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Antibiotic-Containing Bone Cement for Primary Total Hip: DISCUSSION

surgical prophylaxis

Eleven (79%) of the 14 orthopedic surgeons who performed the majority of arthroplasties in the Calgary Health Region during the study period used ABC for at least one patient in the cohort studied, a rate consider­ably higher than that reported by Heck and others in 1995 for a sample from the United States. In that survey of 1015 orthopedists, 56% of respondents stated that they used ABC in their work, but only 11% and 13%, respectively, always used ABC for primary hip and knee arthroplasty; conversely, 69% reported never using ABC for primary arthroplasty. The sample for that study was much larger than that of the study presented here, but it was also limited by the fact that only 14% of the physicians surveyed identified themselves as having an adult reconstructive practice, whereas 49% characterized themselves as general orthopedists. In a major teaching centre such as the Calgary Health Region, each orthopedic surgeon declares a primary subspecialty. In the current study, this simplistically allowed for a focused analysis of the practice of the surgeons who performed most of the hip and knee arthroplasties. Unfortunately, no other similar North American data could be found for comparison.

In contrast, the prophylactic use of ABC for primary arthroplasty is widespread in the European Union, where commercial products have been available for some time. For example, in Norway, the prophylactic use of ABC has doubled in the past 10 years and now occurs in more than 90% of primary arthroplasty cases. Although data on use of ABCs is lacking for North America, the results of this audit show that such products are being used prophylactically and relatively commonly for joint reconstruction in the Calgary Health Region. It was beyond the scope of this audit to determine whether the use of ABC by surgeons in the Calgary Health Region has been influenced by European data published in orthopedic journals (and disseminated through conferences), by the marketing strategies of medical device manufacturers (e.g., complimentary samples), by peer behaviour (at the current hospital site or health region relative to a previous workplace), by health-system influences at the hospital site and at a private facility where some of the surgeons also work (e.g., through products stocked or not stocked on shelves in the operating area, wait times), or by the known or perceived infection rate and a desire to reduce it (taking into account the design and age of the operating room theatre, postoperative care, and other factors). viagra 10 mg

The European literature may be influencing the use of ABC in current practice. In a cohort study based on data from the Norwegian arthroplasty register for 1987 and 2001, Engesaeter and others found that for primary total hip arthroplasty performed for osteoarthritis, prophylactic antibiotics administered both systemically and in bone cement reduced the risk of revision due to infection and also reduced the risk of aseptic loosening. In that study, patients who received systemic prophy­ laxis alone had a risk of revision due to infection 1.8 times higher than the risk for patients who received ABC as well as systemic agents (95% confidence interval 1.1-3.0; p = 0.01). Although the time frame extended back to 1987, the study specified only certain types of prostheses and ABCs, and the product that consisted of gentamicin 0.5 g per 40 g of Palacos cement was the type of ABC most commonly used. This large-scale observational study, along with earlier studies of hip arthroplasty from Sweden and Germany, provides important evidence and may be guiding clinical practice in the Calgary Health Region. There are insufficient studies of ABC prophylaxis for primary arthoplasty of the knee, despite the fact that the rate of surgical site infections is higher for this procedure than for hip arthroplasty.

The study reported here represents the first audit of the use of ABCs in a Canadian health region, providing insight on the use of this form of primary prophylaxis. There are barriers to evaluating the use of ABC. For example, very few hospital regions in Canada have pharmacists with advanced knowledge of surgical services who would be positioned to evaluate the use of ABC. Of note, it is the department of Distribution Services (rather than the pharmacy) that is responsible for the inventory of this drug product for use in the operating theatres in the Calgary Health Region, which makes utilization studies more difficult. In fact, ABCs may have eluded review for the region’s formulary, given that the cost of these products puts them outside the scrutiny of the pharmacy’s budgetary review processes.
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Category: Drug

Tags: antibiotic-containing bone cement, surgical pro­phylaxis

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