Boyd W. Haynes III, MD
There are hundreds of thousands of orthopaedic surgeries and millions of surgeries performed annually in the United States. Most of them result in full recovery with minimal complications. While there are many factors that play a role in a successful surgery and recovery, an important consideration is preventing infection at the surgical site. Post-surgical infections are bad news and they can dramatically worsen the outcome of any surgery, but especially orthopaedic surgery. In worst case scenarios, infections can cause the need for additional surgery(s), loss of limbs, lifelong disability or even death.
Due to strictly enforced sterile operating procedures and the use of prophylactic antibiotics in American hospitals, the infection rate for surgeries is quite low – around 2% nationally. Even though that number is low, every surgeon is worried about the risks of a potential infection. That is why antibiotic prophylaxis is the standard of care for many orthopaedic surgeries, certainly those surgeries which involve the spine, joint replacements, fracture fixation or those that involve the introduction of any type of implant or permanent implantation of instrumentation.
The overuse of antibiotics is one of the most hotly debated issues in medicine today. Not only are antibiotics over prescribed to humans, the animals raised for our consumption are given antibiotics to help them stay healthy while they are being milked or before slaughter. Overprescribing has led to the antibiotic resistance of many strains of bacteria. Super-bugs, such as MRSA or C-Diff, are and should be cause for great concern, especially for hospitalized or surgical patients.
I think everyone can agree that antibiotics should be used only when absolutely necessary (not for the common cold or any little sniffle) and for a limited time. However, when a patient is scheduled for a major orthopaedic surgery, it is not the time to debate the merits of preventative antibiotic use. Almost all experts agree…these patients definitely should receive antibiotics. The benefits far exceed any concerns about overuse and no one wants a post-surgical infection to deal with after a big procedure like joint replacement.
There are areas of disagreement when it comes to the timing of the administration of IV antibiotics before surgery. Some researchers feel that 30 minutes before incision is best, others believe an hour before is optimal. There is also disagreement on whether antibiotics should continue after anesthesia or be discontinued before the patient wakes up. Each surgeon will decide what is appropriate for their patients according to their general condition and the surgery to be performed.
In the past, antibiotic prophylaxis before dental visits was the standard of care for patients with a history of joint replacement or spinal fusion. The reasoning for this is that the mouth is host to a variety of bacteria which can easily be introduced into the bloodstream by the sharp instruments used during a dental cleaning. Prevailing wisdom has always posited that these bacteria could travel through the bloodstream and cling to an implant or fusion instrumentation, causing an infection.
Recently, a difference of opinion has emerged based on studies which seem to contradict the use of antibiotics for those patients, finding them unnecessary. In cases where there is no clear agreement, many orthopaedists take the view of “better safe than sorry” and go ahead and prescribe antibiotics for patients to take before dental cleanings or work. This is the view of the physicians here at OSC. We feel that the risk of a post-surgical infection in a previous surgical site caused by dental work far outweighs concerns about the possibility of antibiotic overprescribing.
Of course, I take patient concerns about antibiotic overuse seriously and I want you to tell me if you have issues with their use during surgery or afterwards. When we work together, you have the best chance for a surgical recovery and outcome with which you will be delighted.