Prophylactic Antibiotic Does Not Reduce SSI Risk After Orthopedic Implant Removal

Syringe and medicine
Syringe and medicine
Although removal of orthopedic implants is considered to be associated with low risk of infection, higher rates of surgical site infection following these procedures have been reported.

According to research published in JAMA, a single prophylactic dose of antibiotic prior to surgical removal of lower leg orthopedic implants did not reduce the risk of surgical site infections (SSIs).

Removal of orthopedic implants is routine surgery, and SSI following the procedure is expected to occur in only 2% to 3% of patients. However, rates as high as 12.2% have been reported for procedures involving the removal of implants below the knee. In response, practitioners advocate for a preoperative single dose of antibiotic. 

The effectiveness of a single intravenous prophylactic dose of cefazolin 1000 mg was therefore evaluated in a multicenter, double-blind, randomized trial ( Identifier: NCT02225821). 

Patients, with a mean age of 44 years, of whom 57% were women, were given either the 1000-mg dose of cefazolin presurgery (n=228) or 0.9% saline (n=242).

The primary outcome of SSI within 30 days occurred in 14% of all patients. In the cefazolin group 13.2% developed an SSI compared with 14.9% in the saline group (absolute risk difference, -1.7 [95% CI: -8.0 to 4.6; P = .60]).

The researchers noted that antibiotic susceptibility may be reduced by a thousand-fold when a biofilm is present, particularly with incomplete removal of implants. A patient’s weight of <60 kg was also noted as a potential factor in outcome but could not be properly addressed in this study. There was some partial evidence that treatment prevented deep SSI.

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Accompanying their conclusion that a single prophylactic antibiotic dose does not reduce SSI risk, the investigators cautioned that “awareness that removal of orthopedic implants is not a straightforward procedure is needed” due to high rates of SSI.


Backes M, Dingemans SA, Dijkgraaf MGW, et al; for the WIFI Collaboration Group. Effect of antibiotic prophylaxis on surgical site infections following removal of orthopedic implants used for treatment of foot, ankle, and lower leg fractures: a randomized clinical trial.  JAMA. 2017;318(24):2438-2445.