Abstract
Introduction
Prosthetic joint infection (PJI) risk continues to receive much attention given its associated morbidity and costs to patients and healthcare systems. It has been hypothesized that invasive colonoscopies may increase the risk of PJI. However, the decision to administer antibiotic prophylaxis lacks clinical guidance. In this study we aimed to compare PJI rates in patients undergoing colonoscopies with and without antibiotic prophylaxis against a control group, analyzing PJI occurrences at 90 days, 6 months, 9 months, and 1-year post-procedure and (2) assess the impact of antibiotic prophylaxis on PJI rates to inform clinical guidelines.
Methods
We queried a national, all-payer database to identify all primary total knee arthroplasty procedures without prior history of PJI between January 2010 and October 2020 (n = 1.9 million). All patients who had a diagnosis of PJI within one year of index procedure were excluded. There were three cohorts identified: colonoscopy with biopsy without antibiotic prophylaxis; colonoscopy with biopsy with antibiotic prophylaxis; and a control of no prior colonoscopy. Both colonoscopy cohorts were slightly younger and had higher comorbidities than the controls. The PJI diagnoses were identified at four separate time intervals within one-year after colonoscopy: 90-days; 6-months; 9-months; and 1-year. Chi-square analyses with odds ratios (ORs) and 95% confidence intervals were conducted for PJI rates between groups at all time-points.
Results
Among all cohorts, no significant differences in PJI rates were found at 90-days (P = 0.459), 6-months (P = 0.608), 9-months (P = 0.598), and 1-year (P = 0.330). Similarly, direct comparison of both colonoscopy groups, with and without antibiotic prophylaxis, demonstrated no PJI rate differences at 90-day (P = 0.540), 6-months (P = 0.812), 9-months (P = 0.958), and 1-year (P = 0.207). Ranges of ORs between the colonoscopy cohorts were 1.07–1.43.
Conclusion
Invasive colonoscopy does not increase the risk of PJI in patients who have pre-existing knee implants. Furthermore, antibiotic prophylaxis may not be warranted in patients undergoing colonoscopy who have a planned biopsy.
Keywords: Prosthetic joint infection, Total knee arthroplasty, Colonoscopy, Biopsy, Antibiotic prophylaxis
1. Introduction
Total knee arthroplasties (TKA) are generally successful operations; however, complications can be devastating. The most common indication for revision TKA is prosthetic joint infections (PJI).1 While PJI does account for 40% of all revision TKA procedures, the rate of TKA PJI remains relatively low occurring in under 2% of cases within 2-year follow-ups.2,3 Despite such a low rate of PJI following primary TKA, implications of such a diagnosis can be severe including much increased morbidity, mortality, re-operation, and strain on the healthcare systems.4 Given the potential implications of causing a PJI, recommendations were devised for dental prophylaxis in hopes of mitigating potential bacterial inoculation during invasive oral and maxillofacial procedures. No consensus was reached regarding such prophylaxis prior to invasive dental procedures and recent literature calls into question its routine use.2 Sax and colleagues demonstrated no difference in PJI risk or revision rate between their antibiotic prophylaxis group and control group following dental procedures.2
Similarly, there has been much debate surrounding the use of antibiotic prophylaxis prior to colorectal procedures as these procedures are hypothesized to increase the risk of PJI due to inherent transiently-induced bacteremia.5 One can argue that routine colonoscopies, without biopsies, pose less of a risk of bacteremia. Unfortunately, it is not uncommon for screening colonoscopies to identify abnormalities requiring biopsies or polypectomies during the procedure.6 Due to this complicating factor, orthopedic surgeons likely manage all colonoscopies, both with and without biopsies, the same. Either they are of the mindset that prophylaxis should be administered, or they believe none is needed.
Recent studies have called the need for routine antibiotic prophylaxis, prior to colonoscopies, into question.7,8 The purpose of this study was to assess the incidence of PJI in patients following colonoscopy with biopsy (CB), a more invasive colorectal procedure, in hopes of guiding recommendations surrounding antibiotic prophylaxis. We hypothesized that no difference in PJI would be found within the first year in patients undergoing invasive colonoscopies who did not have antibiotic prophylaxis compared to those who received antibiotics prior to their procedures.
2. Methods
PearlDiver (Colorado Springs, Colorado), a national, all-payer database, was queried to identify all primary TKA procedures without a prior history of PJI between January 1, 2010, and October 31, 2020. A total of nearly 1.9 million patients comprising all payers (Medicare, Medicaid, government, cash) were identified using Current Procedural Codes (CPT) for right primary TKA (27,447) and left primary TKA (27,438). All patients who had a PJI diagnosis within one year of their index procedure were excluded. The remaining patients were subsequently queried to identify CPT code 45,380 indicative of a colonoscopy with a biopsy. This resulted in 3755 patients who had received antibiotic prophylaxis prior to their colonoscopy and associated biopsy.
A total of 43,755 patients were stratified into mutually exclusive cohorts of colonoscopy with biopsy (n = 20,000) and colonoscopy with biopsy and antibiotic prophylaxis (n = 3755). The study used a matched cohort of patients who did not undergo a colonoscopy (n = 20,000). Average patient age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, and medical comorbidities can be found in Table 1, which demonstrates matching of all cohort demographics and specific medical comorbidities (P < 0.001).
Table 1.
Demographics and baseline characteristics.
| No colonoscopy, n = 20,000 (%) | Colonoscopy with biopsy without antibiotics, n = 20,000 (%) | Colonoscopy with biopsy with antibiotics, n = 3755 (%) | P-value | |
|---|---|---|---|---|
| Age (SD) | 66 (8.8) | 64 (7.9) | 64 (8.3) | <0.001 |
| Sex | <0.001 | |||
| Women | 12,534 (62.67) | 12,602 (63.01) | 2585 (68.84) | |
| Men | 7466 (37.33) | 7398 (36.99) | 1170 (31.16) | |
| Alcohol Abuse | 949 (4.75) | 1160 (5.80) | 241 (6.42) | <0.001 |
| CCI > 3 | 2671 (13.36) | 4397 (21.99) | 1040 (27.70) | <0.001 |
| DM | 9222 (46.11) | 10,620 (53.10) | 2196 (58.48) | <0.001 |
| Obesity | 10,280 (51.40) | 11,989 (59.95) | 2376 (63.28) | <0.001 |
| Chronic Kidney Disease | 4071 (20.36) | 4595 (22.98) | 962 (25.62) | <0.001 |
| Rheumatoid Arthritis | 1371 (6.86) | 1653 (8.27) | 390 (10.39) | <0.001 |
| Tobacco Use | 7277 (36.39) | 8649 (43.25) | 1685 (44.87) | <0.001 |
| Screening Colonoscopy | 19 (0.10) | 155 (0.78) | 49 (1.30) | <0.001 |
| Screening Endoscopy | 22 (0.11) | 190 (0.95) | 37 (0.99) | <0.001 |
| Endoscopy with Biopsy | 91 (0.46) | 1156 (5.78) | 231 (6.15) | <0.001 |
SD: Standard deviation; DM: Diabetes mellitus; CCI: Charlson Comorbidity Index.
All patients were tracked for one year following their colonoscopies. Patient demographics as well as medical comorbidities, including obesity, chronic kidney disease (CKD), diabetes mellitus (DM), history of alcohol abuse, rheumatoid arthritis, history of tobacco use, and Charlson Comorbidity Index (CCI)9 were collected. Baseline characteristics were significantly different between groups with both colonoscopy cohorts being slightly younger and with higher CCIs than the control group (P < 0.001) (Table 1).
Patient charts were assessed for a diagnosis of PJI at 90-days, 6 months, 9 months, and 1 year after their colonoscopy. Continuous variables were compared using Student's t-tests. Categorical variables were compared using Chi-square tests in bivariate analyses. Odds ratios (ORs) were also calculated using a 95% confidence intervals (CI). All analyses were performed using R Studio (Statistics Department of the University of Auckland, Auckland, New Zealand) with significance defined as P < 0.05.
3. Results
Of the 20,000 patients who had a CB without antibiotic prophylaxis, 26 patients were diagnosed with a PJI within 90-days of their index procedure. This number increased to 46 at 6-month follow-up, 65 at 9-month follow-up, and 75 at 1-year follow-up. The antibiotic prophylaxis cohort (n = 3755) had no diagnoses of PJI at 90-days and 6-month follow-up. This increased to 20 at final follow-up. No significant difference was found between the two cohorts at all four time points (Table 2). The same held true when the CB without antibiotics and CB with antibiotic prophylaxis groups were compared to the matched control cohort (n = 20,000) (Table 3).
Table 2.
Bivariate analyses of post-operative outcomes for Total Knee Arthroplasty.
| Colonoscopy with biopsy without antibiotics, n = 20,000 (%) | Colonoscopy with biopsy with antibiotics, n = 3755 (%) | P-value | |
|---|---|---|---|
| 90-Day Complications | |||
| PJI | 26 (0.13) | a | 0.540 |
| 6-Months Complications | |||
| PJI | 46 (0.23) | a | 0.812 |
| 9-Months Complications | |||
| PJI | 65 (0.33) | 13 (0.35) | 0.958 |
| 1-Year Complications | |||
| PJI | 75 (0.38) | 20 (0.53) | 0.207 |
PJI: Prosthetic joint infection; TKA: Total knee arthroplasty.
Censored in accordance with the database confidentiality agreement.
Table 3.
Bivariate analyses of post-operative outcomes for Total Knee Arthroplasty.
| No colonoscopy, n = 20,000 (%) | Colonoscopy with biopsy without antibiotics, n = 20,000 (%) | Colonoscopy with biopsy with antibiotics, n = 3755 (%) | P-value | |
|---|---|---|---|---|
| 90-Day Complications | ||||
| PJI | 35 (0.18) | 26 (0.13) | a | 0.459 |
| 6-Months Complications | ||||
| PJI | 56 (0.28) | 46 (0.23) | a | 0.608 |
| 9-Months Complications | ||||
| PJI | 77 (0.39) | 65 (0.33) | 13 (0.35) | 0.598 |
| 1-Year Complications | ||||
| PJI | 87 (0.44) | 75 (0.38) | 20 (0.53) | 0.330 |
PJI: prosthetic joint infection; TKA: total knee arthroplasty.
Censored in accordance with the database confidentiality agreement.
There was a greater likelihood for PJI in the CB with antibiotic prophylaxis at 90-day (OR: 1.43; 95% CI, 0.62 to 3.31) and 1-year follow-up (OR: 1.42; 95% CI, 0.87 to 2.33) compared to CB without prophylaxis (Table 4). When comparing the two colonoscopy groups to the control group, who did not undergo a colonoscopy, it was determined that there is no significant increase in PJI risk at any time point other than for the antibiotic prophylaxis group at the 1-year follow-up (OR: 1.23; 95% CI 0.75 to 2.00) (Table 5).
Table 4.
Bivariate analysis of post-operative outcomes for Total Knee Arthroplasty.
| Colonoscopy with biopsy with antibiotics |
||
|---|---|---|
| OR | 95% CI | |
| 90-Day Complications | ||
| PJI | 1.43 | 0.62–3.31 |
| 6-Month Complications | ||
| PJI | 1.16 | 0.58–2.30 |
| 9-Month Complications | ||
| PJI | 1.07 | 0.59–1.93 |
| 1-Year Complications | ||
| PJI | 1.42 | 0.87–2.33 |
OR: odds ratio; 95% CI: 95% confidence intervals.
PJI: prosthetic joint infection; TKA: total knee arthroplasty.
*Referent group: colonoscopy with biopsy without antibiotics.
Table 5.
Bivariate analysis of post-operative outcomes for TKA.
| Colonoscopy with biopsy without antibiotics |
Colonoscopy with biopsy with antibiotics |
||||
|---|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | ||
| 90-Day Complications rowhead | |||||
| PJI | 0.74 | 0.45–1.23 | 1.07 | 0.47–2.40 | |
| 6-Month Complications rowhead | |||||
| PJI | 0.82 | 0.56–1.21 | 0.95 | 0.48–1.87 | |
| 9-Month Complications rowhead | |||||
| PJI | 0.84 | 0.61–1.17 | 0.90 | 0.50–1.62 | |
| 1-Year Complications rowhead | |||||
| PJI | 0.86 | 0.63–1.17 | 1.23 | 0.75–2.00 | |
OR: odds ratio; 95% CI: 95% confidence intervals.
PJI: prosthetic joint infection; TKA: total knee arthroplasty.
*Referent group: no colonoscopy.
4. Discussion
As TKA procedures approach seven figures per year by 2030, surgeons continue to make every effort in hopes of minimizing the risk of PJI.10 General health maintenance exams and procedures can cause transient bacteremia, which has led to much debate regarding antibiotic prophylaxis with dental procedures, endoscopies, and colonoscopies.5,11, 12, 13, 14, 15 The current study has identified no difference in PJI risk between patients undergoing a colonoscopy who had a biopsy regardless of the use of antibiotic prophylaxis. There was also no difference in PJI risk between the two colonoscopy groups and the matched control cohort.
Although recent studies estimate the incidence of PJI to be 1–2%, the economic burden is approaching $1.85 billion by the year 2030.10,16, 17, 18, 19, 20 Aside from the major economic implications PJI carries, the morbidity and mortality associated with such a diagnosis is severe resulting in recommendations for antibiotic prophylaxis when patients are undergoing general health maintenance examinations and procedures that may result in transient bacteremia. With colorectal cancer accounting for the third leading cause of death in both men and women, the United States Preventive Services Task Force (USPSTF) recommends screening colonoscopies in all patients aged 45 years and older.21,22
While colonoscopies, with or without biopsies, do pose a risk of systemic infection due to hematogenous bacterial spread several studies did challenge the need for antibiotic prophylaxis.2,7,8,11,13,14 Bains et al. performed a retrospective review of 64,896 patients who underwent screening colonoscopies in the setting of prior TJA. They determined no difference in PJI risk up to 1-year following screening colonoscopies with, or without, the use of antibiotics.8 In their subgroup analysis of patients who underwent screening colonoscopies who did not have the use of antibiotics, the authors determined that alcohol abuse, diabetes mellitus, and rheumatoid arthritis were independent risks for PJI. They also found that tobacco abuse, obesity, and chronic kidney disease were all contributing diagnoses to the development of PJI.8 The present study found no such associations. Specifically, diagnoses known to increase the risk of PJI including alcohol abuse, tobacco abuse, chronic kidney disease, diabetes mellitus, obesity, and rheumatoid arthritis were analyzed in this study.23, 24, 25 With over 50% of patients having a diagnosis of obesity [51.40 to 63.28], nearly 50% of patients having a diagnosis of diabetes mellitus [46.11 to 58.48], and nearly 40% of patients having documented tobacco use [36.39 to 44.87], one would expect this high-risk population to have increased chances of PJI after transient bacteremia inducing procedures (Table 1). We found no significant difference in the rate of PJI at all time-points, regardless of comorbidities, between the colonoscopy with biopsy cohort, the biopsy with antibiotic prophylaxis cohort, and the control cohort (P = 0.330) (Table 3).
Chiu and colleagues recently compared patients who underwent diagnostic colonoscopies to those who underwent invasive colonoscopies in patients who underwent unicompartmental knee arthroplasties, total knee arthroplasties, or total hip arthroplasties.7 While their study showed no increase in PJI in patients who had diagnostic colonoscopies, it unexpectedly showed a protective effect of invasive colonoscopies against revision procedures. Our study did not corroborate these findings. Neither of our colonoscopy cohorts, with or without antibiotic prophylaxis, showed any increase or decrease in PJI risk compared to the control cohort (Table 3). Although we were unable to identify the protective effects that Chiu and co-authors found, our findings reinforce the recommendation that no antibiotic prophylaxis is needed prior to invasive colonoscopies even in the setting of planned biopsies.
This study is not without potential limitations. The dataset used was obtained from a national database which identifies patients through billing codes and was not meant to be accurate for diagnoses. It should be expected that errors were made in the coding process for a small subset of patients due to human error. To minimize these coding errors, the dataset was subjected to an independent third-party audit. Also, patient compliance with antibiotic prophylaxis cannot be guaranteed. However, our dataset consisted of 3755 patients in the colonoscopy with biopsy cohort which is the largest antibiotic prophylaxis cohort in the literature, to our knowledge. Even with a subset of patients not complying with the prescribed prophylaxis, our sizable cohort reduces the likelihood of false positive results. Furthermore, the large-scale grouping of our patient populations makes it difficult to identify high-risk diagnoses that may benefit from antibiotic prophylaxis. We did assess several comorbid conditions previously identified as risks for PJI after invasive colonoscopies and our findings showed no significant difference in PJI within the first year following the procedure. Future studies can more specifically assess high-risk diagnoses and the effect of antibiotic prophylaxis. Prospective studies can help guide surgeon management for this routine health examination.
5. Conclusion
Our findings indicate no increased risk of PJI when biopsies are performed during colonoscopies in those who did not have antibiotics compared to those who did have antibiotic prophylaxis. A finding was that neither colonoscopy group had an increased rate of PJI compared to the non-colonoscopy control group. Our data, which to our knowledge is the largest of its kind, expands upon the premise that antibiotic prophylaxis is not needed for invasive colonoscopies in the setting of prior TKA. Future studies should focus on identifying comorbid conditions that may increase the risk of PJI, and therefore benefit from antibiotic prophylaxis.
Funding
None.
Authors' contribution
JD- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.
SB-Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.
DH- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.
GS- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.
MA- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.
RD- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.
SD- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.
MM- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.
JN- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.
RD- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.
Use of AI tool
No use of AI tool.
Data availability
Available in a repository upon request.
Patient consent
No patient consent needed due to retrospective nature and public database.
Ethical approval
IRB exemption due to retrospective nature and public database.
Declaration of competing interest
JD- None.
DH-None.
SB- None.
MA- None.
GS- 3 M: Paid presenter or speakerBiomet: IP royalties; Paid consultant; Paid presenter or speaker Force Therapeutics: Stock or stock Options Journal of Knee Surgery: Editorial or governing board KCI: Paid consultant Operation Walk USA: Board or committee member ROM Tech: Stock or stock Options SpringerElsevierThiemeWorld Scientific: Publishing royalties, financial or material support Zimmer: IP royalties; Paid consultant; Paid presenter or speaker.
JN- Arthritis Foundation: Board or committee member, Journal of Arthroplasty, Journal of the American Osteopathic Medicine Association, Orthopedic, Knowledge Online: Editorial or governing board, Journal of Knee Surgery: Editorial or governing board, Knee: Editorial or governing board, Microport: Paid consultant; Paid presenter or speaker; Research support, Stryker: Research support United: Research support
RD- Baltimore City Medical Society.: Board or committee member, Biocomposites, Inc.: Research support, CyMedica Orthopedics: Research support, DePuy Synthes, Product, Inc.: Research support, Flexion Therapeutics: Research support, Microport Orthopedics, Inc.: Research support, Orthofix, Inc.: Research support,Patient-Centered Outcomes Research Institute (PCORI): Research support, Smith & Nephew: Research support, Stryker: Research support, Tissue Gene: Research support, United Orthopedic Corporation: Research support
MM-receives consultant fees from Stryker 3MCentrexion CERAS Health Johnson & Johnson Kolon Tissuegene Mirror-AR NXSCI Pacira Peerwell Pfizer Lily Skye Biologics SOLVD Health Smith & Nephew, payments for lectures from Stryker, leadership role for The Knee Society The Hip Society Journal of Arthroplasty Journal of Knee Surgery Surgical Technology International Orthopedics and stock options from CERAS Health MirrorAR Peerwell USMI.
Acknowledgements
None.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Available in a repository upon request.