Perioperative Antibiotic Prophylaxis in Total Joint Arthroplasty: A Single Dose Is as Effective as Multiple Doses

J Bone Joint Surg Am. 2019 Mar 6;101(5):429-437. doi: 10.2106/JBJS.18.00336.


Background: Recent surgical site infection prevention guidelines recommend that no additional prophylactic antibiotics be administered after the surgical incision is closed in clean-contaminated procedures. Although there is ample evidence to support this recommendation in non-arthroplasty surgery, there is concern about extending these guidelines to surgical procedures with an implant such as total joint arthroplasty (TJA). The aim of this study was to compare the efficacy of a single dose of prophylactic antibiotics with that of multiple doses of antibiotics for prevention of periprosthetic joint infection (PJI) in patients undergoing TJA.

Methods: A retrospective study of 20,682 primary TJAs carried out from 2006 to 2017 was performed. Patients who received a single dose of prophylactic antibiotics (n = 4,523) were compared with patients who received multiple doses of antibiotics (n = 16,159). A previously validated PJI risk score was assigned to each patient. Patients who developed PJI within 1 year were identified, and a multivariate logistic regression analysis was performed to control for potential confounders. Analyses using propensity score matching and regression adjustment were also performed.

Results: The overall PJI rate was 0.60% (27 of 4,523) for patients who received a single dose of antibiotics compared with 0.88% (142 of 16,159) for those who received multiple doses. There was no difference in the PJI rate between patients who received a single dose of antibiotics and those who received multiple doses in the univariate (adjusted odds ratio [OR] = 0.674, p = 0.064), multivariate (OR = 0.755, p = 0.205), or propensity score matched analysis (OR = 0.746, p = 0.277). Furthermore, multiple doses did not demonstrate any additional benefit for patients with a high preoperative risk of PJI (p = 0.136).

Conclusions: This study supports the notion that the administration of additional antibiotics following skin closure may not be required for primary TJA, regardless of the patient's preoperative risk of PJI. The findings of this large retrospective study highlight the need for a randomized, prospective study on which to base guidelines.

Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

MeSH terms

  • Anti-Bacterial Agents / administration & dosage*
  • Antibiotic Prophylaxis / methods*
  • Arthroplasty, Replacement, Hip / adverse effects*
  • Arthroplasty, Replacement, Knee / adverse effects*
  • Cefazolin / administration & dosage
  • Drug Administration Schedule
  • Female
  • Humans
  • Infusions, Intravenous
  • Intraoperative Care / methods
  • Male
  • Middle Aged
  • Prosthesis-Related Infections / prevention & control*
  • Retrospective Studies
  • Treatment Outcome
  • Vancomycin / administration & dosage


  • Anti-Bacterial Agents
  • Vancomycin
  • Cefazolin