The Economics of Antibiotic Cement in Total Knee Arthroplasty: Added Cost with No Reduction in Infection Rates.

BACKGROUND: To reduce the substantial clinical and financial burden of periprosthetic joint infection (PJI), some surgeons advocate for the use of antibiotic-loaded bone cement (ALBC) in primary total knee arthroplasty (TKA), although its effectiveness continues to be debated in the literature. The purpose of this study was to determine whether the routine use of ALBC is cost-effective in reducing PJI after primary TKA. METHODS: We retrospectively reviewed a consecutive series of patients undergoing cemented primary TKA at two hospitals within our institution from 2015 to 2017. We compared demographics, comorbidities, costs, and PJI rates between patients receiving ALBC and plain cement. We performed a multivariate regression analysis to determine the independent effect of ALBC on PJI rate. We calculated readmission costs for PJI and reduction in PJI needed to justify the added cost of ALBC. RESULTS: Of 2511 patients, 1077 underwent TKA with ALBC (43%), with no difference in PJI rates (0.56% vs 0.14%, P = .0662) or complications (1.2% vs 1.6%, P = .3968) but higher cement costs ($416 vs $117, P < .0001) and overall procedure costs ($6445 vs $5.968, P < .0001). ALBC had no effect on infection rate (P = .0894). Patients readmitted with PJI had higher overall 90-day episode-of-care claims costs ($49,341 vs $19,032, P < .001). To justify additional costs, ALBC would need to prevent infection in one of every 101 patients. CONCLUSION: Routine use of ALBC in primary TKA is not cost-effective, adding $299 to the cost of episode of care without a reduction in PJI rate. Further study is needed to determine whether select use of ALBC would be justified in high-risk patients.

The Hidden Cost of Commercial Antibiotic-Loaded Bone Cement: A Systematic Review of Clinical Results and Cost Implications Following Total Knee Arthroplasty.

BACKGROUND: The purpose of this systematic review is to compare deep prosthetic joint infections (PJIs) between total knee arthroplasty (TKA) patients treated with either antibiotic-loaded bone cement (ALBC) or plain bone cement, and to explore the potential cost implications of commonly used bone cement regimens. We hypothesized that ALBC would not substantially reduce PJIs and would thereby present an unnecessary cost to the healthcare system. METHODS: Using the PRISMA guidelines, we reviewed articles through May 2017 involving primary TKA patients with both ALBC cohort and plain bone cement cohort. A meta-analysis was performed comparing the prevalence of deep infections between cohorts. A cost comparison for a hypothetical setting with an annual volume of 1000 TKAs was performed to compare 3 commonly used cement regimens: 2 bags of ALBC used during each case, 1 bag of ALBC with 1 bag of plain cement, and 2 bags of plain cement. Pricing at our institution is $215/bag for commercial ALBC and $60/bag for plain cement. RESULTS: Eight articles were included with a total of 34,664 patients. ALBC did not reduce the PJI (ALBC = 93/8189, 1.1% vs plain = 251/26,475, 0.9%; P = .09). The estimated costs for the 3 bone cement regimens per 1000 primary TKAs were as follows: 2 bags of ALBC = $430,000/y, 1 bag of ALBC +1 bag of plain cement = $275,000/y, and 2 bags of plain cement = $120,000/y. CONCLUSION: ALBC did not reduce the prevalence of PJI suggesting that ALBC may be an unnecessary cost to the healthcare system. Hospital systems that perform 1000 TKAs/y could save between $155,000 and $310,000/y by switching to plain cement.

Key features of bone and joint infections following the implementation of reference centers in France.

OBJECTIVES: French reference centers for bone and joint infections (BJI) were implemented from 2009 onwards to improve the management of complex BJIs. This study compared BJI burden before and after the implementation of these reference centers. PATIENTS AND METHODS: BJI hospital stays were selected from the 2008 and 2013 national hospital discharge database using a validated algorithm, adding the new complex BJI code created in 2011. Epidemiology and economic burden were assessed. RESULTS: BJI prevalence increased in 2013 (70 vs. 54/100,000 in 2008). Characteristics of BJI remained similar between 2008 and 2013: septic arthritis (50%), increasing prevalence with age and sex, case fatality 5%, mean length of stay 17.5 days, rehospitalization 20%. However, device-associated BJIs increased (34 vs. 26%) as well as costs (€421 million vs. €259 in 2008). Similar device-associated BJI characteristics between 2008 and 2013 were: septic arthritis (70%), case fatality (3%), but with more hospitalizations in reference centers (34 vs. 30%) and a higher cost per stay. Among the 7% of coded complex BJIs, the mean length of stay was 22.2 days and mean cost was €11,960. CONCLUSIONS: BJI prevalence highly increased in France. Complex BJI prevalence assessment is complicated by the absence of clinical consensus and probable undercoding. A validation of clinical case definition of complex BJI is required.

Cost-effectiveness of antibiotic prophylaxis for bacterial arthritis.

The outcome of bacterial arthritis is generally poor: the mortality is 10 - 15% and there is loss of joint function in 25 - 50% of the survivors. The incidence of bacterial arthritis is low: 2 - 6 cases per 100,000 people per year. Risk factors are age, joint disease (especially rheumatoid arthritis [RA]), diabetes mellitus and the presence of a prosthetic joint. The predominant situations that can lead to bacterial arthritis are skin infections of the feet and rarely invasive medical or dental procedures. Due to the severity of the disease, antibiotic prophylaxis of haematogenous bacterial arthritis in patients with prosthetic joints is advocated. However, due to the rarity of the disease it is unclear whether the advantages of prophylaxis outweigh the disadvantages of the large-scale use of antibiotics, such as side effects, costs and bacterial resistance. In a decision-analysis of a large group of patients with joint diseases, antibiotic treatment of skin infections appeared to be cost-effective in the prevention of haematogenous bacterial arthritis, mainly in high-risk patients. On the other hand, prophylaxis around medical or dental procedures was not cost-effective, except possibly in a small group of patients with increased risk.

[Antibiotic prophylaxis of hematogenous bacterial arthritis]. / Antibiotische preventie van hematogene bacteriële artritis.

The outcome of bacterial arthritis is generally poor: the mortality is 10-15% and there is loss of joint function in 25-50% of the survivors. Adverse prognostic factors are advanced age, a pre-existent joint disease and an infection of a prosthetic joint. The incidence of bacterial arthritis is low: 2-6 per 100,000 persons per year. Risk factors are advanced age, a joint disease--especially rheumatoid arthritis--diabetes mellitus and presence of a prosthetic joint. Situations that can lead to bacterial arthritis are mainly skin infections of the feet and only rarely invasive medical or dental procedures. Because of the severity of the disease, antibiotic prophylaxis of haematogenous bacterial arthritis in patients with prosthetic joints is advocated in guidelines. However, because of the rarity of the disease it is unclear whether the advantages of prophylaxis outweigh the disadvantages of the large-scale use of antibiotics, such as side effects, costs and increased resistance of bacteria. In a decision analysis of a large group of patients with joint diseases, antibiotic treatment of skin infections appeared to be (cost-)effective in the prevention of haematogenous bacterial arthritis, mainly in high-risk patients. On the other hand, prophylaxis around medical or dental procedures was not (cost-)effective, except possibly in a small group of patients with increased risk.

Reduced incidence of septic arthritis in children by Haemophilus influenzae type-b vaccination. Implications for treatment.

In many countries Haemophilus influenzae type b (Hib) is the second most common cause of septic arthritis in children. In Finland large-scale immunisation against Hib using conjugate vaccines began in 1986, four years after a multicentre prospective study of orthopaedic infections in children had started. Since 1982, including six years before and ten after starting routine Hib vaccination, there has been a major change in the pattern of septic arthritis. From 1982 to 1988, 32 of 61 cases (53%) were caused by staphylococci, 22 (36%) by Hib and 7 (11%) by other bacteria. Since 1988, Hib infection has disappeared, and one-third of cases of childhood septic arthritis has been eliminated. This change has allowed us to reduce initial antimicrobial therapy for such children to cover only Gram-positive cocci. The more limited treatment is safer, reduces cost, and simplifies treatment.

Cost-effectiveness of antibiotic prophylaxis for dental procedures in patients with artificial joints.

We performed a cost-effectiveness analysis to evaluate whether patients with artificial joints should take penicillin, erythromycin, or no antibiotics before dental procedures. We modeled the risk of anaphylaxis from penicillin, the risks and consequences of an artificial joint infection, and the actual variable costs of hospitalization and antibiotics. Penicillin prophylaxis is slightly less expensive than erythromycin prophylaxis but is both more expensive and less effective than no prophylaxis. Erythromycin prophylaxis, the most effective, is the most expensive strategy. The marginal cost effectiveness of erythromycin prophylaxis compared to no prophylaxis is $12,900 per quality-adjusted year of life saved. Sensitivity analysis demonstrates that the risk of developing a joint infection is the key parameter in the analysis. Based on our estimated risk of developing a joint infection, the cost-effectiveness of antibiotic prophylaxis with erythromycin compares favorably with other medical interventions. Thus, until a definitive study to quantify the risk is conducted, patients with artificial joints should take prophylactic erythromycin when they undergo dental procedures.

Septic arthritis following arthroscopy, with cost/benefit analysis of antibiotic prophylaxis.

Nine cases of septic arthritis following arthroscopy are reviewed retrospectively. All cases of septic arthritis followed arthroscopic surgery. The average age of the patients was 49 years. The diagnosis was confirmed by bacterial cultures of the joint aspirates. All cases were treated by appropriate antibiotics supplemented by repeat arthroscopy and placement of a suction irrigation system. The average stay in hospital was 21 days. The authors suggest that it is not possible to predict such a major complication based on risk factors and therefore present a cost/benefit analysis of antibiotic prophylaxis using first-generation cephalosporins as a possible means of reducing hospital costs and patient morbidity.