposeacutee et qursquoun espaceur souvent impreacutegneacutee drsquoantibiotiques est mis en place
bull Lors du deuxiegraveme temps bull srsquoil srsquoagit drsquoun laquo deux temps long raquo avec fenecirctre antibiotique de 2 semaines une
antibioprophylaxie est bull possible (cf changement en un temps) srsquoil y reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou
post-opeacuteratoire immeacutediat probablement pas neacutecessaire si cette antibiotheacuterapie est agrave large spectre
bull indiqueacutee srsquoil nrsquoy a pas de reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou post-opeacuteratoire immeacutediat
bull srsquoil srsquoagitlaquo deux temps court raquo ougrave la repose se fait alors que le patient est encore sous antibiotique une antibioprophylaxie agrave large spectre pour eacuteviter la prolifeacuteration de nouvelles bacteacuteries est possible agrave discuter en reacuteunion de concertation pluridisciplinaire
Quid du timing de lrsquoantibioprophylaxie
Timing of antimicrobial prophylaxis and the risk of surgical site infections results from the Trial to Reduce Antimicrobial
Prophylaxis Errors
Steinberg JP1 et al Ann Surg 2009
OBJECTIVE The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP)
SUMMARY BACKGROUND DATA National AMP guidelines should be supported by evidence from large contemporary data sets
METHODS Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac hipknee
arthroplasty and hysterectomy cases Surgical site infections (SSIs) were ascertained through routine surveillance using National
Nosocomial Infections Surveillance system methodology The association between the prophylaxis timing and the occurrence of
SSI was assessed using conditional logistic regression (conditioning on hospital)
RESULTS One-hundred thirteen SSI were detected in 109 patients SSI risk increased incrementally as the interval of time
between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 004) When
antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded the infection risk following
administration of antibiotic within 30 minutes prior to incision was 16 compared with 24 associated with administration of
antibiotic between 31 to 60 minutes prior to surgery (OR 174 95 confidence interval 098-304) The infection risk increased
as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision
(ORthinsp=thinsp220 95 CI 103-466) but not prior to 60 minutes Intraoperative redosing (performed in only 21 of long operations)
appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 308 with no redosing 95 confidence interval 074-
1290) but only when the preoperative dose was given correctly
CONCLUSIONS These data from a large multicenter collaborative study confirm and extend previous observations and show a
consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with
cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision
bull laquo Timing of surgical antibiotic prophylaxis and the risk of surgical site infection raquo Hawn MT et al JAMA Surg 2013
bull Patients et meacutethode bull Etude reacutetrospective bull Registre national des Veacuteteacuterans 2005-2009 bull Chirurgie orthopeacutedique (arthroplastie de hanche et de genou) colorectale vasculaire
gyneacutecologique
bull Reacutesultats bull Plus de 32 000 interventions avec antibioprophylaxie (plus de 20 000 = chirurgie orthopeacutedique) bull Taux global plus eacuteleveacute drsquoISO si antibioprophylaxie administreacutee plus de 60 minutes avant lrsquoincision
dans un modegravele avant ajustement bull Apregraves ajustement sur le type de patient de proceacutedure et lrsquoantibiotique utiliseacute aucune diffeacuterence
significative du taux drsquoISO selon le deacutelai de lrsquoadministration des antibiotiques par rapport au moment de lrsquoincision que lrsquoantibioprophylaxie ait eacuteteacute administreacutee avant ou apregraves lrsquointervention
bull Vancomycine seule utiliseacutee en antibioprophylaxie en chirurgie orthopeacutedique associeacutee agrave un taux drsquoISO plus eacuteleveacutee
Date of download 932015 Copyright copy 2015 American Medical
Association All rights reserved
From Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
JAMA Surg 2013148(7)649-657 doi101001jamasurg2013134
Association Between Timing of Prophylactic Antibiotics and Surgical Site InfectionUnadjusted (A) and adjusted (B) odds ratios (ORs)
for the association between timing of prophylactic antibiotics and surgical site infection with P values representing the significance
of the associationSolid line indicates the OR estimate for surgical site infection shaded area 95 CI dashed vertical line incision
time and dashed horizontal line an OR estimate of 10 Because spline fits for timing in the adjusted overall and vascular models
were nearly linear (dfthinspltthinsp11) final models considered timing as a linear effect
Figure Legend
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull ldquoPrior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infectionrdquo Davud Malekzadeh et al Clin Orthop Relat Res 2010
bull laquo Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprothetic joint infection raquo
Shahi A et al Clin Orthop Relat Res 2015
bull laquo Patients in the antibiotic group had higher rates of negative cultures raquo (264 vs 129)
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Que deacutecider en pratique (3)
bull Infection chronique bull Deacutepose-repose de prothegravese en un temps
bull Deacutepose-repose de prothegravese en 2 temps bull Lors du premier temps une antibioprophylaxie ne parait pas neacutecessaire puisque
la prothegravese est deacuteposeacutee et qursquoun espaceur souvent impreacutegneacutee drsquoantibiotiques est mis en place
bull Lors du deuxiegraveme temps bull srsquoil srsquoagit drsquoun laquo deux temps long raquo avec fenecirctre antibiotique de 2 semaines une
antibioprophylaxie est bull possible (cf changement en un temps) srsquoil y reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou
post-opeacuteratoire immeacutediat probablement pas neacutecessaire si cette antibiotheacuterapie est agrave large spectre
bull indiqueacutee srsquoil nrsquoy a pas de reprise drsquoune antibiotheacuterapie en peropeacuteratoire ou post-opeacuteratoire immeacutediat
bull srsquoil srsquoagitlaquo deux temps court raquo ougrave la repose se fait alors que le patient est encore sous antibiotique une antibioprophylaxie agrave large spectre pour eacuteviter la prolifeacuteration de nouvelles bacteacuteries est possible agrave discuter en reacuteunion de concertation pluridisciplinaire
Quid du timing de lrsquoantibioprophylaxie
Timing of antimicrobial prophylaxis and the risk of surgical site infections results from the Trial to Reduce Antimicrobial
Prophylaxis Errors
Steinberg JP1 et al Ann Surg 2009
OBJECTIVE The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP)
SUMMARY BACKGROUND DATA National AMP guidelines should be supported by evidence from large contemporary data sets
METHODS Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac hipknee
arthroplasty and hysterectomy cases Surgical site infections (SSIs) were ascertained through routine surveillance using National
Nosocomial Infections Surveillance system methodology The association between the prophylaxis timing and the occurrence of
SSI was assessed using conditional logistic regression (conditioning on hospital)
RESULTS One-hundred thirteen SSI were detected in 109 patients SSI risk increased incrementally as the interval of time
between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 004) When
antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded the infection risk following
administration of antibiotic within 30 minutes prior to incision was 16 compared with 24 associated with administration of
antibiotic between 31 to 60 minutes prior to surgery (OR 174 95 confidence interval 098-304) The infection risk increased
as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision
(ORthinsp=thinsp220 95 CI 103-466) but not prior to 60 minutes Intraoperative redosing (performed in only 21 of long operations)
appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 308 with no redosing 95 confidence interval 074-
1290) but only when the preoperative dose was given correctly
CONCLUSIONS These data from a large multicenter collaborative study confirm and extend previous observations and show a
consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with
cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision
bull laquo Timing of surgical antibiotic prophylaxis and the risk of surgical site infection raquo Hawn MT et al JAMA Surg 2013
bull Patients et meacutethode bull Etude reacutetrospective bull Registre national des Veacuteteacuterans 2005-2009 bull Chirurgie orthopeacutedique (arthroplastie de hanche et de genou) colorectale vasculaire
gyneacutecologique
bull Reacutesultats bull Plus de 32 000 interventions avec antibioprophylaxie (plus de 20 000 = chirurgie orthopeacutedique) bull Taux global plus eacuteleveacute drsquoISO si antibioprophylaxie administreacutee plus de 60 minutes avant lrsquoincision
dans un modegravele avant ajustement bull Apregraves ajustement sur le type de patient de proceacutedure et lrsquoantibiotique utiliseacute aucune diffeacuterence
significative du taux drsquoISO selon le deacutelai de lrsquoadministration des antibiotiques par rapport au moment de lrsquoincision que lrsquoantibioprophylaxie ait eacuteteacute administreacutee avant ou apregraves lrsquointervention
bull Vancomycine seule utiliseacutee en antibioprophylaxie en chirurgie orthopeacutedique associeacutee agrave un taux drsquoISO plus eacuteleveacutee
Date of download 932015 Copyright copy 2015 American Medical
Association All rights reserved
From Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
JAMA Surg 2013148(7)649-657 doi101001jamasurg2013134
Association Between Timing of Prophylactic Antibiotics and Surgical Site InfectionUnadjusted (A) and adjusted (B) odds ratios (ORs)
for the association between timing of prophylactic antibiotics and surgical site infection with P values representing the significance
of the associationSolid line indicates the OR estimate for surgical site infection shaded area 95 CI dashed vertical line incision
time and dashed horizontal line an OR estimate of 10 Because spline fits for timing in the adjusted overall and vascular models
were nearly linear (dfthinspltthinsp11) final models considered timing as a linear effect
Figure Legend
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull ldquoPrior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infectionrdquo Davud Malekzadeh et al Clin Orthop Relat Res 2010
bull laquo Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprothetic joint infection raquo
Shahi A et al Clin Orthop Relat Res 2015
bull laquo Patients in the antibiotic group had higher rates of negative cultures raquo (264 vs 129)
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Quid du timing de lrsquoantibioprophylaxie
Timing of antimicrobial prophylaxis and the risk of surgical site infections results from the Trial to Reduce Antimicrobial
Prophylaxis Errors
Steinberg JP1 et al Ann Surg 2009
OBJECTIVE The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP)
SUMMARY BACKGROUND DATA National AMP guidelines should be supported by evidence from large contemporary data sets
METHODS Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac hipknee
arthroplasty and hysterectomy cases Surgical site infections (SSIs) were ascertained through routine surveillance using National
Nosocomial Infections Surveillance system methodology The association between the prophylaxis timing and the occurrence of
SSI was assessed using conditional logistic regression (conditioning on hospital)
RESULTS One-hundred thirteen SSI were detected in 109 patients SSI risk increased incrementally as the interval of time
between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 004) When
antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded the infection risk following
administration of antibiotic within 30 minutes prior to incision was 16 compared with 24 associated with administration of
antibiotic between 31 to 60 minutes prior to surgery (OR 174 95 confidence interval 098-304) The infection risk increased
as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision
(ORthinsp=thinsp220 95 CI 103-466) but not prior to 60 minutes Intraoperative redosing (performed in only 21 of long operations)
appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 308 with no redosing 95 confidence interval 074-
1290) but only when the preoperative dose was given correctly
CONCLUSIONS These data from a large multicenter collaborative study confirm and extend previous observations and show a
consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with
cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision
bull laquo Timing of surgical antibiotic prophylaxis and the risk of surgical site infection raquo Hawn MT et al JAMA Surg 2013
bull Patients et meacutethode bull Etude reacutetrospective bull Registre national des Veacuteteacuterans 2005-2009 bull Chirurgie orthopeacutedique (arthroplastie de hanche et de genou) colorectale vasculaire
gyneacutecologique
bull Reacutesultats bull Plus de 32 000 interventions avec antibioprophylaxie (plus de 20 000 = chirurgie orthopeacutedique) bull Taux global plus eacuteleveacute drsquoISO si antibioprophylaxie administreacutee plus de 60 minutes avant lrsquoincision
dans un modegravele avant ajustement bull Apregraves ajustement sur le type de patient de proceacutedure et lrsquoantibiotique utiliseacute aucune diffeacuterence
significative du taux drsquoISO selon le deacutelai de lrsquoadministration des antibiotiques par rapport au moment de lrsquoincision que lrsquoantibioprophylaxie ait eacuteteacute administreacutee avant ou apregraves lrsquointervention
bull Vancomycine seule utiliseacutee en antibioprophylaxie en chirurgie orthopeacutedique associeacutee agrave un taux drsquoISO plus eacuteleveacutee
Date of download 932015 Copyright copy 2015 American Medical
Association All rights reserved
From Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
JAMA Surg 2013148(7)649-657 doi101001jamasurg2013134
Association Between Timing of Prophylactic Antibiotics and Surgical Site InfectionUnadjusted (A) and adjusted (B) odds ratios (ORs)
for the association between timing of prophylactic antibiotics and surgical site infection with P values representing the significance
of the associationSolid line indicates the OR estimate for surgical site infection shaded area 95 CI dashed vertical line incision
time and dashed horizontal line an OR estimate of 10 Because spline fits for timing in the adjusted overall and vascular models
were nearly linear (dfthinspltthinsp11) final models considered timing as a linear effect
Figure Legend
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull ldquoPrior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infectionrdquo Davud Malekzadeh et al Clin Orthop Relat Res 2010
bull laquo Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprothetic joint infection raquo
Shahi A et al Clin Orthop Relat Res 2015
bull laquo Patients in the antibiotic group had higher rates of negative cultures raquo (264 vs 129)
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Timing of antimicrobial prophylaxis and the risk of surgical site infections results from the Trial to Reduce Antimicrobial
Prophylaxis Errors
Steinberg JP1 et al Ann Surg 2009
OBJECTIVE The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP)
SUMMARY BACKGROUND DATA National AMP guidelines should be supported by evidence from large contemporary data sets
METHODS Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac hipknee
arthroplasty and hysterectomy cases Surgical site infections (SSIs) were ascertained through routine surveillance using National
Nosocomial Infections Surveillance system methodology The association between the prophylaxis timing and the occurrence of
SSI was assessed using conditional logistic regression (conditioning on hospital)
RESULTS One-hundred thirteen SSI were detected in 109 patients SSI risk increased incrementally as the interval of time
between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 004) When
antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded the infection risk following
administration of antibiotic within 30 minutes prior to incision was 16 compared with 24 associated with administration of
antibiotic between 31 to 60 minutes prior to surgery (OR 174 95 confidence interval 098-304) The infection risk increased
as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision
(ORthinsp=thinsp220 95 CI 103-466) but not prior to 60 minutes Intraoperative redosing (performed in only 21 of long operations)
appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 308 with no redosing 95 confidence interval 074-
1290) but only when the preoperative dose was given correctly
CONCLUSIONS These data from a large multicenter collaborative study confirm and extend previous observations and show a
consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with
cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision
bull laquo Timing of surgical antibiotic prophylaxis and the risk of surgical site infection raquo Hawn MT et al JAMA Surg 2013
bull Patients et meacutethode bull Etude reacutetrospective bull Registre national des Veacuteteacuterans 2005-2009 bull Chirurgie orthopeacutedique (arthroplastie de hanche et de genou) colorectale vasculaire
gyneacutecologique
bull Reacutesultats bull Plus de 32 000 interventions avec antibioprophylaxie (plus de 20 000 = chirurgie orthopeacutedique) bull Taux global plus eacuteleveacute drsquoISO si antibioprophylaxie administreacutee plus de 60 minutes avant lrsquoincision
dans un modegravele avant ajustement bull Apregraves ajustement sur le type de patient de proceacutedure et lrsquoantibiotique utiliseacute aucune diffeacuterence
significative du taux drsquoISO selon le deacutelai de lrsquoadministration des antibiotiques par rapport au moment de lrsquoincision que lrsquoantibioprophylaxie ait eacuteteacute administreacutee avant ou apregraves lrsquointervention
bull Vancomycine seule utiliseacutee en antibioprophylaxie en chirurgie orthopeacutedique associeacutee agrave un taux drsquoISO plus eacuteleveacutee
Date of download 932015 Copyright copy 2015 American Medical
Association All rights reserved
From Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
JAMA Surg 2013148(7)649-657 doi101001jamasurg2013134
Association Between Timing of Prophylactic Antibiotics and Surgical Site InfectionUnadjusted (A) and adjusted (B) odds ratios (ORs)
for the association between timing of prophylactic antibiotics and surgical site infection with P values representing the significance
of the associationSolid line indicates the OR estimate for surgical site infection shaded area 95 CI dashed vertical line incision
time and dashed horizontal line an OR estimate of 10 Because spline fits for timing in the adjusted overall and vascular models
were nearly linear (dfthinspltthinsp11) final models considered timing as a linear effect
Figure Legend
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull ldquoPrior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infectionrdquo Davud Malekzadeh et al Clin Orthop Relat Res 2010
bull laquo Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprothetic joint infection raquo
Shahi A et al Clin Orthop Relat Res 2015
bull laquo Patients in the antibiotic group had higher rates of negative cultures raquo (264 vs 129)
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
bull laquo Timing of surgical antibiotic prophylaxis and the risk of surgical site infection raquo Hawn MT et al JAMA Surg 2013
bull Patients et meacutethode bull Etude reacutetrospective bull Registre national des Veacuteteacuterans 2005-2009 bull Chirurgie orthopeacutedique (arthroplastie de hanche et de genou) colorectale vasculaire
gyneacutecologique
bull Reacutesultats bull Plus de 32 000 interventions avec antibioprophylaxie (plus de 20 000 = chirurgie orthopeacutedique) bull Taux global plus eacuteleveacute drsquoISO si antibioprophylaxie administreacutee plus de 60 minutes avant lrsquoincision
dans un modegravele avant ajustement bull Apregraves ajustement sur le type de patient de proceacutedure et lrsquoantibiotique utiliseacute aucune diffeacuterence
significative du taux drsquoISO selon le deacutelai de lrsquoadministration des antibiotiques par rapport au moment de lrsquoincision que lrsquoantibioprophylaxie ait eacuteteacute administreacutee avant ou apregraves lrsquointervention
bull Vancomycine seule utiliseacutee en antibioprophylaxie en chirurgie orthopeacutedique associeacutee agrave un taux drsquoISO plus eacuteleveacutee
Date of download 932015 Copyright copy 2015 American Medical
Association All rights reserved
From Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
JAMA Surg 2013148(7)649-657 doi101001jamasurg2013134
Association Between Timing of Prophylactic Antibiotics and Surgical Site InfectionUnadjusted (A) and adjusted (B) odds ratios (ORs)
for the association between timing of prophylactic antibiotics and surgical site infection with P values representing the significance
of the associationSolid line indicates the OR estimate for surgical site infection shaded area 95 CI dashed vertical line incision
time and dashed horizontal line an OR estimate of 10 Because spline fits for timing in the adjusted overall and vascular models
were nearly linear (dfthinspltthinsp11) final models considered timing as a linear effect
Figure Legend
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull ldquoPrior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infectionrdquo Davud Malekzadeh et al Clin Orthop Relat Res 2010
bull laquo Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprothetic joint infection raquo
Shahi A et al Clin Orthop Relat Res 2015
bull laquo Patients in the antibiotic group had higher rates of negative cultures raquo (264 vs 129)
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Date of download 932015 Copyright copy 2015 American Medical
Association All rights reserved
From Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
JAMA Surg 2013148(7)649-657 doi101001jamasurg2013134
Association Between Timing of Prophylactic Antibiotics and Surgical Site InfectionUnadjusted (A) and adjusted (B) odds ratios (ORs)
for the association between timing of prophylactic antibiotics and surgical site infection with P values representing the significance
of the associationSolid line indicates the OR estimate for surgical site infection shaded area 95 CI dashed vertical line incision
time and dashed horizontal line an OR estimate of 10 Because spline fits for timing in the adjusted overall and vascular models
were nearly linear (dfthinspltthinsp11) final models considered timing as a linear effect
Figure Legend
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull ldquoPrior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infectionrdquo Davud Malekzadeh et al Clin Orthop Relat Res 2010
bull laquo Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprothetic joint infection raquo
Shahi A et al Clin Orthop Relat Res 2015
bull laquo Patients in the antibiotic group had higher rates of negative cultures raquo (264 vs 129)
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull ldquoPrior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infectionrdquo Davud Malekzadeh et al Clin Orthop Relat Res 2010
bull laquo Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprothetic joint infection raquo
Shahi A et al Clin Orthop Relat Res 2015
bull laquo Patients in the antibiotic group had higher rates of negative cultures raquo (264 vs 129)
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des preacutelegravevements
peropeacuteratoires
bull laquo Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection raquo Ghanem E et al Clin Orthop Relat Res 2007
bull laquo Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA raquo Burnett RSJ et al Clin Orthop Relat Res2010
bull ldquoShould Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate CulturesrdquoTetreault MW Clin Orthop Relat Res 2014
bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections Bedencic K et al
Clin Orthop Relat Res 2015
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Administration preacute-opeacuteratoire des antibiotiques et laquo neacutegativation raquo des
preacutelegravevements peropeacuteratoires bull laquo Does preoperative antimicrobial prophylaxis influence the diagnostic
potential of periprosthetic tissues in hip or knee infections Bedencic K et al Clin Orthop Relat Res 2015
bull Patients et meacutethodes bull Etude prospective bull 40 patients avec suspicion drsquoinfection sur prothegravese articulaire bull 3 preacutelegravevements tissulaires apregraves arthrotomie bull Antibioprophylaxie par Ceacutefazoline (2 grammes) bull Plus tard au cours de lrsquointervention avant deacutebridement et lavage 3 nouveaux preacutelegravevements
tissulaires bull Mesure des concentrations tissulaires de la ceacutefazoline
bull Reacutesultats bull Pas de diffeacuterence des performances des preacutelegravevements preacute et post-antibioprophylaxie pour le
diagnostic microbiologique de lrsquoinfection bull Concentrations tissulaires de ceacutefazoline gt CMI dans tous les cas
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Quelle antibioprophylaxie agrave large spectre en cas de reprise de prothegravese infecteacutee
bull Vancomycine + gentamicine ou vancomycine + CIG ou CIIG ou CIIIG bull laquo Microbiological aetiology epidemiology and clinical profile of prosthetic joint infections
are current antibiotic prophylaxis guidelines effective Peel TN et al AAC 2012 proposition drsquoABP par Vancomycine + Ceacutefazoline bull laquo Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total
joint arthroplasty patients raquo Smith EB et al J Arthroplasty 2012 plus de 5000 prothegraveses primaires peacuteriode avec ceacutefazoline puis peacuteriode avec vancomycine reacuteduction du taux global drsquoinfection sur arthroplastie (1 vs 05)
bull laquo Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery raquo Kanj WW et al Orthopedics 2013 Revue de la litteacuterature laquo Given the lack of efficacy of intravenous vancomycin the authors do not recommend its routine use in clean orthopedic surgeryrdquo
bull Teacuteicoplanine et ceacutefuroxime bull laquo Prophylaxis with teicoplanin and cefuroxim reduces the rate of prosthetic joint infection
after primary arthroplasty raquo Tornero E et al AAC 2015
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections report from Australian Surveillance Data (VICNISS) Bull AL1 Worth LJ Richards MJ Ann Surg 2012 OBJECTIVE To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis BACKGROUND Vancomycin is often used as surgical antibiotic prophylaxis for major surgery In nonsurgical populations there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections Since 2002 the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia including any prophylactic antibiotic agent administered before surgical procedures METHODS Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009 Logistic regression analysis was used to examine risk factors for infection including age procedure duration American Society of Anesthesiologists score and choice and timing of antibiotic prophylaxis RESULTS The data set consisted of 22549 procedures including cardiac bypass and hip and knee arthroplasty procedures Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20939 cases A total of 754 SSIs were recorded The most frequent pathogens were MSSA methicillin-resistant Staphylococcus aureus and Pseudomonas species The adjusted odds ratio (OR) for an SSI with MSSA was 279 where vancomycin prophylaxis was administered (P lt 0001) For methicillin-resistant Staphylococcus aureus infection the adjusted OR for vancomycin was 044 (P = 005) whereas for Pseudomonas infection it was 096 (P = 095) CONCLUSIONS In a large Australian study population prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins
Conclusion
bull En cas de reprise de prothegravese infecteacutee la seule situation ougrave lrsquoadministration drsquoune antibioprophylaxie (agrave large spectre) semble neacutecessaire est celle ougrave lrsquoantibiotheacuterapie deacutebuteacutee en per-opeacuteratoire degraves les preacutelegravevements reacutealiseacutes ne semblent pas avoir un spectre suffisant pour couvrir les bacteacuteries reacutesistantes dont le patient pourrait ecirctre porteur suite agrave un seacutejour reacutecent dans un hocircpital ou un autre centre de soins