Revision Shoulder Arthroplasty: IV or Oral Antibiotics?

Surgeons performing revision shoulder arthroplasty typically order postoperative antibiotics to be administered while they wait for results from intraoperative cultures. Based on their index of suspicion from preoperative exams and intraoperative observations, they order either intravenous (high suspicion of infection) or oral (low suspicion) antibiotics during the waiting period. In the June 3, 2020 issue of JBJS, Yao et al. report on a retrospective review of 175 patients who underwent revision shoulder arthroplasty, finding that surgeons’ presumptive choice of antibiotic type matched the culture results in 75% of the cases.

Among the 175 patients in the study, IV antibiotics were initiated in 62, while 113 patients received oral antibiotics. Cultures from 49 of the 62 patients started on IV antibiotics came back positive, and cultures from 83 of the 113 patients started on oral antibiotics came back negative. Treatment of patients whose initial antibiotic regimen did not match culture results was modified accordingly.

After multivariate analysis Yao et al. found that male sex, prior ipsilateral infection, and intraoperative presence of a humeral membrane were 3 independent predictors of surgeons initiating IV antibiotics. Antibiotic-related adverse events (including GI, dermatologic, and allergic reactions) occurred in 19% of the patients. Not surprisingly, the rate of these complications was highest among those receiving IV antibiotics.

Although the surgeons’ empirical initiation of antibiotic administration route was “correct” 75% of the time, that still left 25% of the patients needing modification of therapy based on culture results. While the authors observe that their study was  not designed “to report the relative effectiveness of the 2 antibiotic protocols in minimizing the risk of recurrent infection,” their findings confirm that preoperative and intraoperative observations can help surgeons select the “right” type of antibiotic without culture results—and that is heartening.

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