Investigation and management of prosthetic joint infection in knee replacement: A BASK Surgical Practice Guideline

[Standards in inpatient care of infectious diseases]

In addition to the one-year advanced training program in infectious diseases that has been in place for several years, a six-year-full specialist training in internal medicine and infectious diseases (ID) has recently been introduced in Germany. While recommendations for ID training program curricula were developed, there is no description of genuine ID activities in Germany, nor have any working standards been defined to date. However, this seems to be necessary, both for the structural implementation of ID in German hospitals and for ensuring the quality-of-care. The current article therefore outlines standards for core ID activities as well as quality requirements for efficient ID training programs. As long as no separate speciality for pediatric ID is established in Germany, these principles should also apply in paediatrics and adolescent medicine.

Implementation of multidisciplinary team decisions on the management of complex bone and joint infections: an observational study

BACKGROUND

Multidisciplinary team (MDT) management of prosthetic joint infections (PJI) and other bone and joint infections (BJI) is increasingly put into practice. However, studies evaluating the performance of MDTs in this field are scarce. We aimed to assess our MDT for complex BJI by determining the implementation rate of team decisions, analyzing factors associated with non-implementation and evaluating the clinical outcome of patients in whom MDT decisions were not implemented.

METHODS

An observational study was conducted on all patients with a PJI or other BJI of which the management was discussed during MDT meetings between 2015 and 2022 in a tertiary care academic hospital. Patient characteristics and MDT data were obtained from electronic patient records. The multidisciplinary team consisted of orthopaedic surgeons, trauma surgeons, infectious diseases specialists and clinical microbiologists. A decision was considered not implemented if the patient did not receive the management that was decided by the MDT. Factors possibly associated with non-implementation were statistically analyzed using logistic regression.

RESULTS

The analysis included 1321 MDT decisions on 509 patients. The overall implementation rate of MDT decisions was 92%. Reasons for non-implementation were disagreement by the treating surgeon with the MDT regarding the optimal treatment (n = 24, 23%), patient preference for a different treatment (n = 19, 18%), new clinical information not yet available during the MDT meeting that made the physician change management (n = 17, 16%) or unknown (n = 45, 43%). Trauma surgeons were more likely to not implement an MDT decision (odds ratio 2.4, p = 0.01) The cure rate of patients who received a different surgical strategy than decided by the MDT was 33%. The cure rate was lower if a patient chose to deviate from the MDT decision (46%) than when the treating physician chose to deviate from the MDT decision (77%).

CONCLUSION

The implementation rate of decisions made by our complex BJI MDT was high. Furthermore, the current study suggests that non-implementation of MDT decisions on surgical management and non-implementation initiated by the patient lead to poor clinical outcomes. An analysis of MDT decision implementation is a useful tool to evaluate the impact of MDTs and further improve its quality.

Global practice variation of suppressive antimicrobial treatment for prosthetic joint infections: A cross-sectional survey study

OBJECTIVES

To identify global differences in the use of suppressive antimicrobial therapy (SAT) in the management of prosthetic joint infection (PJI).

METHODS

An online survey was designed to investigate clinician's approach to SAT for PJI, including indications, preferred antimicrobial drugs, dosing, treatment duration and follow-up. The survey was distributed to members of four international (bone and joint) infection societies and study groups.

RESULTS

Respondents comprised 330 physicians (204 infectious diseases specialists, 110 orthopedic surgeons, 23 clinical microbiologists) from 43 different countries (Europe, n = 134, 41%; Oceania n = 112, 34%; North America, n = 51, 16%; other, n = 33, 10%; total response rate 20%). After debridement, antibiotics and implant retention (DAIR) or one-stage revision, SAT would be initiated often or almost always by 38% of respondents from North America, but only in 6% from Europe and 7% from Oceania. First choices of SAT for staphylococcal PJI were oral cephalosporins (39%) and tetracyclines (31%) in North America; tetracyclines (27%) and anti-staphylococcal penicillins (22%) in Europe; and anti-staphylococcal penicillins (55%) in Oceania. There was no global or regional preferred SAT regimen for Gram-negative PJI. Of all respondents, dosage of SAT was never lowered (n = 126, 38%), lowered for specific antibiotics (n = 125, 38%) or lowered for all antibiotics (n = 79, 24%). SAT was prescribed for a lifelong duration (n = 43, 13%), a fixed duration (range 6 months-3 years) (n = 104, 32%) or for an undetermined duration (n = 154, 47%).

CONCLUSIONS

Approach to SAT in PJI is highly regional, with no consensus regarding the indication, selection, dose, or duration of SAT between physicians worldwide. This reflects the paucity of data and need for high quality studies to define the optimal use of SAT in the treatment of patients with PJI.

Serum and Synovial Vancomycin Concentrations in Patients with Prosthetic Joint Infection after Intra-articular Infusion

BACKGROUND AND OBJECTIVES

Vancomycin is one of the most commonly used antibiotics for intra-articular (IA) infusion in the treatment of prosthetic joint infection (PJI). This study aimed to preliminarily investigate the serum and synovial vancomycin concentrations in patients with PJI after IA infusion.

METHODS

In total, 16 patients who developed PJI were enrolled in this study; 14 of the patients were treated with IA infusion of vancomycin postoperatively, while the other 2 patients received intravenous (IV) infusion of vancomycin alone. Chemiluminescent immunoassay assay (CLIA) and high-performance liquid chromatography (HPLC) were used to determine the serum and synovial vancomycin concentrations, respectively.

RESULTS

Administration of vancomycin 0.5 g once daily (qd) IA maintained a high vancomycin trough concentration in synovial fluid before the next IA dose, regardless of whether it was given in combination with IV administration. The combination vancomycin 0.5 g qd IA + vancomycin 1 g every 12 h (q12h) IV yielded relatively good trough concentrations of vancomycin in both serum and synovial fluid. The mean trough serum vancomycin concentration of patients who used vancomycin 1 g q12h IV therapy was above 10 μg/mL; however, no vancomycin was detected in their synovial fluid.

CONCLUSIONS

The rational use of IA vancomycin infusion may help to achieve effective therapeutic concentrations of vancomycin in the serum and synovial fluid of patients with PJI.

Revision knee replacement surgery in the NHS: A BASK surgical practice guideline

BACKGROUND

Revision knee replacement (KR) is both challenging for the surgical team and expensive for the healthcare provider. Limited high quality evidence is available to guide decision-making.

AIM

To provide guidelines for surgeons and units delivering revision KR services.

METHODS

A formal consensus process was followed by BASK's Revision Knee Working Group, which included surgeons from England, Wales, Scotland and Northern Ireland. This was supported by analysis of National Joint Registry data.

RESULTS

There are a large number of surgeons operating at NHS sites who undertake a small number of revision KR procedures. To optimise patient outcomes and deliver cost-effective care high-volume revision knee surgeons working at high volume centres should undertake revision KR. This document outlines practice guidelines for units providing a revision KR service and sets out: The current landscape of revision KR in England, Wales and Northern Ireland. Service organisation within a network model. The necessary infrastructure required to provide a sustainable revision service. Outcome metrics and auditable standards. Financial mechanisms to support this service model.

CONCLUSIONS

Revision KR patients being treated in the NHS should be provided with the best care available. This report sets out a framework to both guide and support revision KR surgeons and centres to achieve this aim.

Financial analysis of revision knee surgery at a tertiary referral centre as classified according to the Revision Knee Complexity Classification (RKCC)

BACKGROUND

Revision total knee arthroplasty (rTKA) can be complex, with greater costs to the treating hospital than primary TKA. A rTKA regional network has been proposed in England. The aim of this work was to accurately quantify current costs and reimbursement for the rTKA service and to assess whether costs are proportional to case complexity at a tertiary referral centre within the National Health Service (NHS).

METHODS

A review of all rTKA performed at our institution over two consecutive financial years (2017-2019) was performed. Cases were classified according to the Revision Knee Complexity Classification (RKCC) and by mode of failure; "infected" and "non-infected". Financial data was acquired through Patient-Level Information and Costing System (PLICS). The primary outcome was the financial difference between tariff and cost per episode. Comparisons between groups were analysed using analysis of variance and two-tailed unpaired t-test as appropriate.

RESULTS

159 patients underwent 188 rTKA procedures. Length of stay and cost significantly increased between complexity groups (p < 0.0001) and for infected revisions (p < 0.0001). All groups sustained a mean deficit but this significantly increased with revision complexity (from £1,903 to £5,269 per case) and for infected revisions. The total deficit to the Trust for the two-year rTKA service was £667,091.

CONCLUSIONS

The current level of NHS reimbursement are inadequate for centres that offer rTKA and should be more closely aligned to case complexity. An increase in the most complex rTKA at major revision centres will undoubtedly place an even greater strain on the finances of these units.