Antibiotic Stewardship for Total Joint Arthroplasty in 2020

Thomas G. Myers, MD, MPT; Jason S. Lipof, MD; Antonia F. Chen, MD, MBA; Benjamin F. Ricciardi, MD


J Am Acad Orthop Surg. 2020;28(18):e793-e802. 

In This Article

Abstract and Introduction


Projections indicate an increase in primary and revision total joint arthroplasties (TJAs). Periprosthetic joint infections (PJIs) are one of the most common and devastating causes of failure after TJA. Perioperative administration of systemic and/or local antibiotics is used for both prophylaxis and treatment of PJI. Antibiotic stewardship is a term that has been met with clinical acceptance and success in other specialties of medicine. Identifying antibiotic best practice use in the fight against PJI is limited by studies that are extremely heterogeneous in their design. Variations in studies include antibiotic selection and duration, surgical débridement steps, type of antibiotic delivery (intra-articular, local, intravenous, and prolonged oral), mix of primary and revision surgery cohorts, both hip and knee cohorts, infecting organisms, and definitions of treatment success/failure. This review highlights the current challenges of antibiotic stewardship in TJA.


Periprosthetic joint infections (PJIs) are one of the most common causes for failure after primary and revision total joint arthroplasties (TJAs).[1,2] Studies have demonstrated that 5-year mortality rates after PJI are worse than two of the top five most common cancers and have a threefold increased mortality when compared with aseptic revision.[3,4] The reported successful eradication rates of PJI in the past decade range from 66% to 95% after two-stage exchange arthroplasty, depending on how success is defined.[5]

Antibiotic administration is a standard practice for both prophylaxis against and treatment of PJI after TJA. However, the Centers for Disease Control (CDC) reports that a large percentage of all antibiotics prescribed in acute care hospitals is estimated to be unnecessary or inappropriate.[6] This can lead to an increase in antibiotic resistant organisms and expose patients to side effects without providing clinical benefit. Antibiotic stewardship programs were designed to improve the appropriate use of antibiotics by optimizing antibiotic selection, dose, and duration while minimizing potential adverse events and antibiotic resistance.[7] Despite improvements in the standardization of infection treatment and prophylaxis at the hospital level, some measures implemented through antibiotic stewardship programs may conflict with more recent evidence focused on TJA. A proper perspective of antibiotic stewardship in TJA requires an understanding of the unique issues surrounding PJI.[8] Thus, the purpose of this review is to review the most up-to-date literature regarding perioperative antibiotic prophylaxis, local antibiotic delivery, two-stage exchange arthroplasty, and antibiotic use associated with débridement, irrigation, and implant retention (DAIR).