What question did this study set out to answer?

This research aims to evaluate the effectiveness of empirical antibiotic therapies for early postoperative orthopaedic infections and their susceptibility across different anatomical sites.

April 17, 2026Open Access

Empirical antibiotic therapy in acute orthopaedic infections: differences in antimicrobial susceptibility across anatomical sites

Key Points

This research aims to evaluate the effectiveness of empirical antibiotic therapies for early postoperative orthopaedic infections and their susceptibility across different anatomical sites.
Conducted a retrospective, single-centre cohort study of early postoperative orthopaedic infections from January 2022 to January 2025.
Analyzed microbiological isolates, susceptibility profiles, anatomical locations, and index procedures.
Assessed empirical coverage for cefazolin, vancomycin–ceftriaxone, and vancomycin–ciprofloxacin overall and by anatomical site.
A total of 304 infections were analyzed, with a predominance of gram-positive organisms like Staphylococcus aureus.
Cefazolin monotherapy only covered 49% of infections due to resistance from other pathogens.
Vancomycin–ceftriaxone provided 89.8% coverage, increasing to approximately 93.4% excluding foot and ankle infections.
Vancomycin–ciprofloxacin achieved the highest coverage of 97.7%.

Abstract

Abstract. Background: The selection of empirical antibiotic therapy for early postoperative orthopaedic infections is challenging because pathogen distribution, antimicrobial resistance, and microbiology vary locally and by anatomical site. Dutch national guidelines from the Dutch Working Party on Antibiotic Policy (SWAB) recommend vancomycin-based combination therapy for prosthetic joint infection (PJI), but the adequacy of these regimens for the broader spectrum of early postoperative orthopaedic infections has not been systematically evaluated. Methods: We conducted a retrospective, single-centre cohort study including early postoperative orthopaedic infections (≤ 90 d) treated between January 2022 and January 2025 with complete microbiological- and antimicrobial-susceptibility data. Microbiological isolates, susceptibility profiles, anatomical location, and the type of index procedure were analysed. Empirical coverage was assessed for cefazolin, vancomycin–ceftriaxone (SWAB-recommended), and vancomycin–ciprofloxacin, both overall and stratified by anatomical site. Results: A total of 304 infections were included. Gram-positive organisms predominated, including Staphylococcus aureus (one MRSA isolate) and coagulase-negative staphylococci, alongside Gram-negative bacteria, mainly Enterobacter spp. Despite high cefazolin susceptibility among S. aureus, cefazolin monotherapy covered only 49 % of infections due to resistance in S. epidermidis and Gram-negative pathogens. Vancomycin–ceftriaxone provided 89.8 % coverage and increased to approximately 93.4 % when foot and ankle infections were excluded; this subgroup showed frequent ceftriaxone-resistant Enterobacter spp. Vancomycin–ciprofloxacin achieved the highest coverage (97.7 %). Conclusion: Cefazolin monotherapy is insufficient as an empirical treatment for early postoperative orthopaedic infections at our centre. Vancomycin–ceftriaxone offers high coverage for most anatomical sites and aligns with SWAB recommendations. For foot and ankle infections, vancomycin–ciprofloxacin offers superior coverage.

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