INTRODUCTION — Effective management of prosthetic joint infection and other types of orthopedic hardware infection requires surgery and prolonged antimicrobial therapy; treatment failure is common. Given the challenges associated with treating these infections, prevention of infection is clearly desirable.

Most literature pertaining to the prevention of orthopedic hardware infection is derived from studies on patients with joint arthroplasties. Data regarding other types of orthopedic hardware are limited; however, in general, similar principles of prevention may apply.

Guidelines addressing prevention strategies include the United States Centers for Disease Control and Prevention guideline for prevention of surgical site infection [1], the National Surgical Infection Prevention Project [2,3], guidelines from the Medical Letter (table 1) [4], guidelines from the American Society of Health-System Pharmacists [5], and an Advisory Statement from the American Academy of Orthopaedic Surgeons [6].

Issues related to the prevention of orthopedic hardware infection will be reviewed here. General principles for prevention of surgical site infection are discussed separately. (See "Overview of control measures for prevention of surgical site infection in adults".)

The epidemiology, clinical manifestations, diagnosis, and treatment of orthopedic hardware infections are discussed separately. (See "Prosthetic joint infection: Epidemiology, microbiology, clinical manifestations, and diagnosis" and "Prosthetic joint infection: Treatment".)

PRIOR TO HARDWARE PLACEMENT

Staphylococcus aureus decolonization — Issues related to Staphylococcus aureus decolonization prior to orthopedic surgery are discussed further separately. (See "Overview of control measures for prevention of surgical site infection in adults", section on 'S. aureus decolonization'.)

Other preventive measures — Other preventive measures prior to hardware placement include:

●There is no role for routine diagnosis or treatment of asymptomatic bacteriuria among patients undergoing joint arthroplasty or other orthopedic hardware placement [7-10]. This issue is discussed further separately. (See "Asymptomatic bacteriuria in adults", section on 'Joint arthroplasty'.)

●A dental evaluation should be undertaken to assess and manage for the presence of gingivitis, occult dental abscess, or decay.

●Patients should be instructed not to shave their lower limbs prior to knee or hip replacement. If needed, hair removal may be performed with clippers immediately prior to surgery [11]. (See "Overview of control measures for prevention of surgical site infection in adults", section on 'Hair removal'.)

●When feasible, certain immunosuppressive therapy should be tapered to the lowest dose possible or discontinued. Tumor necrosis factor-alpha blockers should be discontinued as early as possible prior to hardware placement if feasible [12]. In the absence of relevant comorbid conditions and/or risk factors associated with infection, continuing low doses of methotrexate or steroids may be acceptable during the perioperative period in patients with rheumatoid arthritis [12].

Other issues related to prevention of surgical infection are discussed separately. (See "Overview of control measures for prevention of surgical site infection in adults".)

DURING HARDWARE PLACEMENT

Surgical approach — Surgical issues related to hip and knee arthroplasty are discussed separately. (See "Total hip arthroplasty" and "Total knee arthroplasty".)

Antimicrobial prophylaxis — Orthopedic hardware infections are commonly due to S. aureus or coagulase-negative staphylococci. Surgical antimicrobial prophylaxis with cefazolin is warranted for patients undergoing joint replacement or placement of other orthopedic hardware (ie, plates and screws); acceptable alternatives to cefazolin (particularly for patients with a history of type I penicillin or other beta-lactam allergy) include vancomycin or clindamycin (table 1) [5,13].

It is advisable to refer patients with history of beta-lactam allergy for allergy evaluation prior to orthopedic surgery, given data suggesting alternative antibiotics are inferior to cefazolin for prevention of hardware infection [14-16]; in such cases many patients are skin-test negative and tolerate beta-lactam administration. (See "An approach to the patient with drug allergy".)

Most studies that have evaluated intravenous antimicrobial prophylaxis in orthopedic hardware placement have been conducted in patients undergoing total hip or knee arthroplasty [3,4,6,13,17-19]. There is a lack of efficacy data involving elbow, shoulder, and ankle arthroplasty; however, the same principles of antimicrobial prophylaxis may be applied [5].

In general, the entire dose of antibiotic should be infused prior to tourniquet inflation. Administering part of the dose just prior to tourniquet release may be acceptable in some circumstances [20], particularly for patients undergoing replacement arthroplasty for management of preexisting infection of the prosthesis [21].

Antibiotic prophylaxis should not be delayed in patients undergoing revision arthroplasty for suspected or confirmed prosthetic joint infection in an effort to optimize culture sensitivity [22].

For clean and clean-contaminated procedures, readministration of antimicrobial prophylaxis in the operating room following closure of the surgical incision is not warranted, even in the presence of a drain [1,3,5,23-25].

General principles related to antimicrobial prophylaxis for prevention of surgical site infection are discussed further separately. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)

Local antibiotic delivery — Forms of local antibiotic delivery include antimicrobial-laden fixation cement and antimicrobial-laden sponges.

The use of low-dose antimicrobial-laden fixation cement for prevention of infection in primary cemented hip and knee arthroplasty (in conjunction with intravenous antimicrobial prophylaxis) is common practice [26-29]. The optimal use of this strategy and the potential for the development of resistance has not been fully assessed [30-33]; it may be appropriate in selected patients at increased risk for infection [34,35]. Issues related to use of antibiotic-laden cement for treatment of prosthetic joint infection are discussed separately. (See "Prosthetic joint infection: Treatment", section on 'Resection arthroplasty with reimplantation'.)

The use of gentamicin-containing collagen sponges has not been shown to reduce the incidence of surgical site infection after joint arthroplasty [36]. This issue is discussed further separately. (See "Overview of control measures for prevention of surgical site infection in adults", section on 'Topical and local antibiotic delivery'.)

FOLLOWING HARDWARE PLACEMENT — Signs or symptoms of wound infection following hardware replacement should be addressed promptly and aggressively with local wound measures and antibiotic therapy directed against the likely pathogens.

There is no evidence to suggest that patients with orthopedic hardware undergoing procedures should receive antibiotic prophylaxis in the absence of other indications, such as heart valve disease requiring endocarditis prophylaxis or a surgical procedure for which antibiotics are given to prevent a surgical site infection.

Dental procedures — Patients with orthopedic implants should maintain good dental hygiene [37], and oral infections in patients with orthopedic implants should be treated promptly. Dental procedures are not associated with an increased risk of orthopedic hardware infection, and use of routine antibiotic prophylaxis prior to dental procedures does not alter the risk of subsequent orthopedic hardware infection [38-40].

There have been fewer than 25 reported cases of late-onset prosthetic joint infection (PJI) after dental procedures, and the association between dental treatment and PJI in these cases is circumstantial. In addition, there are no experimental observations suggesting a link between bacteremia induced from a dental procedure and PJI. In a case-control study based on Medicare Current Beneficiary Survey data from 1997 to 2006, including cases with PJI and matched controls with total arthroplasty but no PJI, there was no significant association between dental procedures and PJI risk [41].

In view of these observations, the American Academy of Oral Medicine [42], the American Dental Association (ADA) in conjunction with the American Academy of Orthopedic Surgeons (AAOS) [37,43], and the British Society for Antimicrobial Chemotherapy [44] all advise against universal use of antimicrobial prophylaxis prior to dental procedures for prevention of PJI.

In 2013, the ADA and AAOS published a joint guideline on the prevention of orthopedic implant infections in patients undergoing dental procedures; it states that there is no convincing evidence to support routine use of prophylactic antibiotics in patients with prosthetic joints who undergo dental procedures [37]. Subsequently, in 2015, the ADA Council on Scientific Affairs published a clinical practice guideline to clarify the preceding ADA and AAOS joint guideline; it states that, in general, prophylactic antibiotics are not recommended prior to dental procedures for patients with prosthetic joint implants to prevent prosthetic joint infection [43].

We advise against routine use of antimicrobial therapy for patients with orthopedic hardware undergoing routine dental procedures, such as cleaning, scaling of teeth, or filling of a dental cavity. Dental infections should be treated promptly.

Urologic procedures — In general, antimicrobial prophylaxis for prevention of orthopedic hardware infection is not warranted for patients with orthopedic hardware undergoing cystoscopy [45]. Antimicrobial prophylaxis may be appropriate in selected patients, especially those with immunosuppression undergoing a procedure with increased risk of bacteremia, such as lithotripsy or surgery involving bowel segments [46].

Gastrointestinal procedures — In general, antimicrobial prophylaxis for prevention of orthopedic hardware infection is not warranted for patients with orthopedic hardware undergoing gastrointestinal endoscopies [47].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Osteomyelitis and prosthetic joint infection in adults".)

SUMMARY AND RECOMMENDATIONS

●Management of orthopedic hardware infection is associated with significant morbidity including multiple surgical interventions and prolonged antibiotic therapy. (See 'Introduction' above.)

●Surgical antimicrobial prophylaxis is warranted for patients undergoing orthopedic hardware placement; regimens are summarized in the table (table 1). (See 'Antimicrobial prophylaxis' above.)

●We recommend that antibiotic prophylaxis NOT be administered prior to dental procedures for immunocompetent patients with history of orthopedic hardware implantation (Grade 1B). (See 'Dental procedures' above.)

●In general, antimicrobial prophylaxis for prevention of orthopedic infection is not warranted for patients with prosthetic joints undergoing urologic or gastrointestinal procedures. (See 'Following hardware placement' above.)