The incidence of
infection in clean surgery (i.e. surgery with no major contamination of the operative site) should be less than 2%, although the incidence of postoperative
infections can be higher in patients with various risk factors (namely insertion of
foreign bodies, a compromised immune status or prolonged duration of surgery). Although
antibiotic prophylaxis has been shown to reduce the incidence of postoperative
infections in clean surgery, there is still no consensus regarding its use in this area. However, for clean
surgical procedures that involve implantation of foreign material, grafts or prosthetic devices, prophylaxis is well accepted and justifiable, since this practice is indicated when the benefits exceed the expected risks. Staphylococcus aureus and
coagulase-negative staphylococci are responsible for 70 to 90% of
wound infections in this type of surgery. First and
second generation cephalosporins are considered the drugs of choice for surgical prophylaxis.
Cefazolin and other
cephalosporins have good tissue penetration but poor coverage against methicillin-resistant staphylococci. The frequency with which methicillin-resistant staphylococci have been recovered in
nosocomial infections has increased steadily during recent years. This provides a rationale for the use of alternative
antibiotics, such as the
glycopeptides (
vancomycin and
teicoplanin), for prophylaxis in clean surgery in hospitals where the prevalence of methicillin-resistant staphylococci is high. The effectiveness and tolerability of
teicoplanin as prophylaxis for orthopaedic surgery involving
joint replacement were analysed in 4 randomised controlled trials. Two compared
teicoplanin with
cefamandole, while the others compared
teicoplanin with either
cefuroxime or
cefazolin. The overall early
wound infection rates (within 3 months) in these studies were 1.1% for
teicoplanin and 1.7% for the comparator
cephalosporin. The overall late
infection rate was 0.2% for both treatment groups. Adverse events were attributed to the
drug in 1% of patients in both treatment groups. Therefore, on the basis of these trials, single dose
teicoplanin is as efficacious and as well tolerated as multiple dose
cephalosporin regimens for prophylaxis in prosthetic joint surgery.