Outcome and predictors of treatment failure in early post-surgical prosthetic joint infections due to Staphylococcus aureus treated with debridement

Predicting Failure in Early Acute Prosthetic Joint Infection Treated With Debridement, Antibiotics, and Implant Retention: External Validation of the KLIC Score

BACKGROUND

Debridement, antibiotics, and implant retention (DAIR) is a widely used treatment modality for early acute prosthetic joint infection (PJI). A preoperative risk score was previously designed for predicting DAIR failure, consisting of chronic renal failure (K), liver cirrhosis (L), index surgery (I), cemented prosthesis (C), and C-reactive protein >115 mg/L (KLIC). The aim of this study was to validate the KLIC score in an external cohort.

METHODS

We retrospectively evaluated patients with early acute PJI treated with DAIR between 2006 and 2016 in 3 Dutch hospitals. Early acute PJI was defined as <21 days of symptoms and DAIR performed within 90 days after index surgery. Failure was defined as the need for (1) second DAIR, (2) implant removal, (3) suppressive antimicrobial treatment, or (4) infection-related death within 60 days after debridement.

RESULTS

A total of 386 patients were included. Failure occurred in 148 patients (38.3%). Patients with KLIC scores of ≤2, 2.5-3.5, 4-5, 5.5-6.5, and ≥7 had failure rates of 27.9%, 37.1%, 49.3%, 54.5%, and 85.7%, respectively (P < .001). The receiver-operating characteristic curve showed an area under the curve of 0.64 (95% confidence interval 0.59-0.69). A KLIC score higher than 6 points showed a specificity of 97.9%.

CONCLUSION

The KLIC score is a relatively good preoperative risk score for DAIR failure in patients with early acute PJI and appears to be most useful in clinical practice for patients with low or high KLIC scores.

Treatment of Prosthetic Joint Infection with Debridement, Antibiotics and Irrigation with Implant Retention - a Narrative Review

Prosthetic joint infection usually requires combined medical and surgical therapy. While revision surgery is widely considered to be the gold standard surgical procedure, debridement, antibiotics and irrigation with implant retention is a very appealing alternative. There is however great controversy regarding its real worth with success rates ranging from 0% to over 90%. A number of different patient and host related variables as well as specific aspects of surgical and medical management have been described as relevant for the final outcome. Along this paper, the authors will provide the readers with a critical narrative review of the currently available literature while trying to provide concise and practical treatment recommendations regarding adequate patient selection criteria, proper surgical technique and optimal antibiotic therapy.

Preoperative Anemia Is Associated With Failure of Open Debridement Polyethylene Exchange in Acute and Acute Hematogenous Prosthetic Joint Infection

BACKGROUND

Acute and acute hematogenous prosthetic joint infections (PJIs) are often treated with open debridement and polyethylene exchange (ODPE) in an effort to save the prosthesis, decrease morbidity, and reduce costs. However, failure of ODPE may compromise a subsequent 2-stage treatment. The purpose of this study is to identify patient factors that impact the success of ODPE for acute and acute hematogenous PJIs.

METHODS

A retrospective review examined comorbidities, preoperative laboratory values, and patient history for patients with successful and failed ODPE treatment for acute perioperative or acute hematogenous periprosthetic hip or knee joint infections. Successful treatment was defined as retaining a well-fixed implant without the need for additional surgery for a minimum of 6-month follow-up with or without lifelong oral maintenance antibiotics.

RESULTS

Fifty-three of 72 patients (73.6%) underwent successful ODPE. Of the 19 failures, 14 completed 2-stage revision with one subsequent known failure for recurrent infection. Patients with a Staphylococcus aureus infection were more likely to fail ODPE (48.3% vs 11.6%, P = .0012, odds ratio 7.1, 95% confidence interval 2.3-25.3). Patients with a preoperative hematocrit ≤32.1 were also more likely to fail ODPE (55% vs 16%, P = .0013, odds ratio 6.7, 95% confidence interval 2.2-22.4). When neither risk factor was present, 97.1% of PJIs were successfully treated with ODPE.

CONCLUSION

S aureus infection and preoperative hematocrit ≤32.1 are independent risk factors for ODPE failure. ODPE is a safe alternative to 2-stage revision in patients without preoperative anemia and without S aureus infection. Two-thirds of patients with a failed ODPE were successfully treated with a 2-stage reimplantation.

Outcomes following debridement, antibiotics and implant retention in the management of periprosthetic infections of the hip: a review of cohort studies

AIMS

The aims of the study were to review and analyse the reported series of debridement, antibiotics and implant retention (DAIR) in the management of infected total hip arthroplasties (THAs) to establish the overall success and the influencing factors.

PATIENTS AND METHODS

Using a standardised recognised study protocol, meta-analysis of observational studies in epidemiology guidelines, a comprehensive review and analysis of the literature was performed. The primary outcome measure was the success of treatment. The search strategy and inclusion criteria which involved an assessment of quality yielded 39 articles for analysis, which included 1296 patients.

RESULTS

The proportion of success following DAIR in the management of an infected THA appeared to improve after 2004 with a pooled mean proportion of success of 72.2%. For all reported series, from 1977 onwards, there was improved success with early debridement (< 7 days; 75.7%) and exchange of modular components (77.5%). There was a statistically non-significant improvement if debridement was performed within four weeks of the initial procedure (73.0%).

CONCLUSION

The reported success following DAIR has improved since 2004. The only determinants of outcome which we found were the timing of debridement after the onset of symptoms of infection and the exchange of modular components. Cite this article: Bone Joint J 2017;99-B:1488-66.

Efficacy of Open Debridement and Polyethylene Exchange in Strictly Selected Patients with Infection after Total Knee Arthroplasty

Purpose

To assess the efficacy of open debridement and polyethylene exchange (ODPE) combined with proper antibiotic therapy in strictly selected patients with infection after total knee arthroplasty (TKA) and analyze factors associated with treatment failure.

Materials and Methods

From January 2010 to January 2014, 25 cases that underwent ODPE under the diagnosis of infection within four weeks after TKA or acute hematogenous infection within five days of symptom onset were reviewed in this study.

Results

Treatment was successful in 22 out of 25 cases (88.0%). Factors associated with failure were accompanying infection (periprosthetic infection in the ipsilateral foot, cervical parotid abscess, and masticator space abscess) and diagnosis of rheumatoid arthritis (RA) before TKA. Resistant bacteria did not entail a risk. On clinical results, the mean postoperative Lysholm score and Korean Knee score were 81.4 and 79.4, respectively, the knee range of motion was 115.4°±12.9°, and duration of hospitalization was 32.3±8.4 days. On radiographic results, 3.47±1.56 mm joint line elevation and a valgus change of 0.61°±2.35° in knee alignment were observed.

Conclusions

ODPE combined with appropriate antibiotics therapy could be a useful treatment method for infection after TKA if the procedure is performed within a symptom duration of five days or less in the absence of accompanying infection in patients whose indication for TKA was not RA.

Staphylococcus aureus biofilm elicits the expansion, activation and polarization of myeloid-derived suppressor cells in vivo and in vitro

Staphylococcus aureus (S. aureus) is one of the most common causes of biofilm infections in periprosthetic joint infections (PJIs). Accumulating evidence has shown that the immunosuppressive environment established by S. aureus biofilm infection in PJIs involves the presence of myeloid-derived suppressor cells (MDSCs) and M2-macrophages. Due to the diversity of MDSCs, little is known about whether S. aureus biofilm preferentially expands specific MDSC subsets or whether MDSCs can further differentiate into M2-macrophages during S. aureus biofilm infection. Here, we show that in agreement with the results from an established rat PJI model, S. aureus biofilm cocultured with freshly isolated bone marrow cells (BMCs) in vitro significantly increases the proportions of MDSCs, total macrophages and M2-macrophages. Interestingly, we find that treatment of the BMCs in vitro with S. aureus biofilm preferentially promotes the expansion of monocytic MDSCs but not granulocytic MDSCs. Biofilm treatment also substantially enhances the overall MDSC immunosuppressive activity in addition to the MDSC expansion in vitro. Importantly, we provide evidence that S. aureus biofilm is capable of further stimulating the conversion of monocytic MDSCs into M2-macrophages in vitro and in vivo. Collectively, our studies reveal a direct link between MDSCs and M2-macrophages occurring in S. aureus-associated PJIs.

The Not-So-Good Prognosis of Streptococcal Periprosthetic Joint Infection Managed by Implant Retention: The Results of a Large Multicenter Study

BACKGROUND.

Streptococci are not an infrequent cause of periprosthetic joint infection (PJI). Management by debridement, antibiotics, and implant retention (DAIR) is thought to produce a good prognosis, but little is known about the real likelihood of success.

METHODS.

A retrospective, observational, multicenter, international study was performed during 2003-2012. Eligible patients had a streptococcal PJI that was managed with DAIR. The primary endpoint was failure, defined as death related to infection, relapse/persistence of infection, or the need for salvage therapy.

RESULTS.

Overall, 462 cases were included (median age 72 years, 50% men). The most frequent species was Streptococcus agalactiae (34%), and 52% of all cases were hematogenous. Antibiotic treatment was primarily using β-lactams, and 37% of patients received rifampin. Outcomes were evaluable in 444 patients: failure occurred in 187 (42.1%; 95% confidence interval, 37.5%-46.7%) after a median of 62 days from debridement; patients without failure were followed up for a median of 802 days. Independent predictors (hazard ratios) of failure were rheumatoid arthritis (2.36), late post-surgical infection (2.20), and bacteremia (1.69). Independent predictors of success were exchange of removable components (0.60), early use of rifampin (0.98 per day of treatment within the first 30 days), and long treatments (≥21 days) with β-lactams, either as monotherapy (0.48) or in combination with rifampin (0.34).

CONCLUSIONS.

This is the largest series to our knowledge of streptococcal PJI managed by DAIR, showing a worse prognosis than previously reported. The beneficial effects of exchanging the removable components and of β-lactams are confirmed and maybe also a potential benefit from adding rifampin.

Acute periprosthetic knee infection: is there still a role for DAIR?

BACKGROUND AND AIM OF THE WORK

Periprosthetic knee infection is a rare complication associated with prosthetic failure; incidence change from 0,4-2% of primary total knee replacement and 5.6% in revisions. Indications for debridment, antibiotics and implant retention (DAIR) are early acute infections or acute delayed infection. Aim of the work is to check if this technique is still a successful in early infections.

METHODS

We have analyzed recent literature data on DAIR and all DAIR procedures in our clinic in the last 10 years, the mean time between onset of symptoms and surgery, the mean antibiotic therapy duration and results we have obtained. We evaluate the diagnostic process and different treatments in early knee periprosthetic infections, especially the DAIR approach.

RESULTS

If correct indications are followed, DAIR has a success rate in 31-100% of the cases; if it is applied in late chronic infection the success rate is 28-62%. In our experience DAIR has an 80% success rate: in 20 patients treated with DAIR we had 4 failures.

CONCLUSIONS

DAIR can be considered a successful treatment, but it depends from individual patient factors, from the microorganisms involved, from the duration of antibiotic therapy and from correct choice in timing and in execution of DAIR by the orthopedic surgeon.

Management of periprosthetic infections

Periprosthetic joint infection (PJI) is considered one of the most challenging complications compromising patient health and is considered an economic burden. Despite all strategies PJI prevalence is between 1%-2%. Considerable efforts have been investigated in the past decade to diminish or erradicate PJI prevalence. This article manages the definition of PJI and the new major and minor criteria from Parvizi et al Then a scientific analysis of every minor and major criteria. Multidisciplinary management is reccommended according to guidelines. A numerous of surgical options exist each and everyone with its indications, contraindications and specific antibiotic therapy regimen. Surgical options are: (1) irrigation and cleaning with retention of the prosthesis with a success rate 0%-89%; (2) single-stage revision surgery with a succes rate of > 80%; and (3) two-stage revision surgery (authors preferred method) with a succes rate of 87%. Radical treatment options like arthrodesis and amputation are reserved for specific group of patients, with a succes rate varying from 60%-100%. The future of PJI is focused on improving the diagnostic tools and to combat biofilm. The cornerstone of management consists in a rapid diagnosis and specific therapy. This article presents the most current diagnostic and treatment criteria as well as the different surgical treatment options depending on the type of infection, bacterial virulence and patient comorbidities.

Proposal for shorter antibiotic therapies

OBJECTIVES

Reducing antibiotic consumption has now become a major public health priority. Reducing treatment duration is one of the means to achieve this objective. Guidelines on the therapeutic management of the most frequent infections recommend ranges of treatment duration in the ratio of one to two. The Recommendation Group of the French Infectious Diseases Society (SPILF) was asked to collect literature data to then recommend the shortest treatment durations possible for various infections.

METHODS

Analysis of the literature focused on guidelines published in French and English, supported by a systematic search on PubMed. Articles dating from one year before the guidelines publication to August 31, 2015 were searched on the website.

RESULTS

The shortest treatment durations based on the relevant clinical data were suggested for upper and lower respiratory tract infections, central venous catheter-related and uncomplicated primary bacteremia, infective endocarditis, bacterial meningitis, intra-abdominal, urinary tract, upper reproductive tract, bone and joint, skin and soft tissue infections, and febrile neutropenia. Details of analyzed articles were shown in tables.

CONCLUSION

This work stresses the need for new well-conducted studies evaluating treatment durations for some common infections. Following the above-mentioned work focusing on existing literature data, the Recommendation Group of the SPILF suggests specific study proposals.

The DAIR (debridement, antibiotics and implant retention) procedure for infected total knee replacement - a literature review

Prosthetic joint infection (PJI) is a devastating complication in total knee arthroplasty (TKA) and third most common cause of revision of TKA with significant morbidity and surgical challenges. Treatment options include non-operative measures with long term antibiotic suppression, debridement and implant retention (DAIR), one- or two-stage revision arthroplasty, arthrodesis and amputation. Implant retention without infection is ideal and DAIR has been reported to have variable success rates depending on patient factors, duration of infection, infecting micro-organisms, choice of procedure, single or multiple debridement procedures, arthroscopic or open, antibiotic choice and duration of antibiotic use. We present a thorough literature review of DAIR for infected TKA. The important factors contributing to failure are presence of sinus, immunocompromised patient, delay between onset of infection and debridement procedure, Staphylococcal infection in particular Meticillin Resistant Staphylococcal aureus, multiple debridement procedures, retention of exchangeable components and short antibiotic duration. In conclusion DAIR can be successful procedure to eradicate infection in TKA in selective patients with factors contributing to failure taken into account.

Debridement, antibiotics and implant retention in early periprosthetic joint infection

INTRODUCTION

Periprosthetic joint infection (PJI) is a devastating complication in hip arthroplasty surgery. Debridement, antibiotics (AB) and implant retention (DAIR) is recommended in early PJI in association with stable implants. The aim of this study was to evaluate the success rate of DAIR in early PJI (&lt;4 weeks) and to identify factors predicting the outcome.

METHODS

This cohort study included a consecutive series of 35 patients (median age 74 years, 25 women, 26 primary arthroplasties) treated with DAIR for an early PJI in a regional hospital.

RESULTS

28 patients (80%) had their infection eradicated. DAIR-only eradicated the PJI in 22 (63%) patients with a median follow-up of 50 (24-84) months. In 17 (49%) patients, oral AB had been given prior to intraoperative cultures, which delayed first debridement with average 6 days and delayed hospital stay. Primary surgery for a hip fracture increased the risk of DAIR-failure. Surgical experience did not affect the outcome. 17% (n = 6) of the patients sustained a secondary infection during their hospital stay; the majority was beta-lactam resistant coagulase negative Staphylococcus aureus.

CONCLUSIONS

The success rate of DAIR was inferior to pervious controls from experienced revision centers. Hip fracture patients should be informed about the increased risk of DAIR treatment failure. In order not to delay surgery, empirically based oral AB should not be administered prior to deep cultures.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02087020.

Implant retention after acute and hematogenous periprosthetic hip and knee infections: Whom, when and how?

Periprosthetic joint infections (PJI) of the hip and the knee are grossly classified as early post-operative, acute hematogenous and late chronic infections. Whereas two-stage exchange arthroplasty is the standard of care in North America for treating chronic infections, irrigation and debridement (I and D) with retention of implants has been used in an attempt to treat the other two types of PJIs. The rationale of this approach is that a PJI may be eradicated without the need of explanting the prostheses, as long as it has not transitioned into a chronic state. With the present paper, we review current evidence regarding the role of I and D with implant retention for treating PJIs of the hip and the knee. While a very wide range of success rates is reported in different studies, a short period of time between initiation of symptoms and intervention seems to play a prominent role with regards to a successful outcome. Moreover, pathogens of higher virulence and resistance to antibiotics are associated with a poorer result. Specific comorbidities have been also correlated with a less favorable outcome. Finally, one should proceed with serial I and Ds only under the condition that a predefined, aggressive protocol is applied. In conclusion, when treating a PJI of the hip or the knee, all the above factors should be considered in order to decide whether the patient is likely to benefit from this approach.

Short- versus long-duration levofloxacin plus rifampicin for acute staphylococcal prosthetic joint infection managed with implant retention: a randomised clinical trial

Levofloxacin plus rifampicin (L+R) is the treatment of choice for acute staphylococcal prosthetic joint infection (PJI) managed with debridement and implant retention (DAIR). Long courses have been empirically recommended, but some studies have suggested that shorter treatments could be as effective. Our aim was to prove that a short treatment schedule was non-inferior to the standard long schedule. An open-label, multicentre, randomised clinical trial (RCT) was performed. Patients with an early post-surgical or haematogenous staphylococcal PJI, managed with DAIR and initiated on L+R were randomised to receive 8 weeks of treatment (short schedule) versus a long schedule (3 months or 6 months for hip or knee prostheses, respectively). The primary endpoint was cure rate. From 175 eligible patients, 63 were included (52% women; median age, 72 years): 33 patients (52%) received the long schedule and 30 (48%) received the short schedule. There were no differences between the two groups except for a higher rate of polymicrobial infection in the long-schedule group (27% vs. 7%; P = 0.031). Median follow-up was 540 days. In the intention-to-treat analysis, cure rates were 58% and 73% in patients receiving the long and short schedules, respectively (difference -15.7%, 95% CI -39.2% to 7.8%). Forty-four patients (70%) were evaluable per-protocol: cure rates were 95.0% and 91.7% for the long and short schedules, respectively (difference 3.3%, 95% CI -11.7% to 18.3%). This is the first RCT suggesting that 8 weeks of L+R could be non-inferior to longer standard treatments for acute staphylococcal PJI managed with DAIR.

An update on surgical and antimicrobial therapy for acute periprosthetic joint infection: new challenges for the present and the future

Periprosthetic joint infection (PJI) is a devastating complication that can occur following any arthroplasty procedure. Approximately half of these infections develop within the first year after arthroplasty, mainly in the first 1 to 3 months. These infections are known as early PJI. It is widely accepted that many early PJIs can be successfully managed by debridement, irrigation, and prosthetic retention, followed by a course of biofilm-effective antibiotics (debridement, antibiotics, implant retention procedure), but candidate patients should meet the requirements set down in Zimmerli's algorithm. The best antibiotic regimen for acute PJI treated without implant removal remains uncertain. Rifampin-containing regimens, when feasible, are recommended in gram-positive infections, and fluoroquinolones in gram-negative cases. The duration, dosage, and administration route of antibiotics and the use of combined therapy are matters that requires further clarification, as the current level of evidence is low and most recommendations are based on experimental data, studies in small series, and expert experience.

The Effectiveness of Debridement, Antibiotics and Irrigation for Periprosthetic Joint Infections after Primary Hip and Knee Arthroplasty. A 15 Years Retrospective Study in Two Community Hospitals in the Netherlands

The aim of our study was to evaluate the effectiveness of debridement, antibiotics, irrigation and retention (DAIR) in patients who developed a periprosthetic joint infection (PJI) after primary hip or knee arthroplasty in two community hospitals in the Netherlands. We retrospectively collected data in two hospitals in the Netherlands on all episodes of PJI after primary hip (THA) and knee arthroplasty (TKA) from 1998-2012. In 109 of 8234 THA (1.32%) and 65 of 5752 TKA (1.13%) a PJI developed. DAIR was used as treatment in 84 patients after THA (77.1%) and 56 patients after TKA (86.2%). 34 Patients only received antibiotics or were immediately revised. After 1 year follow-up, prosthesis retention was achieved in 81 THA patients (74.3%) and 48 TKA patients (73.8%). Acute infections showed a better survival compared to late infections (84.0% vs 46.6% respectively; p<0.01). Furthermore, a young age was associated with an increased revision risk (p<0.01). In conclusion, debridement, antibiotics and irrigation in acute PJI may lead to retention of the prosthesis in a majority of cases. Large patient cohort studies can provide data on PJI outcome, complementing National Registries which have limited detail.

Multiple Irrigation and Debridements for Periprosthetic Joint Infections: Facing a Necessity or Just Prolonging the Inevitable?

Irrigation and debridement (I&D) may be a viable option in selected cases of periprosthetic joint infections (PJI). Our aim was to investigate the role of multiple I&Ds. Among 141 patients with PJI treated with I&D in our institution, 19 were subjected to additional procedures. Their clinical characteristics were retrospectively reviewed and compared to the remaining patients treated with a single I&D. The probability of treatment failure (removal of implants) was not significantly different among the two groups. The interval between serial I&Ds was a significant factor determining outcomes. Patients treated with multiple I&Ds had a significantly higher prevalence of peripheral vascular disease. The decision to proceed with repeat of I&D should be made with caution.

Surgical Treatment of Prosthetic Joint Infections of the Hip and Knee: Changing Paradigms?

Prosthetic joint infection (PJI) of the hip and knee remains one of the most common and feared arthroplasty complications. The impact and cost of PJI is significant, both to the patient and to the health care system. Recent reports of results of different treatment strategies have led many surgeons to modify their approach to management of PJI. This paper will explore apparent paradigm shifts, both to indications and technique, including the importance of waiting for bacterial identification, the decreasing role for irrigation and debridement (I&D) with retention of components, the increased utilization of single stage revision, and conversely a decreasing role for two-stage exchange. Strategies for treating drug-resistant organisms and management of failed treatment will also be examined.

KLIC-score for predicting early failure in prosthetic joint infections treated with debridement, implant retention and antibiotics

Debridement, irrigation and antibiotic treatment form the current approach in early prosthetic joint infection (PJI). Our aim was to design a score to predict patients with a higher risk of failure. From 1999 to 2014 early PJIs were prospectively collected and retrospectively reviewed. The primary end-point was early failure defined as: 1) the need for unscheduled surgery, 2) death-related infection within the first 60 days after debridement or 3) the need for suppressive antibiotic treatment. A score was built-up according to the logistic regression coefficients of variables available before debridement. A total of 222 patients met the inclusion criteria. The most frequently isolated microorganisms were coagulase-negative staphylococci (95 cases, 42.8%) and Staphylococcus aureus (81 cases, 36.5%). Treatment of 52 (23.4%) cases failed. Independent predictors of failure were: chronic renal failure (OR 5.92, 95% CI 1.47-23.85), liver cirrhosis (OR 4.46, 95% CI 1.15-17.24), revision surgery (OR 4.34, 95% CI 1.34-14.04) or femoral neck fracture (OR 4.39, 95% CI1.16-16.62) compared with primary arthroplasty, C reactive protein >11.5 mg/dL (OR 12.308, 95% CI 4.56-33.19), cemented prosthesis (OR 8.71, 95% CI 1.95-38.97) and when all intraoperative cultures were positive (OR 6.30, 95% CI 1.84-21.53). A score for predicting the risk of failure was designed using preoperative factors (KLIC-score: Kidney, Liver, Index surgery, Cemented prosthesis and C-reactive protein value) and it ranged between 0 and 9.5 points. Patients with scores of ≤2, >2-3.5, 4-5, >5-6.5 and ≥7 had failure rates of 4.5%, 19.4%, 55%, 71.4% and 100%, respectively. The KLIC-score was highly predictive of early failure after debridement. In the future, it would be necessary to validate our score using cohorts from other institutions.

Clinical experience with linezolid for the treatment of orthopaedic implant infections

Gram-positive cocci are commonly isolated in orthopaedic implant infections and their resistance to β-lactams and fluoroquinolones is increasing. The high oral bioavailability of linezolid makes it an attractive oral alternative to glycopeptides and its use has increased in the last decade. To evaluate experience with linezolid in orthopaedic implant infections a systematic review of the literature available in English was undertaken. Only those articles describing series of ≥10 patients with acute or chronic orthopaedic implant infections treated with linezolid and with a clear definition of diagnosis and outcome were selected. A total of 293 patients (79.9% had prosthetic joint infections) were analysed in the 10 articles included. The overall remission rate with at least 3 months of follow-up was 79.9%, depending on whether the implant was removed or not (94% versus 69.9%). The addition of rifampicin was described in only two articles and no significant difference was observed. Adverse events were frequent during prolonged administration of linezolid (34.3%), requiring treatment discontinuation in 12.8%. The most common event was anaemia (13.4%) followed by gastrointestinal symptoms (11.1%). In conclusion, linezolid seems a good oral treatment alternative for orthopaedic implant infections due to Gram-positive cocci resistant to β-lactams and fluoroquinolones. However, close monitoring of adverse events is required.

Periprosthetic knee infections treated with irrigation and debridement: outcomes and preoperative predictive factors

The role of irrigation and debridement (I&D) in the treatment of periprosthetic joint infections (PJI) of the knee remains controversial. Our purpose was to identify the success rate and factors determining outcome of I&D in those patients. Clinical characteristics of 78 patients with PJI of the knee treated with I&D were retrospectively reviewed. Implant retention at final follow-up was achieved in 43 patients (55.1%). Logistic regression analysis revealed that duration of symptoms >5days and thyroid disease were independent predictors of I&D failure. Patients with methicillin-resistant staphylococcal infections had a success rate of 45.5% and significantly lower odds of success compared to patients with negative cultures. In selected patients, I&D is a reasonable option in the context of acute PJI of the knee.

75% success rate after open debridement, exchange of tibial insert, and antibiotics in knee prosthetic joint infections

BACKGROUND AND PURPOSE

Prosthetic joint infection (PJI) is a leading cause of early revision after total knee arthroplasty (TKA). Open debridement with exchange of tibial insert allows treatment of infection with retention of fixed components. We investigated the success rate of this procedure in the treatment of knee PJIs in a nationwide material, and determined whether the results were affected by microbiology, antibiotic treatment, or timing of debridement.

PATIENTS AND METHODS

145 primary TKAs revised for the first time, due to infection, with debridement and exchange of the tibial insert were identified in the Swedish Knee Arthroplasty Register (SKAR). Staphylococcus aureus was the most common pathogen (37%) followed by coagulase-negative staphylococci (CNS) (23%). Failure was defined as death before the end of antibiotic treatment, revision of major components due to infection, life-long antibiotic treatment, or chronic infection.

RESULTS

The overall healing rate was 75%. The type of infecting pathogen did not statistically significantly affect outcome. Staphylococcal infections treated without a combination of antibiotics including rifampin had a higher failure rate than those treated with rifampin (RR = 4, 95% CI: 2-10). In the 16 cases with more than 3 weeks of symptoms before treatment, the healing rate was 62%, as compared to 77% in the other cases (p = 0.2). The few patients with a revision model of prosthesis at primary operation had a high failure rate (5 of 8).

INTERPRETATION

Good results can be achieved by open debridement with exchange of tibial insert. It is important to use an antibiotic combination including rifampin in staphylococcal infections.

Efficacy of Debridement for Early Periprosthetic Joint Infection after Hip Arthroplasty

Purpose

In early prosthetic joint infection after hip arthroplasty, debridement with prosthesis retention may be performed for implant salvage, but the reported success rates are highly variable. Hence we reviewed the outcome of radical debridement and retention of prosthesis using established diagnostic criteria and surgical procedures in relation to significant variables including clinical characteristics, pathogenicity, and antibiotic treatment.

Materials and Methods

We retrospectively reviewed 20 patients (11 men and 9 women) with early prosthetic joint infection after unilateral hip arthroplasty, treated by radical debridement with retention of prosthesis from January 2000 to May 2011. Average follow-up period was 55 months (12-178 months). The outcome was evaluated and analyzed based on recurrence of infection and clinical (Harris hip score) and radiological criteria.

Results

Pathogens were isolated from 11 hips (methicillin-resistant Staphylococcus aureus [MRSA] in three, methicillin-resistant Staphylococcus epidermidis [MRSE] in two, methicillin-sensitive Staphylococcus aureus [MSSA] in one, Acinetobacter baumannii in two, Enterococcus faecalis in two patients, and Enterococcus, Citrobacter species in one). The mean duration of antibiotic administration was 43.5 days. Recurrence of infection was not observed in any case. Average Harris hip score was 91 points at the last follow-up. Revision surgery was not required for any reason including implant failure. Dislocation occurred in two hips after debridement and was treated conservatively.

Conclusion

Radical debridement with prosthesis retention is an effective procedure for early prosthetic joint infection after hip arthroplasty in carefully selected patients and with early diagnosis.

Risk factors for failure in early prosthetic joint infection treated with debridement. Influence of etiology and antibiotic treatment

PURPOSES

The aim of the present study was to evaluate the importance of isolated microorganisms according to the Gram stain and the type of antibiotic received on the outcome of early prosthetic joint infection (PJI) treated with debridement, antibiotics and implant retention (DAIR).

METHODS

From January 1999 to December 2009, all patients with an early PJI were prospectively registered in a database and they were retrospectively reviewed for this study.

RESULTS

During the study period, 160 patients met the inclusion criteria of the study. After a mean (SD) post-debridement follow-up of 5.2 (2.5) years, 117 patients (73.1%) were considered to be in remission and 43 (26.9%) were classified as failure. Variables associated with failure were liver cirrhosis (66.7% vs. 22.8%, p=0.001), diagnosis within the first 30 days from arthroplasty (30.4% vs. 8.0%, p=0.020), C-reactive protein (CRP) >12 mg/dl (46.7% vs. 21.2%, p=0.005), microorganism isolated in all deep samples (31.1% vs. 16.0%, p=0.047) and Gram-negative (GN) infection not treated with a fluoroquinolone (57.1% vs. 20.0%, P=0.004). Gram-positive (GP) infection not treated with rifampin was close to be statistically significantly associated with failure (34.4% vs. 19.2%, p=0.067). A multivariate analysis identified liver cirrhosis (OR: 12.4 CI95%: 3.1-49.7, p<0.001), CRP-value (OR: 1.06 CI95%: 1.0-1.11, p=0.049), and when a GN-infection was not treated with a fluoroquinolone (OR: 6.5, CI95%: 1.8-23.8, p=0.005) as independent predictors of failure.

CONCLUSION

The remission rate of PJI treated with DAIR after 3 years of follow-up was 73%. The main predictors of failure were liver cirrhosis, the selected antibiotic most specially fluoroquinolones for GN and rifampin for GP infections, the C-reactive protein and the number of samples culture positive as a potential surrogate markers of bacterial density.

Postoperative Staphylococcus aureus infections in Medicare beneficiaries

Staphylococcus aureus (S. aureus) infections are important because of their increasing frequency, resistance to antibiotics, and high associated rates of disabilities and deaths. We examined the incidence and correlates of S. aureus infections following 219,958 major surgical procedures in a 5% random sample of fee-for-service Medicare beneficiaries from 2004-2007. Of these surgical patients, 0.3% had S. aureus infections during the hospitalizations when index surgical procedures were performed; and 1.7% and 2.3%, respectively, were hospitalized with infections within 60 days or 180 days following admissions for index surgeries. S. aureus infections occurred within 180 days in 1.9% of patients following coronary artery bypass graft surgery, 2.3% following hip surgery, and 5.9% following gastric or esophageal surgery. Of patients first hospitalized with any major infection reported during the first 180 days after index surgery, 15% of infections were due to S. aureus, 18% to other documented organisms, and no specific organism was reported on claim forms in 67%. Patient-level predictors of S. aureus infections included transfer from skilled nursing facilities or chronic hospitals and comorbid conditions (e.g., diabetes, congestive heart failure, chronic obstructive pulmonary disease, and chronic renal disease). In a logarithmic regression, elective index admissions with S. aureus infection stayed 130% longer than comparable patients without that infection. Within 180 days of the index surgery, 23.9% of patients with S. aureus infection and 10.6% of patients without this infection had died. In a multivariate logistic regression of death within 180 days of admission for the index surgery with adjustment for demographics, co-morbidities, and other risks, S. aureus was associated with a 42% excess risk of death. Due to incomplete documentation of organisms in Medicare claims, these statistics may underestimate the magnitude of S. aureus infection. Nevertheless, this study generated a higher rate of S. aureus infections than previous studies.

Gram-negative prosthetic joint infection: outcome of a debridement, antibiotics and implant retention approach. A large multicentre study

We aim to evaluate the epidemiology and outcome of gram-negative prosthetic joint infection (GN-PJI) treated with debridement, antibiotics and implant retention (DAIR), identify factors predictive of failure, and determine the impact of ciprofloxacin use on prognosis. We performed a retrospective, multicentre, observational study of GN-PJI diagnosed from 2003 through to 2010 in 16 Spanish hospitals. We define failure as persistence or reappearance of the inflammatory joint signs during follow-up, leading to unplanned surgery or repeat debridement>30 days from the index surgery related death, or suppressive antimicrobial therapy. Parameters predicting failure were analysed with a Cox regression model. A total of 242 patients (33% men; median age 76 years, interquartile range (IQR) 68-81) with 242 episodes of GN-PJI were studied. The implants included 150 (62%) hip, 85 (35%) knee, five (2%) shoulder and two (1%) elbow prostheses. There were 189 (78%) acute infections. Causative microorganisms were Enterobacteriaceae in 78%, Pseudomonas spp. in 20%, and other gram-negative bacilli in 2%. Overall, 19% of isolates were ciprofloxacin resistant. DAIR was used in 174 (72%) cases, with an overall success rate of 68%, which increased to 79% after a median of 25 months' follow-up in ciprofloxacin-susceptible GN-PJIs treated with ciprofloxacin. Ciprofloxacin treatment exhibited an independent protective effect (adjusted hazard ratio (aHR) 0.23; 95% CI, 0.13-0.40; p<0.001), whereas chronic renal impairment predicted failure (aHR, 2.56; 95% CI, 1.14-5.77; p 0.0232). Our results confirm a 79% success rate in ciprofloxacin-susceptible GN-PJI treated with debridement, ciprofloxacin and implant retention. New therapeutic strategies are needed for ciprofloxacin-resistant PJI.

Characteristics of prosthetic joint infections due to Enterococcus sp. and predictors of failure: a multi-national study

The objective of this study was to review the characteristics and outcome of prosthetic joint infections (PJI) due to Enterococcus sp. collected in 18 hospitals from six European countries. Patients with a PJI due to Enterococcus sp. diagnosed between January 1999 and July 2012 were retrospectively reviewed. Relevant information about demographics, comorbidity, clinical characteristics, microbiological data, surgical treatment and outcome was registered. Univariable and multivariable analyses were performed. A total of 203 patients met the inclusion criteria. The mean (SD) was 70.4 (13.6) years. In 59 patients the infection was diagnosed within the first 30 days (29.1%) from arthroplasty, in 44 (21.7%) between 31 and 90 days, in 54 (26.6%) between 91 days and 2 years and in 43 (21%) after 2 years. Enterococcus faecalis was isolated in 176 cases (89%). In 107 (54%) patients the infection was polymicrobial. Any comorbidity (OR 2.53, 95% CI 1.18-5.40, p 0.01), and fever (OR 2.65, 95% CI 1.23-5.69, p 0.01) were independently associated with failure. The only factor associated with remission was infections diagnosed later than 2 years (OR 0.25, 95% CI 0.09-0.71, p 0.009). In conclusion, prosthetic joint infections due to Enterococcus sp. were diagnosed within the first 2 years from arthroplasty in >70% of the patients, almost 50% had at least one comorbidity and infections were frequently polymicrobial (54%). The global failure rate was 44% and patients with comorbidities, fever, and diagnosed within the first 2 years from arthroplasty had a poor prognosis.

The challenge of methicillin resistant staphylococcal infection after total hip replacement

Advances in the treatment of periprosthetic joint infections of the hip have once more pushed prosthesis preserving techniques into the limelight. At the same time, the common infecting organisms are evolving to become more resistant to conventional antimicrobial agents. Whilst the epidemiology of resistant staphylococci is changing, a number of recent reports have advocated the use of irrigation and debridement and one-stage revision for the treatment of periprosthetic joint infections due to resistant organisms. This review presents the available evidence for the treatment of periprosthetic joint infections of the hip, concentrating in particular on methicillin resistant staphylococci.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):60–5.

A Retrospective Review of the Clinical Experience of Linezolid with or Without Rifampicin in Prosthetic Joint Infections Treated with Debridement and Implant Retention

Introduction

Debridement and prosthesis retention, combined with a prolonged antibiotic regimen including rifampicin, is an accepted therapeutic approach when the duration of symptoms is less than 4 weeks and there are no radiological signs of loosening. The outcome of patients managed with this strategy has been previously assessed in several articles with success rates of 60–90%. This study aims to review the clinical experience with linezolid in 3 different hospitals from Spain and France in patients with prosthetic joint infection (PJI) managed with debridement, retention of the implant and treated with linezolid with or without rifampicin.

Methods

Patients with an acute PJI who underwent open debridement with implant retention treated with linezolid for more than 7 days in 3 hospitals from Barcelona, Tours and Lille between 2005 and 2011 were retrospectively reviewed. Relevant information about demographics, co-morbidity, type of implant, surgical treatment, microorganism isolated, antimicrobial therapy, adverse events (AEs) and outcomes were recorded from patients.

Results

A total of 39 patients were retrospectively reviewed. The mean age (SD) was 70.5 (8.8) years and 9 patients had diabetes mellitus (23%). There were 25 (64%) knee prostheses, 13 (33%) hips and 1 shoulder (3%). The median interquartile range (IQR) days from arthroplasty to infection diagnosis was 17 (19–48) and 33 (85%) cases were diagnosed within the first 60 days. The median (IQR) duration of antibiotic treatment was 70.5 (34–96) days and the median (IQR) number of days on linezolid treatment was 44.5 (30–81). AEs were observed in 15 patients (38%), with gastrointestinal complaints in 8 cases and anemia in 5 being the most frequent. After a median (IQR) follow-up of 2.5 (1.8–3.6) years, there were 11 failures (28%) (8 relapses and 3 new infections). The failure rate was higher in the rifampicin group (36% vs. 18%) mainly due to a higher relapse rate (27% vs. 12%) although differences were not statistically significant.

Conclusion

Management of acute PJIs with debridement and retention of the implant linezolid, with or without rifampicin, is associated with a high remission rate and it is an alternative treatment for infections due to fluoroquinolone and/or rifampicin-resistant staphylococci.

Electronic supplementary material

The online version of this article (doi:10.1007/s40121-014-0032-z) contains supplementary material, which is available to authorized users.

Factors related to outcome of early and delayed prosthetic joint infections

In this prospective study, we evaluate the impact of adherence to a diagnostic and therapeutic protocol on prosthetic joint infections (PJI) diagnostic accuracy and outcome.

PATIENTS AND METHODS

Patients with early or delayed PJI referred over a 5-year period were included. Diagnosis was based on characteristic clinical signs, radiographic findings and microbiological evidence. Antibiotics were chosen on the basis of microbiological findings, and drugs active against methicillin-resistant staphylococci were administered if no microbiological evidence had been obtained.

RESULTS

Inclusion criteria were met in 159 cases (median age 64 years, males 45%). 56 were early infections and 103 delayed infections. Comorbidities were reported in 99 (62%) cases. Positive cultures were obtained in 122/159 (77%), coagulase-negative staphylococci were cultured in 20%, Staphylococcus aureus in 28%, and Pseudomonas aeruginosa in 7%. In early infections, cure rate after debridement and antibiotic therapy was 80%. In delayed infections, cure rate after two-stage exchange was 85%. Of 28 patients with delayed infection treated with antibiotics without surgery, only 8 (29%) infections were suppressed 48 weeks after treatment discontinuation. Rifampin afforded a better outcome.

CONCLUSION

Appropriate diagnostic and surgical procedures and microbiologically driven antibiotic therapy including rifampin are recommended to improve diagnostic accuracy and outcome.

Can periprosthetic hip joint infections be successfully managed by debridement and prosthesis retention?

To evaluate the current literature about how successfully periprosthetic hip joint infections can be managed by debridement and prosthesis retention. A literature search was performed through PubMed until September 2013. Search terms were “DAIR (debridement, antibiotics, irrigation, and retention)” alone and in combination with “hip” as well as “hip infection + prosthesis retention”. A total of 11 studies reporting on 292 cases could be identified. Five different treatment modalities have been described with varying success rates (debridement-21% infection eradication rate; debridement + lavage-75% infection eradication rate; debridement, lavage, with change of modular prosthesis components-70.4% infection eradication rate; debridement, lavage, change of modular prosthesis components + vacuum-assisted closure-92.8% infection eradication rate; acetabular cup removal + spacer head onto retained stem-89.6% infection eradication rate). With regard to the postoperative antibiotic therapy, no general consensus could be drawn from the available data. Debridement, antibiotic therapy, irrigation, and prosthesis retention is an acceptable solution in the management of early and acute hematogenous periprosthetic hip joint infections. The current literature does not allow for generalization of conclusions with regard to the best treatment modality. A large, multi-center study is required for identification of the optimal treatment of these infections.

Measuring Outcomes: Pain and Quality of Life 48 Months After Acute Postoperative Total Knee Prosthetic Joint Infection

BACKGROUND

Measuring HRQOL is simple, inexpensive, permits the health status to be measured over time, and is useful to compare or initiate treatments and evaluate results, facilitating homogenization in patient inclusion.

OBJECTIVES

To evaluate disease-specific and generic HRQOL and influence of associated factors in patients undergoing open debridement for acute postsurgical knee prosthetic joint infection after TKR at 12 and 48 months after completing antibiotic treatment and considered cured of infection.

METHODS

Health-related quality-of-life measures were administered at baseline (WOMAC) and 12 and 48 months (WOMAC and SF-36) in patients with prosthesis retention, no symptoms of infection, and CRP (≤ 1 mg/dL).

RESULTS

Thirty patients were included, and 24 were evaluated at 48 months. WOMAC scores improved significantly (P < 0.01) at 12 and 48 months. The effect size was 0.72 for stiffness, 2.01 for pain, and 2.15 for function. At 48 months, improvements were greater (P < 0.02) except for stiffness. The most frequently isolated microorganisms were Staphylococcus aureus (14 patients) and coagulase-negative staphylococci (9 patients). SF-36 physical role, bodily pain, emotional role, and mental health dimension scores at 12 and 48 months were significantly worse in patients with isolates of Staphylococcus aureus (P < 0.05).

CONCLUSIONS

Health-related quality-of-life measures detected significant differences in outcomes in patients infected by S. aureus compared with patients infected by other microorganisms. HRQOL measures may provide useful complementary information on outcomes after acute postoperative infection.

Prosthetic joint infection

Prosthetic joint infection (PJI) is a tremendous burden for individual patients as well as the global health care industry. While a small minority of joint arthroplasties will become infected, appropriate recognition and management are critical to preserve or restore adequate function and prevent excess morbidity. In this review, we describe the reported risk factors for and clinical manifestations of PJI. We discuss the pathogenesis of PJI and the numerous microorganisms that can cause this devastating infection. The recently proposed consensus definitions of PJI and approaches to accurate diagnosis are reviewed in detail. An overview of the treatment and prevention of this challenging condition is provided.

Long-term results of acute prosthetic joint infection treated with debridement and prosthesis retention: a case-control study

PURPOSES

To evaluate the long-term outcome (at least 4 years) of patients who underwent a surgical debridement due to an acute prosthetic joint infection (PJI) and to compare them with a control group that did not have an acute septic complication.

METHODS

From January 1999 to December 2007, 61 patients with an acute PJI in remission after 2 years of follow-up (cases) were retrospectively reviewed and compared with a control group (2:1) without an acute PJI matched by age, year of arthroplasty, and type of prosthesis. Septic and aseptic complications of each group were gathered and compared using a chi-square test. A two-tailed p value <0.05 was considered statistically significant.

RESULTS

Out of 183 patients, 4 cases and 2 controls were excluded due to death or lost to follow up; 113 (63.8%) were females and 109 (61.5%) had a knee replacement. The mean age and time of followup were 68.3 and 6.4 years, respectively. There were no statistically significant differences between cases and controls in the percentage of late septic or aseptic loosening. However, the late relapse rate in patients with acute PJI caused by S. aureus, was 12.5% (2 out of 16) and there was a trend towards significance when compared with the rest of the cohort (3.3%, p = 0.09). Aseptic late complications were more frequent in GN-cases (10.7%) than in the other groups (3.4% in GP-cases and 5% in controls) but this difference was not statistically significant (p = 0.19).

CONCLUSIONS

In conclusion, although analyzing all late complications together, patients with an acute PJI have a similar long-term outcome in comparison with controls; patients with an acute PJI due to S. aureus had a higher late relapse rate; and GN-cases developed an aseptic loosening more ?frequently. In the future, it is necessary to evaluate larger series to confirm our results.