How Many Prophylactic Antibiotic Doses Do Joint Replacement Patients Need?

    The Centers for Disease Control and Prevention’s (CDC) latest guideline on prevention of surgical site infections say that, “In clean and clean-contaminated procedures, do not administer additional prophylactic antimicrobial agent doses after the surgical incision is closed in the operating room, even in the presence of a drain.” [1] This is considered to be a strong recommendation backed by high-quality evidence.

    The problem is, the evidence used to develop the CDC guideline comes from the non-arthroplasty literature. Given that, is this recommendation appropriate for joint replacement patients, who often receive prophylactic antibiotics before and after the procedure?

    In a study recently presented at the 2018 Annual Meeting of the American Association of Hip and Knee Surgeons, researchers sought to answer this question by reviewing the literature on antibiotic use in total joint arthroplasty and retrospectively analyzing data on 20,682 primary total joint arthroplasties performed between 2006 and 2014. Patients received either a single dose (n=4523) or multiple doses of prophylactic antibiotics (n=16,159). The researchers compared rates of periprosthetic joint infection (PJI) between groups at 1 year after surgery.

    Overall, the rate of PJI was 0.60% (27/4523) in the single-dose group and 0.87% (142/16159) in multiple-dose group, which was not significantly different on univariate (odds ratio [OR] 0.708; P=0.107) or multivariate analysis (OR 0.674; P=0.064). The researchers did not see any added benefit of multiple antibiotic doses in patients who were at high preoperative risk of PJI according to a previously validated PJI risk score (adjusted OR 0.981; P=0.943).

    The researchers concluded that additional doses of antibiotics administered after skin closure in total joint arthroplasty may not be required, even in patients at higher risk of PJI. They noted, however, that their findings, combined with the literature, “highlight the need for a randomized, prospective study [on which] to base current guidelines.”


    Tan TL, Shohat N, Rondon AJ, Goswami K, Ryan SP, Seyler TM, Javad Parvizi J. Perioperative Antibiotic Prophylaxis in Total Joint Arthroplasty: A Single Dose Is as Effective as Multiple Doses (Paper #27). Presented at the 2018 Annual Meeting of the American Association of Hip & Knee Surgeons, November 1-4, 2018, Dallas, Texas.


    1. Berrios-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017 Aug 1;152(8):784-791. doi: 10.1001/jamasurg.2017.0904.