What Is the Duration of Irrigation? An In Vitro Study of the Minimum Exposure Time to Eradicate Bacteria With Irrigation Solutions

Efficacy of Adjunctive Antiseptic Lavage Solution in Managing Acute Hip/Knee Prosthetic Joint Infection: A Comparative Study in a Tertiary Revision Center

Background

Debridement, antibiotics and implant retention (DAIR) procedure is well-established as a management option for acute periprosthetic joint infection (PJI). We investigated the infection eradication rates of DAIR procedures at our center using Bactisure wound lavage.

Methods

A retrospective consecutive review of DAIR procedures for hip and knee PJI was conducted between 2018 and 2023 with a minimum 12-month follow-up at our tertiary revision arthroplasty center. Suitability for DAIR was determined at the multi-disciplinary team discussion. Revision procedures and patients with previous PJI were excluded. Patient, surgical, microbiological, and postoperative data (minimum 12 months) was reviewed. The use of Bactisure was in addition to routine surgical management.

Results

During the study period, 76 DAIR procedures were performed (55 knees and 21 hips). Bactisure was used in 26 cases (20 knees and 6 hips). Overall, 6 of 26 Bactisure DAIRs failed (23%), while 14 of 50 non-Bactisure DAIRs failed (28%), which did not demonstrate statistical significance (P = .644). Subgroup analysis demonstrated no difference in knee DAIRs (P = .761) but a trend toward significance in hip DAIRs (P = .262). No adverse effects of Bactisure use were noted intraoperatively or postoperatively. DAIR failed in 50% of diabetic patients compared to 20% of nondiabetic patients (P = .015). Age, body mass index, and organism identification did not influence outcome.

Conclusions

The addition of Bactisure to DAIR procedures did not demonstrate statistically significant improvement of successful eradication of infection, but a potential trend toward significance was noted in hip DAIRs. Diabetic patients failed DAIR in 50% of cases. The in-vivo outcomes of Bactisure use during DAIR procedures remain inconclusive.

Efficacy of Commercially Available Irrigation Solutions on Removal of Staphylococcus Aureus and Biofilm From Porous Titanium Implants: An In Vitro Study

BACKGROUND

Periprosthetic joint infection remains a major problem. The bactericidal efficacy of commercial irrigation solutions for the treatment of infection is not well established in the presence of porous titanium (Ti) implants. This study compared the in vitro efficacy of five irrigation solutions on infected three-dimensional-printed porous Ti discs.

METHODS

Titanium discs (2 × 4 mm, 400, 700, and 1,000 μm) were infected with S. aureus (1 × 106 colony-forming unit/mL) and incubated for 3 hours or 3 days to create acute or chronic infection with biofilm. Discs were irrigated with saline, antibiotic, or antiseptic solutions, then repeatedly sonicated. Sonicates were cultured for bacterial quantification. Statistical analyses were performed using one-way analysis of variance (ANOVA), followed by Tukey-Kramer post hoc testing (P < .05 significance). Biofilms were visualized by scanning electron microscopy.

RESULTS

Saline irrigation was ineffective in both groups. In acute infections with 400 μm pores, differences were found with saline versus solution #3 (P = .015) and #4 (P = .015). Solution #4 had the lowest bacterial counts for all pore sizes. For biofilm, irrigation with saline, solutions #1, #2, and #3 inadequately cleared bacteria in all pore sizes. Lower remaining concentrations were observed in #4 with 400μm pores compared to saline (P = .06) and #2 (P = .039). The scanning electron microscopy showed a reduction of biofilm in samples washed with #4.

CONCLUSIONS

Irrigation of infected porous Ti discs with saline, solutions #1 and #2 failed to reduce the bacterial load. The 400 μm discs consistently had more bacteria despite irrigation, highlighting the difficulty of removing bacteria from small pores. Solutions #3 and #4 reduced bacteria acutely, but only #4 demonstrated efficacy in clearing biofilm compared to saline. These results should be considered when treating periprosthetic joint infection in the presence of porous components and the potential presence of biofilm.

Evidence-based Approach for Prevention of Surgical Site Infection

Periprosthetic joint infection (PJI) is regarded as a critical factor contributing to the failure of primary and revision total joint arthroplasty (TJA). With the increasing prevalence of TJA, a significant increase in the incidence of PJI is expected. The escalating number of cases, along with the significant economic strain imposed on healthcare systems, place emphasis on the pressing need for development of effective strategies for prevention. PJI not only affects patient outcomes but also increases mortality rates, thus its prevention is a matter of vital importance. The longer-term survival rates for PJI after total hip and knee arthroplasty correspond with or are lower than those for prevalent cancers in older adults while exceeding those for other types of cancers. Because of the multifaceted nature of infection risk, a collaborative effort among healthcare professionals is essential to implementing diverse strategies for prevention. Rigorous validation of the efficacy of emerging novel preventive techniques will be required. The combined application of these strategies can minimize the risk of infection, thus their comprehensive adoption is important. Collectively, the risk of PJI could be substantially minimized by application of a multifaceted approach implementing these strategies, leading to improvement of patient outcomes and a reduced economic burden.

The effects of chlorhexidine, povidone-iodine and vancomycin on growth and biofilms of pathogens that cause prosthetic joint infections: an in-vitro model

BACKGROUND

Chlorhexidine gluconate (CHG) and povidone-iodine (PI) are commonly used to prevent prosthetic joint infection (PJI) during total joint replacement; however, their effective concentrations and impact on biofilms are not well defined.

AIM

To determine: (1) the in-vitro minimum inhibitory concentration of CHG and PI against model PJI-causing organisms and clinical isolates; (2) their impact on biofilm formation; (3) whether there is a synergistic benefit to combining the two solutions; and (4) whether adding the antibiotic vancomycin impacts antiseptic activity.

METHODS

We measured in-vitro growth and biofilm formation of Staphylococcus epidermidis, meticillin-sensitive and meticillin-resistant Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa and Candida albicans, as well as recent clinical isolates, in the presence of increasing concentrations of CHG and/or PI. Checkerboard assays were used to measure potential synergy of the solutions together and with vancomycin.

FINDINGS

CHG and PI inhibited growth and biofilm formation of all model organisms tested at concentrations of 0.0004% and 0.33% or lower, respectively; highly dilute concentrations paradoxically increased biofilm formation. The solutions did not synergize with one another and acted independently of vancomycin.

CONCLUSION

CHG and PI are effective at lower concentrations than typically used, establishing baselines to support further clinical trials aimed at optimizing wound disinfection. There is no synergistic advantage to using both in combination. Vancomycin is effective at inhibiting the growth of S. epidermidis and S. aureus; however, it stimulates P. aeruginosa biofilm production, suggesting in the rare case of P. aeruginosa PJI, it could exacerbate infection.

Clinical use and applications of a citrate-based antiseptic lavage for the prevention and treatment of PJI

Total joint arthroplasties (TJA) are some of the most commonly performed surgeries in the United States with the number of TJA expected to rise significantly over the next decade as the population ages and arthritic burden worsens. However, the rise in TJA volume correlates with a heightened risk of complications, notably prosthetic joint infections (PJI), despite their low occurrence rate of less than 2%. PJI imposes a significant burden on surgery success, patient well-being, and healthcare costs, with an estimated annual expense of 1.85 billion dollars for hip and knee PJI by 2030. This manuscript delves into the pathophysiology of PJI, exploring our current understanding of the role of bacterial biofilm formation on implanted foreign hardware, providing protection against the host immune system and antibiotics. The article reviews current agents and their efficacy in treating PJI, as well as their cytotoxicity toward native cells involved in wound healing, prompting the exploration of a novel citrate-based solution. The paper highlights the superior properties and efficacy of a novel citrate-based irrigation solution on the treatment and prevention of PJI via increased antimicrobial properties, greater biofilm disruption, increased exposure time, and reduced cytotoxicity compared to conventional solutions, positioning it as a promising alternative. It also provides a perspective on its clinical use in the operating theater, with a step-by-step approach in TJA, whether primary or revisionary.

Impact of a Novel Antiseptic Lavage Solution on Acute Periprosthetic Joint Infection in Hip and Knee Arthroplasty

Background: Periprosthetic joint infection (PJI) represents a challenge following hip or knee arthroplasty, demanding immediate intervention to prevent implant failure and systemic issues. Bacterial biofilm development on orthopedic devices worsens PJI severity, resulting in recurrent hospitalizations and significant economic burdens. The objective of this retrospective cohort study is to evaluate the efficacy of this novel antiseptic solution, never previously evaluated in vivo, in managing early post-operative or acute hematogenous PJI following primary hip and knee joint replacements. Methods: The inclusion criteria consist of patients with total hip arthroplasty (THA) or knee arthroplasty diagnosed with acute PJI through preoperative and intraoperative investigations, in accordance with the MSIS ICM 2018 criteria. The minimum required follow-up was 12 months from the cessation of antibiotic therapy. This novel antiseptic lavage solution is composed of ethanol, acetic acid, sodium acetate, benzalkonium chloride and water. Data included demographic characteristics, diagnostic criteria, surgical techniques, post-operative treatment and follow-up outcomes. Results: A total of 39 patients treated with Debridement, Antibiotics Pearls and Retention of the Implant (DAPRI) procedures using this solution between May 2021 and April 2023 were analyzed. At a mean follow-up of 24.6 ± 6.4 months, infection recurrence-free survival rates were 87.2%, with no local allergic reactions or relevant systemic adverse effects detected. Persistent PJI necessitated two-stage revision surgery. Conclusions: This novel antiseptic lavage solution shows promise as an adjunctive tool in the treatment of PJI, demonstrating support in infection control while maintaining a favorable safety profile.

The effect and mechanism of iodophors on the adhesion and virulence of Staphylococcus aureus biofilms attached to artificial joint materials

BACKGROUND

Iodophors are known to be a treatment for biofilm-related periprosthetic joint infection. However, the efficacy and mechanism of eradicating biofilms from different artificial joint materials after iodophor treatment are unknown. This study was conducted to understand the effect and mechanism of iodophors with respect to the adhesion and virulence of Staphylococcus aureus biofilms attached to artificial joint materials.

METHODS

Biofilms of Staphylococcus aureus strains were grown on titanium alloy, cobalt chromium molybdenum and polyethylene coupons, which are commonly used materials for artificial joints, for 24 h. Afterward, all coupons were divided into experimental and control groups: (1) exposed to a 0.5 ± 0.05% iodophor for 5 min and (2) exposed to phosphate-buffered saline for 5 min. To gauge the level of biofilm, colony forming units (CFU), live/dead staining confocal microscopy and crystal violet staining were used. Meanwhile, the expression of icaACDR and clfA, which are related to virulence and adhesion, was examined in both the experimental and control groups.

RESULTS

A roughly three-log decrease in CFU/cm2 was seen in the viable plate count compared to the control group. Confocal imaging and crystal violet staining verified the CFU data. Moreover, the expression of icaACDR was reduced on three different orthopaedic implant materials, and the expression of clfA was also inhibited on titanium alloy coupons exposed to the iodophor.

CONCLUSIONS

Our results indicated that exposure to an iodophor for 5 min could significantly eliminate biofilms. When Staphylococcus aureus that had adhered to these three materials, which were used for artificial joints, was treated with an iodophor for 5 min, the expression of icaACDR was significantly reduced. This provides strong evidence for clinically clearing periprosthetic joint infections without removing the artificial joints.

The role of negative pressure wound therapy with instillation and dwell time in the treatment of deep sternal wound infections-A retrospective cohort study

Background and Aims

Negative pressure wound therapy (NPWT) has gained a central role in the treatment of deep sternal wound infections (DSWIs) after median thoracotomy. Our study aims at proving the safety of using NPWT with instillation and dwell time (NPWTi-d) in the treatment of DSWI.

Methods

We retrospectively evaluated the patients who were treated at our institution between March 2018 and November 2021 for DSWI after radical sternectomy using NPWT or NPWTi-d. The NPWTi-d was applied to start the first postoperative day using 75 mmHg negative pressure for 3 h, followed by instillation of sodium hypochlorite <0.08% with a 3-min dwell time.

Results

The NPWTi-d group showed a shorter length of stay (29.39 ± 12.09 vs. 39.54 ± 17.07 days; p = 0.049), a shorter elapsed time between the debridement and the flap coverage (7.18 ± 4.27 vs. 11.86 ± 7.7 days; p = 0.003) and less operative or nonoperative dressing changes (1.73 ± 1.14 vs. 2.68 ± 56; p < 0.001). The in-hospital mortality was 8.2%, with no significant differences between the two groups (p = 1).

Conclusion

NPWTi-d can be safely employed in the treatment of DSWI. Further prospective randomized studies need to establish the role of NPWTi-d in the control of infection and biofilm as well as in wound healing.

Hydrogen Peroxide, Povidone-Iodine and Chlorhexidine Fail to Eradicate Staphylococcus aureus Biofilm from Infected Implant Materials

Hydrogen peroxide, povidone-iodine, and chlorhexidine are antiseptics that are commonly added to irrigants to either prevent or treat infection. There are little clinical data available that demonstrate efficacy of adding antiseptics to irrigants in the treatment of periprosthetic joint infection after biofilm establishment. The objective of the study was to assess the bactericidal activity of the antiseptics on S. aureus planktonic and biofilm. For planktonic irrigation, S. aureus was exposed to different concentrations of antiseptics. S. aureus biofilm was developed by submerging a Kirschner wire into normalized bacteria and allowing it to grow for forty-eight hours. The Kirschner wire was then treated with irrigation solutions and plated for CFU analysis. Hydrogen peroxide, povidone-iodine, and chlorhexidine were bactericidal against planktonic bacteria with over a 3 log reduction (p < 0.0001). Unlike cefazolin, the antiseptics were not bactericidal (less than 3 log reduction) against biofilm bacteria but did have a statistical reduction in biofilm as compared to the initial time point (p < 0.0001). As compared to cefazolin treatment alone, the addition of hydrogen peroxide or povidone-iodine to cefazolin treatment only additionally reduced the biofilm burden by less than 1 log. The antiseptics demonstrated bactericidal properties with planktonic S. aureus; however, when used to irrigate S. aureus biofilms, these antiseptics were unable to decrease biofilm mass below a 3 log reduction, suggesting that S. aureus biofilm has a tolerance to antiseptics. This information should be considered when considering antibiotic tolerance in established S. aureus biofilm treatment.

Principles of mechanical and chemical debridement with implant retention

BACKGROUND

Periprosthetic joint infection (PJI) is one of the most common causes of early revision for total hip and knee arthroplasty. Mechanical and chemical debridement typically referred to as debridement, antibiotics, and implant retention (DAIR) can be a successful technique to eradicate PJI in acute postoperative or acute hematogenous infections. This review will focus specifically on the indications, techniques, and outcomes of DAIR.

DISCUSSION

The success of mechanical and chemical debridement, or a DAIR operation, is reliant on a combination of appropriate patient selection and meticulous technique. There are many technical considerations to take into consideration. One of the most important factors in the success of the DAIR procedure is the adequacy of mechanical debridement. Techniques are surgeon-specific and perhaps contribute to the large variability in the literature on the success of DAIR. Factors that have been shown to be associated with success include the exchange of modular components, performing the procedure within seven days or less of symptom onset, and possibly adjunctive rifampin or fluoroquinolone therapy, though this remains controversial. Factors that have been associated with failure include rheumatoid arthritis, age greater than 80 years, male sex, chronic renal failure, liver cirrhosis, and chronic obstructive pulmonary disease.

CONCLUSIONS

DAIR is an effective treatment option for the management of an acute postoperative or hematogenous PJI in the appropriately selected patient with well-fixed implants.

Preclosure povidone-iodine lavage in total hip replacement surgery: Infection outcomes and cost-benefit analysis

OBJECTIVE

To report the outcomes and cost-benefit analysis of preclosure povidone-iodine lavage (PrePIL) used to reduce the risk of infection following total hip replacement (THR) surgery.

STUDY DESIGN

Retrospective study.

ANIMALS

One thousand six hundred ninety-nine dogs, 17 cats.

METHODS

The medical records of 2213 consecutive THR cases were reviewed to determine the incidence of infection. The last 102 were treated with PrePIL using a commercially sourced 0.035% povidone-iodine solution. Postoperative infection rates were compared. A cost-benefit analysis was used to calculate if a PrePIL protocol is economically feasible.

RESULTS

Twenty-one THRs out of 2111 (0.99%) that did not have PrePIL developed infection. Infection occurred in none of the 102 PrePIL cases. Cost analysis revealed a PrePIL break-even cost at $49.74 and a break-even infection rate of 0.949%. No complications were identified related to the use of PrePIL.

CONCLUSION

Preclosure povidone-iodine lavage appeared to be efficacious in lowering THR infection rates, and it appeared to be safe for this use based on our 102 consecutive cases. The cost of the PrePIL was minimal compared to the overall cost to resolve THR infection and the potential effect on hip function prognosis. The math formulas developed can be used by surgeons to calculate cost effectiveness and break-even cost based on their THR infection rate, and to compare to the cost of a THR revision and infection resolution.

CLINICAL SIGNIFICANCE

At current costs, PrePIL can be used in 2415 THR cases at a similar cost of a single revision surgery and resolution of a periprosthetic infection.

Irrigation Solutions in Total Joint Arthroplasty

INTRODUCTION

Despite advancements in the field of adult reconstruction, prosthetic joint infection (PJI) remains a common and devastating complication of total joint arthroplasty. Eradication of these infections can often prove difficult, and they remain a source of considerable morbidity and mortality. This clinical review paper will focus on some of the more commonly used irrigation solutions; povidone-iodine (PI), chlorhexidine (CHG), acetic acid (AA), hydrogen peroxide (HP), antibiotic irrigations, taurolidine, and polyhexanide-betaine (PB).

SUMMARY OF THE EVIDENCE

Significant research has been performed on the prevention of PJI, including use of intraoperative joint irrigation solutions. Several solutions have been theorized to aid in infection prevention, but no evidence-based practice guidelines in this area of orthopaedics have been established. There is a paucity of prospective randomized control trials to compare the efficacy of these joint irrigation solutions.

CONCLUSIONS

The authors present a review regarding seven major categories of commonly used intraoperative joint irrigation solutions. The current literature fails to demonstrate a clear consensus for a preferred solution and concentration for povidone-iodine, chlorhexidine, hydrogen peroxide, acetic acid, antibiotic irrigations, taurolidine, and polyhexanide-betaine. Prospective, randomized control trials directly comparing these different irrigation solutions are needed.

A review of current practices in periprosthetic joint infection debridement and revision arthroplasty

BACKGROUND

Periprosthetic joint infection remains a significant challenge for arthroplasty surgeons globally. Over the last few decades, there has been much advancement in terms of treatment and diagnosis, however, the fight rages on. As management of periprosthetic joint infections continues to evolve, it is critical to reflect back on current debridement practices to establish common ground as well as identify areas for future research and improvement. BODY: In order to understand the debridement techniques of periprosthetic joint infections, one must also understand how to diagnose a periprosthetic joint infection. Multiple definitions have been elucidated over the years with no single consensus established but rather sets of criteria. Once a diagnosis has been established the decision of debridement method becomes whether to proceed with single vs two-stage revision based on the probability of infection as well as individual patient factors. After much study, two-stage revision has emerged as the gold standard in the management of periprosthetic infections but single-stage remains prominent with further and further research.

CONCLUSION

Despite decades of data, there is no single treatment algorithm for periprosthetic joint infections and subsequent debridement technique. Our review touches on the goals of debridement while providing a perspective as to diagnosis and the particulars of how intraoperative factors such as intraarticular irrigation can play pivotal roles in infection eradication. By providing a perspective on current debridement practices, we hope to encourage future study and debate on how to address periprosthetic joint infections best.

Irrigation Solutions and Antibiotic Powders: Should I Use Them in Primary and Revision Total Joint Arthroplasty?

BACKGROUND

The prevention and treatment of periprosthetic joint infection is of utmost importance to orthopedic surgeons. Irrigation solutions have become a popular additive to the prevention and treatment armamentarium.

METHODS

This symposium summarizes the mechanism of action, basic science, and clinical research to date on the use of irrigation solutions. The four most commonly used irrigation solutions, povidone iodine, chlorhexidine, hydrogen peroxide, and acetic acid, are discussed. In addition, the role of antibiotic powers is reviewed.

RESULTS

Each solution has its risks and benefits that must be weighed by the surgeon. There is no clear irrigation solution that is superior. The role of additive antibiotic powder (vancomycin) remains controversial.

CONCLUSION

More rigorous prospective clinical trials are needed to determine the optimal irrigation solution for the prevention and treatment of periprosthetic joint infection.

A Novel Irrigant to Eliminate Planktonic Bacteria and Eradicate Biofilm Superstructure With Persistent Effect During Total Hip Arthroplasty

BACKGROUND

Numerous studies have examined the use of topical and irrigation-related adjuvants to decrease the risk of periprosthetic joint infection (PJI) after total hip arthroplasty. Many issues related to their use remain to be investigated. These include cost, antibiotic stewardship, bactericidal effect on planktonic bacteria, host cytotoxicity, necessity to irrigate/dilute potentially cytotoxic agents after their application, and impact on biofilm.

METHODS

Bacterial strains of microorganisms were grown in optimal medium. After the growth phase, the organisms were exposed to the novel irrigation solution (XPerience) or phosphate buffer solution (PBS) for 5 minutes before a neutralizing broth was added. The colony-forming units per milliliter and the log reduction in colony-forming units in the treated sample vs the control were then determined. Subsequently, biofilms of microorganisms were grown on hydroxyapatite-coated glass slides. Each slide was then exposed to irrigation solutions for various contact times. Biofilm quantification was performed and the log10 density of each organism was obtained.

RESULTS

In vitro testing of the irrigant demonstrated 6-log reductions in planktonic bacteria in 5 minutes, and 4-log to 8-log reductions in biofilms. Laboratory tissue testing has demonstrated minimal cytotoxic effects to host tissue allowing for solution to remain in contact with the host without need for subsequent irrigation, creating a barrier to biofilm for up to 5 hours after its application.

CONCLUSION

This novel irrigant demonstrates high efficacy against both planktonic bacteria and bacterial biofilms in laboratory testing. Large series in vivo data are necessary to further establish its efficacy in reducing primary and recurrent surgical site infections.

Antiseptic Irrigation Solutions Used in Total Joint Arthroplasty: A Critical Analysis Review

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There are limited data that directly compare the efficacy of antiseptic irrigation solutions used for the prevention and treatment of periprosthetic joint infections in orthopaedic procedures; there is a notable lack of prospective data.

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For prevention of periprosthetic joint infections, the strongest evidence supports the use of low-pressure povidone-iodine.

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For the treatment of periprosthetic joint infections, delivering multiple solutions sequentially may be beneficial.