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Thompson E, Qureshi A. Pathogens in FRI - Do bugs matter? - An analysis of FRI studies to assess your enemy. J Orthop 2024; 53:59-72. [PMID: 38476676 PMCID: PMC10925936 DOI: 10.1016/j.jor.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 02/09/2024] [Indexed: 03/14/2024] Open
Abstract
Fracture-related infection (FRI) is a devasting complication for both patients and their treating Orthopaedic surgeon that can lead to loss of limb function or even amputation. The unique and unpredictable features of FRI make its diagnosis and treatment a significant challenge. It has substantial morbidity and financial implications for patients, their families and healthcare providers. In this article, we perform an in-depth and comprehensive review of FRI through recent and seminal literature to highlight evolving definitions, diagnostic and treatment approaches, focusing on common pathogens such as Staphylococcus aureus, polymicrobial infections and multi-drug-resistant organisms (MDRO). Furthermore, multiple resistance mechanisms and adaptations for microbial survival are discussed, as well as modern evidence-based medical and surgical advancements in treatment strategies in combating FRI.
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Affiliation(s)
- Emmet Thompson
- Limb Reconstruction Service, Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
| | - Amir Qureshi
- Limb Reconstruction Service, Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
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2
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Eiselt VA, Bereswill S, Heimesaat MM. Phage therapy in prosthetic joint infections caused by Staphylococcus aureus - A literature review. Eur J Microbiol Immunol (Bp) 2024; 14:75-85. [PMID: 38436674 PMCID: PMC11097790 DOI: 10.1556/1886.2024.00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 02/19/2024] [Indexed: 03/05/2024] Open
Abstract
Prosthetic joint infections (PJIs) are dreaded arthroplasty complications often caused by Staphylococcus aureus. Due to methicillin-resistant S. aureus (MRSA) strains or biofilm formation, successful treatment remains difficult. Currently, two-stage revision surgery constitutes the gold standard therapy of PJIs, sometimes replaced or supplemented by debridement, antibiotics, and implant retention (DAIR). Given the dire consequences of therapeutic failure, bacteriophage therapy might be another treatment option. Here we provide a comprehensive literature review addressing the efficacy of phages applied against S. aureus as causative agent of PJIs. The included 17 publications had in common that the applied phages proved to be effective against various S. aureus isolates including MRSA even in biofilms. Experiments with mice, rats, rabbits, and moth larvae confirmed favorable features of phage preparations in PJI treatment in vivo; including its synergistic with antibiotics. Case reports of PJI patients unanimously described the bacterial eradication following, alongside other measures, intravenous and intra-articular phage administration. Generally, no major side effects occurred, but in some cases elevated liver transaminases were observed. To conclude, our review compiled promising evidence suggesting the safety and suitability of phage therapy as an adjuvant to DAIR in S. aureus PJIs, and thus, underscores the significance of further research.
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Affiliation(s)
- Vincent A. Eiselt
- Gastrointestinal Microbiology Research Group, Institute of Microbiology, Infectious Diseases and Immunology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Stefan Bereswill
- Gastrointestinal Microbiology Research Group, Institute of Microbiology, Infectious Diseases and Immunology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Markus M. Heimesaat
- Gastrointestinal Microbiology Research Group, Institute of Microbiology, Infectious Diseases and Immunology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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3
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Vicenti G, Pesare E, Colasuonno G, Buono C, Albano F, Ladogana T, Passarelli AC, Solarino G. Debridement, Antibiotic Pearls, and Retention of the Implant (DAPRI) in the Treatment of Early Periprosthetic Knee Joint Infections: A Literature Review. Healthcare (Basel) 2024; 12:843. [PMID: 38667605 PMCID: PMC11050335 DOI: 10.3390/healthcare12080843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
(1) Background: Periprosthetic joint infections (PJIs) are severe and frightening complications in orthopaedic surgery, and they are generally divided into three categories: early infections (those occurring within the first 4-6 weeks), delayed infections (those occurring between 3 and 24 months), and late infections (those occurring more than 2 years after surgery). PJI treatment comprises "debridement, antibiotics, and implant retention" (DAIR), single-stage revision, and double-stage revision. Nowadays, to improve the chances of retaining an infected implant and to improve the traditional DAIR method, a modified surgical technique has been developed, named DAPRI (debridement, antibiotic pearls, and retention of the implant). Our study aims to present an up-to-date concept evaluation of the DAPRI technique and its success rate. (2) Methods: Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards were followed, applying a protocol defined by the authors: a total of 765 articles were identified, and at the end of the screening process only 7 studies were included. (3) Results: Currently, the DAPRI procedure can be performed only on patients who have had PJI symptoms for less than 4 weeks, and in order to achieve the highest success rate, indications are quite strict: it is appropriate in patients with acute, superficial infections without sinus tract presence, and well-fixed implants with known sensitive bacteria. The DAPRI surgical method follows a step-by-step process consisting of a first phase of biofilm identification with intra-articular injection of methylene blue, followed by biofilm removal (thermic, mechanical, and chemical aggression), and a last step consisting of prevention of PJI recurrence by using calcium sulphate antibiotic-added beads. (4) Conclusions: The DAPRI approach improves the traditional DAIR technique. It is a correct treatment for acute and early haematogenous PJI, and improves the DAIR success rate.
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Affiliation(s)
| | - Elisa Pesare
- Orthopaedics Unit, Department of Basic Medical Science, Neuroscience and Sensory Organs, School of Medicine, University of Bari “Aldo Moro”, AOU Consorziale Policlinico, 70124 Bari, Italy; (G.V.); (G.C.); (C.B.); (F.A.); (T.L.); (A.C.P.); (G.S.)
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Barksfield R, Hamal P, Hamal D, Porteous A, Murray J. The Safety of Glycopeptide-Impregnated Calcium Sulphate Following Debridement, Antibiotics and Implant Retention (DAIR) for Infected Total Knee Replacement. Cureus 2024; 16:e57955. [PMID: 38738147 PMCID: PMC11083777 DOI: 10.7759/cureus.57955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 05/14/2024] Open
Abstract
Background and objective The impact of prosthetic joint infection (PJI) stretches far beyond the physical nature of the disease. It can result in psychological and social consequences, with significant morbidity and mortality for patients. Calcium sulphate-based delivery agents are effective in the management of PJI, yet with associated risks of systemic adverse events. This study aims to evaluate the risk of systemic adverse events when using calcium-sulphate-based local antibiotic delivery agents in the management of PJIs. Methodology We identified 43 patients who underwent debridement, antibiotics and implant retention (DAIR) for infected total knee arthroplasty (TKA) between 2008 and 2014. Patients in the control groupunderwent conventional intravenous and then oral antibiotic administration, while those in the intervention groupunderwent additional local antibiotic therapy via a calcium sulphate alpha hemihydrate matrix. Case notes and laboratory results data were compiled to establish the safety and efficacy of local glycopeptide delivery. Results Serum vancomycin levels were within the safe therapeutic range for all patients in the intervention group with no difference in serum assays between treatment groups (intervention 7.7 mg/L; control 8.0 mg/L; P = 0.85). Renal function for the study cohort improved at every time point post-operatively when referenced against pre-operative renal function (P < 0.05). There was no difference in renal function between intervention and control groups on day 1, one week, six weeks or 12 weeks post-operatively (P = 0.78, 0.89, 0.20 and 0.50). Conclusions Local glycopeptide delivery via a calcium sulphate alpha hemihydrate matrix did not result in systemic adverse consequences specifically not raising the systemic level of glycopeptide, nor reducing renal function. Implications for future research Although demonstrates a safety profile and potential therapeutic benefit, the long-term efficacy of this approach needs to be established. Importantly, selection bias may contribute to masking clinically significant differences in post-operative outcomes.
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Affiliation(s)
- Richard Barksfield
- Orthopaedics, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, GBR
| | - Pravakar Hamal
- Orthopaedics, University Hospital of Llandough, Cardiff, GBR
| | - Divakar Hamal
- Intensive Care Unit, Kings College London, London, GBR
| | - Andrew Porteous
- Trauma and Orthopaedics, North Bristol NHS Trust, Bristol, GBR
| | - James Murray
- Trauma and Orthopaedics, North Bristol NHS Trust, Bristol, GBR
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McCormick KL, Xu W, Cozzarelli NF, Crawford D, Wilson EJ, Berend KR, Fricka KB, Lonner JH, Geller JA. Debridement, Antibiotics, and Implant Retention in Unicompartmental Knee Arthroplasty Infection. J Arthroplasty 2024:S0883-5403(24)00273-0. [PMID: 38548232 DOI: 10.1016/j.arth.2024.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND This multicenter study sought to further investigate the method and outcome of debridement, antibiotics, and implant retention (DAIR) for the management of unicompartmental knee periprosthetic joint infection (PJI). METHODS This retrospective study was performed on 52 patients who underwent DAIR for PJI of a unicompartmental knee arthroplasty (UKA) across 4 academic medical centers, all performed by fellowship-trained arthroplasty surgeons. Patient demographics, American Society of Anesthesiologists score, infecting organism, operative data, antibiotic data, and success in infection control at 1 year were collected. RESULTS The average time from index surgery to diagnosis of PJI was 11.1 weeks (range, 1.4 to 48). There was no correlation between time of diagnosis and success at 1 year (R = 0.09, P = .46). There was an association between surgical synovectomy and the eradication of infection (R = 0.28, P = .04). Overall, there was an 80.8% (42 of 52) infection-controlled success rate at 1 year from the DAIR procedure. All DAIR failures went on to require another procedure, either 1-stage (2 of 10) or 2-stage (8 of 10) revision to total knee arthroplasty (TKA). Of the DAIR successes, 6 (14.3%) went on to require conversion to TKA for progression of arthritis within 5 years. CONCLUSIONS This study demonstrates that DAIR is a safe and moderately effective procedure in the setting of acute PJI of UKA across institutions, with a success rate consistent with DAIR for TKA. The data suggest that a wide exposure and thorough synovectomy be incorporated during the DAIR UKA to improve the likelihood of successful eradication of PJI at the 1-year mark. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Kyle L McCormick
- Department of Orthopedic Surgery, New York Presbyterian - Columbia University, New York, New York
| | - Winnie Xu
- Department of Orthopedic Surgery, New York Presbyterian - Columbia University, New York, New York
| | - Nicholas F Cozzarelli
- Department of Orthopedic Surgery, Rothman Orthopaedic Institute, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - David Crawford
- Department of Orthopedic Surgery, Joint Implant Surgeons (JIS) Orthopedics, New Albany, Ohio
| | - Eric J Wilson
- Department of Orthopedic Surgery, Anderson Orthopaedic Clinic, Alexandria, Virginia
| | - Keith R Berend
- Department of Orthopedic Surgery, Joint Implant Surgeons (JIS) Orthopedics, New Albany, Ohio
| | - Kevin B Fricka
- Department of Orthopedic Surgery, Anderson Orthopaedic Clinic, Alexandria, Virginia
| | - Jess H Lonner
- Department of Orthopedic Surgery, Rothman Orthopaedic Institute, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jeffrey A Geller
- Department of Orthopedic Surgery, New York Presbyterian - Columbia University, New York, New York
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Lora-Tamayo J, Mancheño-Losa M, Meléndez-Carmona MÁ, Hernández-Jiménez P, Benito N, Murillo O. Appropriate Duration of Antimicrobial Treatment for Prosthetic Joint Infections: A Narrative Review. Antibiotics (Basel) 2024; 13:293. [PMID: 38666969 PMCID: PMC11047716 DOI: 10.3390/antibiotics13040293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/16/2024] [Accepted: 03/19/2024] [Indexed: 04/29/2024] Open
Abstract
Prosthetic joint infections are considered difficult to treat they needing aggressive surgery and long antimicrobial treatments. However, the exact duration of these therapies has been established empirically. In the last years, several studies have explored the possibility of reducing the length of treatment in this setting, with conflicting results. In this narrative review, we critically appraise the published evidence, considering the different surgical approaches (implant retention [DAIR] and one-step and two-step exchange procedures) separately. In patients managed with DAIR, usually treated for at least 12 weeks, a large, randomized trial failed to show that 6 weeks were non-inferior. However, another randomized clinical trial supports the use of 8 weeks, as long as the surgical conditions are favorable and antibiotics with good antibiofilm activity can be administered. In patients managed with a two-step exchange procedure, usually treated during 6 weeks, a randomized clinical trial showed the efficacy of a 4-week course of antimicrobials. Also, the use of local antibiotics may allow the use of even shorter treatments. Finally, in the case of one-step exchange procedures, there is a trend towards reducing the length of therapy, and the largest randomized clinical trial supports the use of 6 weeks of therapy.
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Affiliation(s)
- Jaime Lora-Tamayo
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, 28041 Madrid, Spain; (M.M.-L.); (P.H.-J.)
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
- CIBERINFEC—CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Mikel Mancheño-Losa
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, 28041 Madrid, Spain; (M.M.-L.); (P.H.-J.)
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
| | - María Ángeles Meléndez-Carmona
- Department of Microbiology, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, 28041 Madrid, Spain;
| | - Pilar Hernández-Jiménez
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, 28041 Madrid, Spain; (M.M.-L.); (P.H.-J.)
| | - Natividad Benito
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
- CIBERINFEC—CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- UQ Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane 4072, Australia
| | - Oscar Murillo
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
- CIBERINFEC—CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Department of Infectious Diseases, Hospital Universitario Bellvitge, IDIBELL (Instituto de Investigación Biomédica de Bellvitge), 08908 L’Hospitalet de Llobregat, Spain
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7
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Asadollahi S, Hamilton TW, Sabah SA, Scarborough M, Price AJ, Gibbons CLMH, Murray DW, Alvand A. The outcomes of acute periprosthetic joint infection following unicompartmental knee replacement managed with early debridement, Antibiotics, and implant retention. Knee 2024; 47:13-20. [PMID: 38171207 DOI: 10.1016/j.knee.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 11/28/2023] [Accepted: 12/03/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) following unicompartmental knee replacement (UKR) is an uncommon, yet serious, complication. There is a paucity of evidence regarding the effectiveness of Debridement-Antibiotics-and-Implant-Retention (DAIR) in this setting. The aim of this study is to investigate the effectiveness of DAIR for acute UKR PJI. METHOD Between 2006 and 2019, 5195 UKR were performed at our institution. Over this period, sixteen patients underwent DAIR for early, acute PJI. All patients met MSIS PJI diagnostic criteria. The median age at DAIR was 67 years (range 40-73) and 12 patients were male (75.0%). The median time to DAIR was 24 days (range 6-60). Patients were followed up for a median of 6.5 years (range1.4-10.5) following DAIR. RESULTS 0.3% (16/5195) of UKR in our institution had a DAIR within 3 months. 15 of 16 patients (93.8%) were culture positive, with the most common organism MSSA (n = 8, 50.0%). Patients were treated with an organism-specific intravenous antibiotic regime for a median of 6 weeks, followed by oral antibiotics for a median duration of 6 months. The Kaplan-Meier survivor estimate for revision for PJI was 57% (95%CI: 28-78%) at five years, and survivor estimate for all cause revision 52% (95%CI: 25-74%).The median Oxford Knee Score for patients with a viable implant at final follow-up was 45 points (range 39-46). CONCLUSION Early, acute PJI after UKR is rare. DAIR had a moderate success rate, with infection-free survivorship of 57% at 5 years. Those successfully treated with DAIR had excellent functional outcome and implant survival.
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Affiliation(s)
- S Asadollahi
- Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7LD, UK
| | - T W Hamilton
- Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7LD, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK
| | - S A Sabah
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK
| | - M Scarborough
- Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7LD, UK
| | - A J Price
- Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7LD, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK
| | - C L M H Gibbons
- Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7LD, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK
| | - D W Murray
- Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7LD, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK
| | - A Alvand
- Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7LD, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK.
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8
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Longo UG, De Salvatore S, Bandini B, Lalli A, Barillà B, Budhiparama NC, Lustig S. Debridement, antibiotics, and implant retention (DAIR) for the early prosthetic joint infection of total knee and hip arthroplasties: a systematic review. J ISAKOS 2024; 9:62-70. [PMID: 37714518 DOI: 10.1016/j.jisako.2023.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 09/17/2023]
Abstract
PURPOSE Early periprosthetic joint infection (PJI) represents one of the most fearsome complications of joint replacement. No international consensus has been reached regarding the best approach for early prosthetic knee and hip infections. The aim of this updated systematic review is to assess whether debridement, antibiotics, and implant retention (DAIR) is an effective choice of treatment in early postoperative and acute hematogenous PJI. METHODS This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The diagnostic criteria defining a PJI, the most present pathogen, and the days between the index procedure and the onset of the PJI were extracted from the selected articles. Additionally, the mean follow-up, antibiotic regimen, and success rate of the treatment were also reported. RESULTS The articles included provided a cohort of 970 patients. Ten studies specified the joint of their cohort in PJIs regarding either hip prostheses or knee prostheses, resulting in 454 total knees and 460 total hips. The age of the patients ranged from 18 to 92 years old. Success rates for the DAIR treatments in the following cohort ranged from 55.5% up to a maximum of 90% (mean value of 71%). CONCLUSION Even though the DAIR procedure is quite limited, it is still considered an effective option for patients developing an early post-operative or acute hematogenous PJI. However, there is a lack of studies, in particular randomized control trials (RCTs), comparing DAIR with one-stage and two-stage revision protocols in the setting of early PJIs, reflecting the necessity to conduct further high-quality studies to face the burden of early PJI.
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Affiliation(s)
- Umile Giuseppe Longo
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy.
| | - Sergio De Salvatore
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy.
| | - Benedetta Bandini
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy.
| | - Alberto Lalli
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy.
| | - Bruno Barillà
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy.
| | | | - Sebastien Lustig
- Orthopaedic Department, Lyon North University Hospital, Hôpital de La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004 Lyon, France.
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9
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Van Engen MG, Carender CN, Glass NA, Noiseux NO. Outcomes After Successful Debridement, Antibiotic, and Implant Retention Therapy for Periprosthetic Joint Infection in Total Knee Arthroplasty. J Arthroplasty 2024; 39:483-489. [PMID: 37572722 DOI: 10.1016/j.arth.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 08/01/2023] [Accepted: 08/04/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND Controversy surrounds debridement, antibiotic and implant retention (DAIR) for treatment of acute periprosthetic joint infection (PJI). Data regarding DAIR's rate of infection resolution is variable with little investigation of functional outcomes. METHODS We identified 191 DAIR cases at a single institution from 2008 to 2020. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and Patient Reported Outcome Measurement Information System-10 (PROMIS) scores were collected. Patient Reported Outcome Scores were obtained from 60 cases. Median follow-up (IQR) was 4.5 (2.1 to 7.6) versus 3.0 (1.2 to 5.3) years for the control group. Mean scores were compared to a cohort of uncomplicated total knee arthroplasties matched by age, body mass index, and sex using generalized linear models adjusted for follow-up duration. Kaplan-Meier survivorship curves for PJI were constructed. RESULTS Mean Patient Reported Outcome Scores for the DAIR cohort were 57.2 ± 19.7 for KOOS-JR, 41.6 ± 7.1 for PROMIS physical health (PH), and 46.6 ± 8.7 for PROMIS mental health (MH). Mean control group values were 65.8 ± 21.0 for KOOS-JR, 44.6 ± 8.4 for PROMIS PH, and 49.2 ± 9.2 for PROMIS MH. No difference was observed in KOOS-JR (P = .83) or PROMIS MH (P = .11). PROMIS PH was lower in the DAIR cohort compared to the control group (P = .048). Median follow-up (years) for all 191 cases was 5.9 (range, 0.5 to 13.1). Survivorship (years) without subsequent operation for infection was 84% at 1, 82% at 2, and 79% at 5. CONCLUSION Knee and MH outcomes in successful DAIR procedures were similar to uncomplicated total knee arthroplasty. DAIR's success rate was 79% in treating acute PJI at 5 years. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Matthew G Van Engen
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Christopher N Carender
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Natalie A Glass
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Nicolas O Noiseux
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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10
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Cortes-Penfield N, Krsak M, Damioli L, Henry M, Seidelman J, Hewlett A, Certain L. How We Approach Suppressive Antibiotic Therapy Following Debridement, Antibiotics, and Implant Retention for Prosthetic Joint Infection. Clin Infect Dis 2024; 78:188-198. [PMID: 37590953 DOI: 10.1093/cid/ciad484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/03/2023] [Accepted: 08/14/2023] [Indexed: 08/19/2023] Open
Abstract
The optimal treatment of prosthetic joint infection (PJI) remains uncertain. Patients undergoing debridement, antibiotics, and implant retention (DAIR) receive extended antimicrobial treatment, and some experts leave patients at perceived highest risk of relapse on suppressive antibiotic therapy (SAT). In this narrative review, we synthesize the literature concerning the role of SAT to prevent treatment failure following DAIR, attempting to answer 3 key questions: (1) What factors identify patients at highest risk for treatment failure after DAIR (ie, patients with the greatest potential to benefit from SAT), (2) Does SAT reduce the rate of treatment failure after DAIR, and (3) What are the rates of treatment failure and adverse events necessitating treatment discontinuation in patients receiving SAT? We conclude by proposing risk-benefit stratification criteria to guide use of SAT after DAIR for PJI, informed by the limited available literature.
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Affiliation(s)
- Nicolas Cortes-Penfield
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Martin Krsak
- Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laura Damioli
- Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Michael Henry
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
- Department of Medicine, Division of Infectious Diseases, Hospital for Special Surgery, New York, New York, USA
| | - Jessica Seidelman
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Angela Hewlett
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Laura Certain
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
- Department of Internal Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, Utah, USA
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Debridement, antibiotics and implant retention (DAIR) is successful in the management of acutely infected unicompartmental knee arthroplasty: a case series. Ann Med 2023; 55:680-688. [PMID: 37074322 PMCID: PMC9970236 DOI: 10.1080/07853890.2023.2179105] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Infections are rare and poorly studied complications of unicompartmental knee arthroplasty (UKA) surgery. They are significantly less common compared to infections after total knee arthroplasties (TKAs). Optimal management of periprosthetic joint infections (PJIs) after a UKA is not clearly defined in the literature. This article presents the results of the largest multicentre clinical study of UKA PJIs treated with Debridement, Antibiotics and Implant Retention (DAIR). MATERIALS AND METHODS In this retrospective case series, patients presenting between January 2016 and December 2019 with early UKA infection were identified at three specialist centres using the Musculoskeletal Infection Society (MSIS) criteria. All patients underwent a standardized treatment protocol consisting of the DAIR procedure and antibiotic therapy comprising two weeks of intravenous (IV) antibiotics followed by six weeks of oral therapy. The main outcome measure was overall survivorship free from reoperation for infection. RESULTS A total of 3225 UKAs (2793 (86.2%) medial and 432 (13.8%) lateral UKAs) were performed between January 2016 and December 2019. Nineteen patients had early infections necessitating DAIR. The mean follow-up period was 32.5 months. DAIR showed an overall survivorship free from septic reoperation of 84.2%, with overall survivorship free from all-cause reoperation of 78.95%.The most common bacteria were Coagulase-negative Staphylococci, Staphylococcus aureus and Group B Streptococci. Three patients required a second DAIR procedure but remained free from re-infection at follow-up obviating the need for more demanding, staged revision surgery. CONCLUSIONS In infected UKAs, the DAIR procedure produces a high rate of success, with a high survivorship of the implant.Key messagesDebridement, Antibiotics and Implant Retention (DAIR) is a successful and minimally invasive surgical option for the management of periprosthetic joint infections (PJIs) after UKA.The surface area available for bacteria to colonise is much smaller in UKAs compared to total knee arthroplasties (TKAs), and this may account for the higher success rates of the DAIR procedure in infected UKAs versus infected TKAs.A second DAIR procedure can be considered in the management of the early recurrence of PJIs with a well-fixed UKA.
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12
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Chambers MM, Namdari S. A Review of Surgical Irrigation Solutions for Infection Prevention in Orthopaedic Surgery. JBJS Rev 2023; 11:01874474-202312000-00003. [PMID: 38079492 DOI: 10.2106/jbjs.rvw.23.00158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
» Intraoperative surgical irrigation is a common practice in orthopaedic procedures, although there is no universally established standard of care due to a lack of concrete data supporting an optimal irrigation agent.» Isotonic normal saline has long been considered a safe and cost effective solution for wound irrigation as compared with other antibiotic and antiseptic irrigation solutions.» Currently, the only adjunct to saline that is formally supported by American Academy of Orthopaedic Surgeons, the Centers for Disease Control and Prevention, and World Health Organization is povidone-iodine.» Further in vivo clinical studies are needed to identify the ideal irrigation solution that carries low cytotoxic effects while also exerting optimal antimicrobial properties.
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13
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Awad F, Boktor J, Joseph V, Lewis MH, Silva C, Sarasin S, Lewis PM. Debridement, antibiotics and implant retention (DAIR) following hip and knee arthroplasty: results and findings of a multidisciplinary approach from a non-specialist prosthetic infection centre. Ann R Coll Surg Engl 2023. [PMID: 37983007 DOI: 10.1308/rcsann.2023.0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023] Open
Abstract
INTRODUCTION Prosthetic joint infection (PJI) is a catastrophic complication following arthroplasty surgery. Recently a debridement, antibiotics and implant retention (DAIR) procedure has gained popularity for PJI where a thorough debridement, irrigation and modular component exchange is undertaken. METHOD We present the outcome for DAIR, data collected prospectively, in a busy orthopaedic unit but not one specialising in PJI. All patients with PJI were included without loss of data or patients from 2012 to 2018 with a minimum follow-up of 5 years. RESULTS Four total knee replacements, 17 total hip replacements, one revision total hip replacement and three hip hemiarthroplasties are included with an average duration from onset of symptoms to the DAIR procedure of 11 days (range 1-22 days). Staphylococcus aureus (24%) and Staphylococcus epidermidis (32%) were the most common causative organisms, and the most common antibiotic regimens included intravenous teicoplanin and flucloxacillin. Average follow-up was 67 months (range 9-104 months). Only four patients went on to require revision surgery. An analysis of midterm patient outcome measures for 6 of the total hip replacement (THR) DAIR patients were compared with a database of 792 THRs (with a minimum two-year follow-up) carried out by the same surgeon revealed no significant difference in Oxford hip scores at one-year post-surgery (OHS DAIR 36.2 vs 39 for control group). CONCLUSION This study includes 25 consecutive patients treated with DAIR with only one reinfection, with a mean follow-up period of 5 years. Using a strict protocol, DAIR appears to offer a successful treatment strategy for the management of early PJI.
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Affiliation(s)
- F Awad
- Prince Charles Hospital, UK
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Eriksson HK, Lazarinis S, Järhult JD, Hailer NP. Early Staphylococcal Periprosthetic Joint Infection (PJI) Treated with Debridement, Antibiotics, and Implant Retention (DAIR): Inferior Outcomes in Patients with Staphylococci Resistant to Rifampicin. Antibiotics (Basel) 2023; 12:1589. [PMID: 37998791 PMCID: PMC10668653 DOI: 10.3390/antibiotics12111589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/25/2023] Open
Abstract
It is unknown how rifampicin resistance in staphylococci causing a periprosthetic joint infection (PJI) affects outcomes after debridement, antibiotics, and implant retention (DAIR). We thus aimed to compare the risk of relapse in DAIR-treated early PJI caused by staphylococci with or without rifampicin resistance. In total, 81 patients affected by early PJI were included, and all patients were treated surgically with DAIR. This was repeated if needed. The endpoint of relapse-free survival was estimated using the Kaplan-Meier method, and Cox regression models were fitted to assess the risk of infection relapse for patients infected with rifampicin-resistant bacteria, adjusted for age, sex, type of joint, and type of index surgery. In patients with rifampicin-resistant staphylococci, relapse was seen in 80% after one DAIR procedure and in 70% after two DAIR procedures. In patients with rifampicin-sensitive bacteria, 51% had an infection relapse after one DAIR procedure and 33% had an infection relapse after two DAIR procedures. Patients with rifampicin-resistant staphylococcal PJI thus had an increased adjusted risk of infection relapse of 1.9 (95% CI: 1.1-3.6, p = 0.04) after one DAIR procedure compared to patients with rifampicin-sensitive bacteria and a 4.1-fold (95% CI: 1.2-14.1, p = 0.03) increase in risk of infection relapse after two DAIR procedures. Staphylococcal resistance to rifampicin is associated with inferior outcomes after DAIR. These findings suggest that DAIR may not be a useful strategy in early PJI caused by rifampicin-resistant staphylococci.
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Affiliation(s)
- Hannah K. Eriksson
- Department of Surgical Sciences, Section of Orthopaedics, Uppsala University, 751 83 Uppsala, Sweden; (S.L.); (N.P.H.)
| | - Stergios Lazarinis
- Department of Surgical Sciences, Section of Orthopaedics, Uppsala University, 751 83 Uppsala, Sweden; (S.L.); (N.P.H.)
| | - Josef D. Järhult
- Zoonosis Science Center, Department of Medical Sciences, Uppsala University, 751 83 Uppsala, Sweden;
| | - Nils P. Hailer
- Department of Surgical Sciences, Section of Orthopaedics, Uppsala University, 751 83 Uppsala, Sweden; (S.L.); (N.P.H.)
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Shao H, Zhou Y. Management of soft tissues in patients with periprosthetic joint infection. ARTHROPLASTY 2023; 5:52. [PMID: 37784182 PMCID: PMC10546773 DOI: 10.1186/s42836-023-00205-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/31/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Appropriate soft tissue management represents a critical step in treating periprosthetic joint infection (PJI). This review discusses relevant guidelines that surgeons should follow in the management of soft tissues in PJI treatment. BODY: It is imperative for arthroplasty surgeons to thoroughly debride and rebuild soft tissue with a good blood supply. Relevant guidelines that surgeons should follow rigorously include preoperative evaluation of soft tissue status and plan-making, adequate surgical area exposure, intraoperative removal of all necrotic and infected soft tissues, adequate coverage of soft tissue defects, timely postoperative assessment and management of soft tissues, wound management and proper rehabilitation. CONCLUSION Soft tissue management plays a critical role in the treatment of PJI. To improve the infection control rate and postoperative joint function, surgeons should be familiar with these general principles and rigorously practice them in PJI management.
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Affiliation(s)
- Hongyi Shao
- Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Capital Medical University, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Yixin Zhou
- Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Capital Medical University, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China.
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16
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Tidd JL, Pasqualini I, McConaghy K, Higuera CA, Deren ME, Visperas A, Klika AK, Piuzzi NS. The Use of Oral Antibiotics After Total Joint Arthroplasty: A Critical Analysis Review. JBJS Rev 2023; 11:01874474-202310000-00004. [PMID: 37812675 DOI: 10.2106/jbjs.rvw.23.00083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
» There is conflicting and insufficient evidence that extended oral antibiotic (EOA) therapy prevents infection in high-risk patients undergoing primary total joint arthroplasty (TJA), limiting recommendation for or against the practice.» In the case of aseptic revision TJA, the evidence is also conflicting and limited by underlying confounders, preventing recommendation for use of EOA.» There is fair evidence that use of EOA after debridement antibiotic therapy and implant retention of the prosthesis prolongs infection-free survival, but randomized controlled trials are needed. On the other hand, there is strong evidence that patients undergoing 2-stage revision should receive a period of suppressive oral antibiotics after the second stage.» The optimal duration of EOA in primary TJA, aseptic revision, and debridement antibiotic therapy and implant retention of the prosthesis is unknown. However, there is strong evidence that 3 months of EOA suppression may be appropriate after reimplantation as part of 2-stage exchange arthroplasty.» Complications secondary to EOA are reported to be between 0% and 13.7%, yet are inconsistently reported and poorly defined. The risks associated with antibiotic use, including development of antimicrobial resistance, must be weighed against a possible decrease in infection rate.
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Affiliation(s)
- Joshua L Tidd
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | | | - Kara McConaghy
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Carlos A Higuera
- Levitetz Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Matthew E Deren
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Anabelle Visperas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio
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Krizsán G, Sallai I, Veres DS, Prinz G, Kovács M, Skaliczki G. Investigation of the effect of rifampicin resistance and risk factors on recovery rates after DAIR procedure in patients with prosthetic joint infection. J Orthop Surg Res 2023; 18:611. [PMID: 37605214 PMCID: PMC10441700 DOI: 10.1186/s13018-023-04091-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Rifampicin plays a key role in the management of prosthetic joint infections (PJIs), however, the emergence of rifampicin resistance is associated with less favourable clinical outcomes. The purpose of this study was to investigate the impact of rifampicin resistance and other patient-related factors on recovery rates among patients with PJI undergoing debridement, antibiotics and implant retention (DAIR). METHODS We reviewed medical records and microbiology reports of 67 patients (37 males and 30 females) undergoing DAIR due to PJI between 2014 and 2021. Patient-related factors, co-morbidities and microbiological reports were collected and reviewed. Forty-four patients had hip, 21 had knee, 1 had shoulder and 1 had elbow joint infection. Obtained data were statistically analysed with a logistic regression model. RESULTS Rifampicin-sensitive organism was isolated in 47 cases. Recovery rate was 72.3% in the sensitive and 76.9% in the resistant group. We found no significant effect of rifampicin resistance on the probability of recovery. Age and diabetes mellitus showed negative clinical impact on recovery. Staphylococcus aureus and coagulase-negative Staphylococci were predominant in the rifampicin-sensitive (66.6% of the isolates) and Gram-negative rods in the resistant group (65.2%). CONCLUSIONS Based on our results, higher age and diabetes mellitus may have a clinically relevant negative impact on clinical outcome, however, this effect was not statistically significant. This may be due to the limited number of patients included in this study. We observed no clinically relevant effect of rifampicin-resistance, sex and body mass index (BMI) on recovery rates among patients undergoing DAIR due to PJI.
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Affiliation(s)
- Gergely Krizsán
- Department of Orthopaedics, Semmelweis University, Budapest, Hungary
| | - Imre Sallai
- Department of Orthopaedics, Semmelweis University, Budapest, Hungary
| | - Dániel Sándor Veres
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
| | - Gyula Prinz
- Department of Orthopaedics, Semmelweis University, Budapest, Hungary
| | - Máté Kovács
- Department of Orthopaedics, Semmelweis University, Budapest, Hungary
| | - Gábor Skaliczki
- Department of Orthopaedics, Semmelweis University, Budapest, Hungary.
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Affiliation(s)
- Fabio Mancino
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK
- Princess Grace Hospital, London, UK
| | - Vanya Gant
- Department of Microbiology, University College Hospital, London, UK
| | - Dominic R M Meek
- Department of Trauma and Orthopaedic Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Fares S Haddad
- Princess Grace Hospital, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
- The Bone & Joint Journal , London, UK
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19
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Bartsch A, Krenn P, Lubberts B, Morgenstern M, Pagenstert G, Clauss M. Management of acute periprosthetic knee infection: a comparison of arthroscopic and open debridement. Arch Orthop Trauma Surg 2023; 143:4309-4316. [PMID: 36735051 PMCID: PMC10293353 DOI: 10.1007/s00402-023-04782-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/14/2023] [Indexed: 02/04/2023]
Abstract
INTRODUCTION In acute periprosthetic knee infections, debridement and implant retention (DAIR) is the preferred treatment prior to one- and two-stage revisions. The aim of this study is to compare the outcomes of arthroscopic and open debridement of infected primary total knee arthroplasties (TKA). MATERIAL AND METHODS We analyzed clinical, laboratory, and antibiotic treatment data, collected in patients with periprosthetic knee infection treated with DAIR at a Swiss Level 1 orthopedic and trauma center over a 10-year period between January 2005 and May 2015. Inclusion criteria were primary total knee arthroplasty and early postoperative or acute hematogenous periprosthetic joint infection (PJI). The primary endpoint was the need for further revision surgery due to persistent infection. The secondary endpoint was the prosthesis salvage in further infection surgeries. RESULTS Forty-two patients with 44 acute or hematogenous periprosthetic knee infections were included. We recorded 20 recurrent infections (45%) in our study population: 10 (77%) out of 13 in the arthroscopic DAIR group and 10 (32%) out of 31 in the open DAIR group. Two-stage revision, meaning complete removal of the TKA, insertion of a spacer and replantation at a second stage, had to be performed in three patients treated initially arthroscopically (23%) and in six patients treated initially with an open surgical procedure (21%). CONCLUSIONS Open debridement for acute periprosthetic knee infection shows clear benefits in terms of infection eradication and prosthesis salvage compared to arthroscopic DAIR.
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Affiliation(s)
- A Bartsch
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Spitalstr. 21, 4031, Basel, Switzerland
| | - P Krenn
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Spitalstr. 21, 4031, Basel, Switzerland
| | - B Lubberts
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Spitalstr. 21, 4031, Basel, Switzerland
| | - M Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Spitalstr. 21, 4031, Basel, Switzerland
- Centre for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - G Pagenstert
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Spitalstr. 21, 4031, Basel, Switzerland
- Clarahof Praxisgemeinschaft für Orthopädie Basel, Clarahofweg 19a, 4058, Basel, Switzerland
| | - M Clauss
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Spitalstr. 21, 4031, Basel, Switzerland.
- Centre for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
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Ruiz-Sancho A, Núñez-Núñez M, Castelo-Corral L, Martínez-Marcos FJ, Lois-Martínez N, Abdul-Aziz MH, Vinuesa-García D. Dalbavancin as suppressive antibiotic therapy in patients with prosthetic infections: efficacy and safety. Front Pharmacol 2023; 14:1185602. [PMID: 37448966 PMCID: PMC10337584 DOI: 10.3389/fphar.2023.1185602] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023] Open
Abstract
Suppressive antibiotic therapy (SAT) is a strategy to alleviate symptoms and/or to reduce the progression of an infection when other treatment options cannot be used. Dalbavancin, due to its prolonged half-life, enables (bi) weekly dosing. Here, we report our multicenter real-life clinical experience with dalbavancin used as SAT in patients with prosthetic joint or vascular infections. Medical records of all adult patients with documented vascular or orthopedic chronic prosthetic infections, who received dalbavancin as SAT between 2016 and 2018 from four Spanish hospitals were reviewed for inclusion. Descriptive analysis of demographic characteristics, Charlson Comorbidity index, Barthel index, isolated pathogens and indication, concomitant antibiotic use, adverse events, and clinical outcome of SAT were performed. Eight patients were eligible for inclusion, where six patients had prosthetic vascular infections (aortic valve) and two patients had knee prosthetic joint infections. The most common pathogens were methicillin-susceptible Staphylococcus aureus and Enterococcus faecium. All patients had a history of prior antibiotic treatment for the prosthetic infection [median duration of antibiotic days 125 days (IQR, 28-203 days)]. The median number of dalbavancin doses was 29 (IQR, 9-61) and concomitant antibiotic use (n = 5, 62.5%). Clinical success was reported in 75% (n = 6) of patients. Adverse events were reported in two patients (mild renal and hepatic impairment). The median estimated cost savings due to the avoided hospital days was €60185 (IQR, 19,916-94984) per patient. Despite the limitations of our study, this preliminary data provides valuable insight to support further evaluation of dalbavancin for SAT in patients with prosthetic infections in the outpatient setting when alternative treatments are not feasible.
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Affiliation(s)
- Andrés Ruiz-Sancho
- Infectious Diseases Department, University Hospital Clinico San Cecilio, Granada, Spain
- Biosanitary Research Institute, Ibs Granada, Granada, Spain
| | - María Núñez-Núñez
- Biosanitary Research Institute, Ibs Granada, Granada, Spain
- Pharmacy Department, University Hospital Clinico San Cecilio, Granada, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Laura Castelo-Corral
- Infectious Diseases Department, University Hospital Complexo A Coruña, A Coruña, Spain
| | | | | | - Mohd Hafiz Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - David Vinuesa-García
- Infectious Diseases Department, University Hospital Clinico San Cecilio, Granada, Spain
- Biosanitary Research Institute, Ibs Granada, Granada, Spain
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Wakabayashi H, Hasegawa M, Naito Y, Tone S, Sudo A. Outcome of Irrigation and Debridement with Topical Antibiotic Delivery Using Antibiotic-Impregnated Calcium Hydroxyapatite for the Management of Periprosthetic Hip Joint Infection. Antibiotics (Basel) 2023; 12:antibiotics12050938. [PMID: 37237841 DOI: 10.3390/antibiotics12050938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/03/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
We assessed the clinical results of irrigation and debridement (I&D) with antibiotic-impregnated calcium hydroxyapatite (CHA) as a novel antibiotic delivery system for the treatment of prosthetic-joint-associated infection (PJI) after total hip arthroplasty (THA). Thirteen patients (14 hips) treated with I&D for PJI after THA at our institution between 1997 and 2017 were retrospectively evaluated. The study group included four men (five hips) and nine women, with an average age of 66.3 years. Four patients (five hips) had symptoms of infection within less than 3 weeks; however, nine patients had symptoms of infection over 3 weeks. All patients received I&D with antibiotic-impregnated CHA in the surrounding bone. In two hips (two cups and one stem), cup and/or stem revision were performed with re-implantation because of implant loosening. In ten patients (11 hips), vancomycin hydrochloride was impregnated in the CHA. The average duration of follow-up was 8.1 years. Four patients included in this study died of other causes, with an average follow-up of 6.7 years. Eleven of thirteen patients (12 of 14 hips) were successfully treated, and no signs of infection were observed at the latest follow-up. In two patients (two hips) for whom treatment failed, infection was successfully treated with two-stage re-implantation. Both patients had diabetes mellitus and symptoms of infection over 3 weeks. Eighty-six percent of patients were successfully treated. No complications were observed with this antibiotic-impregnated CHA. I&D treatment with antibiotic-impregnated CHA produced a higher rate of success in patients with PJI after THA.
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Affiliation(s)
- Hiroki Wakabayashi
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Masahiro Hasegawa
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Yohei Naito
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Shine Tone
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
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Ceccarelli G, Perciballi B, Russo A, Martini P, Marchetti F, Capparuccia MR, Iaiani G, Fabris S, Ciccozzi M, Villani C, Venditti M, D'Ettorre G, De Meo D. Chronic Suppressive Antibiotic Treatment for Staphylococcal Bone and Joint Implant-Related Infections. Antibiotics (Basel) 2023; 12:antibiotics12050937. [PMID: 37237840 DOI: 10.3390/antibiotics12050937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
Prosthetic joint infection (PJI) and fracture-related infection (FRI) are difficult-to-treat conditions in patients with severe comorbidity or significant surgical risk. In cases not eligible for standard strategy, debridement procedures with the retention of prosthesis or internal fixation device, combined with long-term antibiotic treatment and subsequent indefinite chronic oral antimicrobial suppression (COAS), can be the only reasonable choice. The aim of this study was to investigate the role of COAS and its follow-up in the management of these cases. We retrospectively analyzed a cohort of 16 patients with a follow-up of at least 6 months (mean age 75 yo, 9F, 7M, 11 PJI, 5 FRI). All microbiological isolates were tetracycline-susceptible staphylococci and for this reason a minocycline-based COAS was adopted after debridement and 3 months of antibiogram-guided antibiotic treatment. Patient monitoring was carried out on a clinical basis, with bimonthly execution of the inflammation indices and serial radiolabeled leukocyte scintigraphy (LS). The overall median time of COAS follow-up was 15 months (min 6-max 30). Moreover, 62.5% of patients were still taking COAS with no relapse after cure at the last evaluation available. Clinical failure with a relapse of the infection was observed in 37.5% of patients; interestingly, 50% of them had previously stopped COAS due to side effects of the antibiotic used. In the COAS follow-up, a combination of clinical, laboratory and LS evaluation seems to monitor the infection properly. COAS can be considered as an interesting approach in patients not suitable for standard treatments of PJI or FRI but it requires careful monitoring.
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Affiliation(s)
- Giancarlo Ceccarelli
- Department of Internal Medicine, Endocrine-Metabolic Sciences and Infectious Diseases, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- Department of Public Health an Infectious Diseases, Sapienza University of Rome, 00161 Rome, Italy
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I University Hospital, 00161 Rome, Italy
| | - Beatrice Perciballi
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- Department of Anatomical, Histological, Forensic Medicine and Musculoskeletal System Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Alessandro Russo
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, 88100 Catanzaro, Italy
| | - Paolo Martini
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- Department of Anatomical, Histological, Forensic Medicine and Musculoskeletal System Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Francesco Marchetti
- Plastic Surgery Outpatient Clinic, Villa Mafalda Hospital, 00199 Rome, Italy
| | - Marco Rivano Capparuccia
- Department of Internal Medicine, Endocrine-Metabolic Sciences and Infectious Diseases, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I University Hospital, 00161 Rome, Italy
| | - Giancarlo Iaiani
- Department of Internal Medicine, Endocrine-Metabolic Sciences and Infectious Diseases, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I University Hospital, 00161 Rome, Italy
| | - Silvia Fabris
- National Center for Control and Emergency Against Animal Diseases and Central Crisis Unit, Office III, Directorate General for Animal Health and Veterinary Drugs, Italian Ministry of Health, 00153 Rome, Italy
| | - Massimo Ciccozzi
- Unit of Medical Statistics and Molecular Epidemiology, University Campus Bio-Medico of Rome, 00128 Rome, Italy
| | - Ciro Villani
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- Department of Anatomical, Histological, Forensic Medicine and Musculoskeletal System Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Mario Venditti
- Department of Internal Medicine, Endocrine-Metabolic Sciences and Infectious Diseases, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- Department of Public Health an Infectious Diseases, Sapienza University of Rome, 00161 Rome, Italy
| | - Gabriella D'Ettorre
- Department of Internal Medicine, Endocrine-Metabolic Sciences and Infectious Diseases, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- Department of Public Health an Infectious Diseases, Sapienza University of Rome, 00161 Rome, Italy
| | - Daniele De Meo
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- Department of Anatomical, Histological, Forensic Medicine and Musculoskeletal System Sciences, Sapienza University of Rome, 00161 Rome, Italy
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Rahardja R, Zhu M, Davis JS, Manning L, Metcalf S, Young SW. Success of Debridement, Antibiotics, and Implant Retention in Prosthetic Joint Infection Following Primary Total Knee Arthroplasty: Results from a Prospective Multicenter Study of 189 Cases. J Arthroplasty 2023:S0883-5403(23)00370-4. [PMID: 37084921 DOI: 10.1016/j.arth.2023.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND This study aimed to identify the success rate of debridement, antibiotics, and implant retention (DAIR) for prosthetic joint infection (PJI) in a large prospective cohort of patients undergoing total knee arthroplasty (TKA). The ability for different PJI classification systems to predict success was assessed. METHODS Prospective data recorded in the Prosthetic Joint Infection in Australia and New Zealand Observational (PIANO) study was analyzed. 189 newly diagnosed knee PJIs were managed with DAIR between July 2014 and December 2017. Patients were prospectively followed up for 2 years. A strict definition of success was used, requiring the patient being alive with documented absence of infection, no ongoing antibiotics and the index prosthesis in place. Success was compared against the Coventry (early PJI = ≤1 month), International Consensus Meeting (early = ≤90 days), Auckland (early = <1 year), and Tsukayama (early = ≤1 month, hematogenous = >1 month with <7 days symptoms, chronic = >1 month with >7 days symptoms) classifications. RESULTS DAIR success was 45% (85/189) and was highest in early PJIs defined according to the Coventry (adjusted odds ratio [aOdds Ratio (OR)] = 3.9, P=0.01), the ICM (aOR = 3.1, p=0.01), and the Auckland classifications (aOR = 2.6, P=0.01). Success was lower in both hematogenous (aOR = 0.4, P=0.03) and chronic infections (aOR = 0.1, P=0.003). CONCLUSION Time since primary TKA is an important predictor of DAIR success. Success was highest in infections occurring <1 month of the primary TKA and progressively decreased as time since the primary TKA increased.
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Affiliation(s)
- Richard Rahardja
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
| | - Mark Zhu
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Joshua S Davis
- School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
| | - Laurens Manning
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia; Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia
| | - Sarah Metcalf
- Department of Infectious Diseases, Christchurch Hospital, Christchurch, New Zealand
| | - Simon W Young
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
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Deckey DG, Christopher ZK, Bingham JS, Spangehl MJ. Principles of mechanical and chemical debridement with implant retention. ARTHROPLASTY 2023; 5:16. [PMID: 37020248 PMCID: PMC10077701 DOI: 10.1186/s42836-023-00170-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 01/17/2023] [Indexed: 04/07/2023] Open
Abstract
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.
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Affiliation(s)
- David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, 85054, USA
| | | | - Joshua S Bingham
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, 85054, USA.
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25
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Flaten D. Risk of Treatment Failure for Prosthetic Joint Infections: Retrospective Chart Review in an Outpatient Parenteral Antimicrobial Therapy Program. Can J Hosp Pharm 2023; 76:14-22. [PMID: 36683659 PMCID: PMC9817224 DOI: 10.4212/cjhp.3264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Prosthetic joint infections (PJIs) are a major complication of total joint replacement surgeries. Treatment includes surgical intervention with prolonged courses of IV antibiotics in outpatient parenteral antimicrobial therapy (OPAT) programs. The risk of PJI treatment failure is high and may be associated with various clinical factors. Objectives To determine the rate of PJI treatment failure and to identify potential risk factors for failure in patients admitted to an OPAT program. Methods A retrospective chart review was conducted for adult patients with PJI admitted to an OPAT program between July 1, 2013, and July 1, 2019. Treatment courses were deemed to have failed according to predetermined criteria. χ2 tests and multiple linear regression were used to examine associations of comorbidities, pathogens, and antimicrobial regimens with treatment failure. Results In total, 100 patients associated with 137 PJI treatment courses in the OPAT program were included. Of these, 28 patients accounted for 65 of the treatment courses. Methicillin-susceptible Staphylococcus aureus was the most frequently isolated pathogen (31/137 or 22.6% of treatment courses). Patient comorbidities included body mass index of at least 30 kg/m2 (58% of patients) and diabetes (41% of patients). The overall rate of treatment failure was 56.2% (77/137 treatment courses). Selected risk factors associated with treatment failure or success were diabetes (50.9% versus 29.8%; odds ratio [OR] 4.03, 95% confidence interval [CI] 1.38-12.88, p = 0.013) and depression (32.1% versus 14.9%; OR 5.02, 95% CI 1.30-22.89, p = 0.025). Conclusions The overall rate of PJI treatment failure in the study population was high. Patients with diabetes and depression experienced higher incidences of failure. Future investigations of comprehensive PJI management should be considered to ensure successful treatment and to minimize excessive use of health care resources.
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26
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Dmitrov IA, Zagorodniy NV, Obolenskiy VN, Leval' PS, Zakharyan NG, Apresyan VS, Panin MA, Samkovich DA, Aliev RN, Grigoryan AA. Diagnosis and treatment of periprosthetic infection after hip replacement (a review). BULLETIN OF THE MEDICAL INSTITUTE "REAVIZ" (REHABILITATION, DOCTOR AND HEALTH) 2022. [DOI: 10.20340/vmi-rvz.2022.6.clin.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction. The frequency of hip arthroplasty is steadily increasing throughout the world and, although this operation has become routine, the likelihood of postoperative complications reaches 4.3 % [1]. The most dangerous of them are infectious lesions in the area of the endoprosthesis and adjacent tissues. At the same time, in addition to the threat of generalization of the infectious process, there are functional disorders in the joint area and a general deterioration in the quality of life of the patient. Timely diagnosis and treatment of the infectious process and related disorders can minimize the adverse effects of infection.Target. The purpose of this review is to analyze modern methods for diagnosing and treating periprosthetic infection resulting from hip replacement.Materials and methods. The subject literature was searched using the PubMed and Google Sholar databases.Results. The main methods for diagnosing periprosthetic infection include histological and bacteriological examination of the biopsy specimen, determination of sensitivity to antibiotics, blood, and synovial fluid analysis for the content of leukocytes, IL-6, CRP, PCR diagnostics of infectious agents. Treatment consists of re-intervention and/or antibiotic therapy.Conclusion. The most optimal method for diagnosing periprosthetic infection is a bacteriological study of biopsy specimens taken intraoperatively. The preferred method of treatment is determined by the severity of the infection, the degree of involvement of tissues adjacent to the prosthesis, the comorbid background, the nature of the infectious agent, and includes repeated revision surgery.
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Affiliation(s)
| | - N. V. Zagorodniy
- RUDN University; Pirogov Russian National Research Medical University
| | - V. N. Obolenskiy
- Pirogov Russian National Research Medical University; City Clinical Hospital No. 13
| | - P. Sh. Leval'
- City Clinical Hospital No. 13; European Clinic of Traumatology and Orthopedics (ECSTO)
| | | | | | - M. A. Panin
- RUDN University; City Clinical Hospital No. 17
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27
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Humphrey TJ, Dunahoe JA, Nelson SB, Katakam A, Park ABK, Heng M, Bedair HS, Melnic CM. Peri-Prosthetic Joint Infection in Patients Prescribed Suppressive Antibiotic Therapy Undergoing Primary Total Joint Arthroplasty: A 1:4 Case Control Matched Study. Surg Infect (Larchmt) 2022; 23:917-923. [PMID: 36472508 DOI: 10.1089/sur.2022.261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Oral suppressive antibiotic therapy (SAT) has emerged as a potential means to increase rates of infection-free survival in many complex peri-prosthetic joint infection (PJI) cases after total joint arthroplasty (TJA). The purpose of the present study is to evaluate the risk of PJI of a new primary TJA in patients on oral SAT. Patients and Methods: A retrospective matched cohort study from five hospitals in a 20-year period within a large hospital network was performed. Inclusion criteria consisted of patients over age 18 undergoing primary TJA, with any order for oral long-term (>6 months duration) SAT, and minimum of one-year clinical follow-up. Patients were matched 1:4 on age, gender, body mass index (BMI), hip or knee surgery, diabetes mellitus, smoking status, and indication for primary TJA. Student t-test, Fisher exact, and χ2 tests were utilized for group comparisons. Our study was powered to detect a 10.5% increase in PJI incidence compared with a 1% baseline rate of PJI. Results: We identified 45 TJA in 33 patients receiving SAT, which were matched to 180 control cases. There was no difference in the rate of development of PJI at any time point within follow-up between the SAT cohort and control group (2.22% vs. 1.11%; p = 0.561). Conclusions: We found a 2.22% rate of PJI in a cohort of patients receiving SAT identified over a 20-year period. As the clinical scenario of primary TJA while on SAT is rare but likely to become more prevalent, future large-scale studies can be performed to better clarify rates and risk of PJI in this population.
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Affiliation(s)
- Tyler J Humphrey
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Kaplan Joint Center, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Jacqueline A Dunahoe
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sandra B Nelson
- Department of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Akhil Katakam
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Kaplan Joint Center, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Andy B K Park
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Kaplan Joint Center, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Marilyn Heng
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hany S Bedair
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Kaplan Joint Center, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Christopher M Melnic
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Kaplan Joint Center, Newton-Wellesley Hospital, Newton, Massachusetts, USA
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Meléndez-Carmona MÁ, Mancheño-Losa M, Ruiz-Sorribas A, Muñoz-Gallego I, Viedma E, Chaves F, Van Bambeke F, Lora-Tamayo J. Strain-to-strain variability among Staphylococcus aureus causing prosthetic joint infection drives heterogeneity in response to levofloxacin and rifampicin. J Antimicrob Chemother 2022; 77:3265-3269. [PMID: 36124848 DOI: 10.1093/jac/dkac311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 08/19/2022] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Levofloxacin and rifampicin are the preferred treatment for prosthetic joint infection (PJI) caused by Staphylococcus aureus, especially when managed with implant retention (DAIR). However, a significant variability of success has been reported, which could be related to intrinsic characteristics of the microorganism. Our aim was to evaluate the variability in the anti-biofilm response to levofloxacin and rifampicin in a clinical collection of S. aureus. MATERIAL AND METHODS Eleven levofloxacin- and rifampicin-susceptible S. aureus isolates causing PJI managed with DAIR were included. Levofloxacin, rifampicin and levofloxacin + rifampicin were tested in an in vitro static biofilm model in microtitre plates, where 48 h biofilms were challenged with antimicrobials during 24 h. Additionally, two genetically similar strains were tested in the CDC Biofilm Reactor, where 48 h biofilms were treated during 56 h. Antimicrobial activity was assessed by viable biofilm-embedded cells recount, and by crystal violet staining. RESULTS All antimicrobial regimens showed significant anti-biofilm activity, but a notable scattering in the response was observed across all strains (inter-strain coefficient of variation for levofloxacin, rifampicin and levofloxacin + rifampicin of 22.8%, 35.8% and 34.5%, respectively). This variability was tempered with the combination regimen when tested in the biofilm reactor. No correlation was observed between the minimal biofilm eradicative concentration and the antimicrobial activity. Recurrent S. aureus isolates exhibited higher biofilm-forming ability compared with strains from resolved infections (7.6 log10 cfu/cm2±0.50 versus 9.0 log10 cfu±0.07). CONCLUSIONS Significant variability may be expected in response to levofloxacin and rifampicin among biofilm-embedded S. aureus. A response in the lower range, together with other factors of bad prognosis, could be responsible of treatment failure.
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Affiliation(s)
- María Ángeles Meléndez-Carmona
- Department of Clinical Microbiology, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica 'i+12' Hospital 12 de Octubre, Madrid, Spain
| | - Mikel Mancheño-Losa
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica 'i+12' Hospital 12 de Octubre, Madrid, Spain
| | - Albert Ruiz-Sorribas
- Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Irene Muñoz-Gallego
- Department of Clinical Microbiology, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica 'i+12' Hospital 12 de Octubre, Madrid, Spain
| | - Esther Viedma
- Department of Clinical Microbiology, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica 'i+12' Hospital 12 de Octubre, Madrid, Spain
| | - Fernando Chaves
- Department of Clinical Microbiology, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica 'i+12' Hospital 12 de Octubre, Madrid, Spain
| | - Françoise Van Bambeke
- Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Jaime Lora-Tamayo
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica 'i+12' Hospital 12 de Octubre, Madrid, Spain.,CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
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29
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Blom AW, Beswick AD, Burston A, Carroll FE, Garfield K, Gooberman-Hill R, Harris S, Kunutsor SK, Lane A, Lenguerrand E, MacGowan A, Mallon C, Moore AJ, Noble S, Palmer CK, Rolfson O, Strange S, Whitehouse MR. Infection after total joint replacement of the hip and knee: research programme including the INFORM RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2022. [DOI: 10.3310/hdwl9760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background
People with severe osteoarthritis, other joint conditions or injury may have joint replacement to reduce pain and disability. In the UK in 2019, over 200,000 hip and knee replacements were performed. About 1 in 100 replacements becomes infected, and most people with infected replacements require further surgery.
Objectives
To investigate why some patients are predisposed to joint infections and how this affects patients and the NHS, and to evaluate treatments.
Design
Systematic reviews, joint registry analyses, qualitative interviews, a randomised controlled trial, health economic analyses and a discrete choice questionnaire.
Setting
Our studies are relevant to the NHS, to the Swedish health system and internationally.
Participants
People with prosthetic joint infection after hip or knee replacement and surgeons.
Interventions
Revision of hip prosthetic joint infection with a single- or two-stage procedure.
Main outcome measures
Long-term patient-reported outcomes and reinfection. Cost-effectiveness of revision strategies over 18 months from two perspectives: health-care provider and Personal Social Services, and societal.
Data sources
National Joint Registry; literature databases; published cohort studies; interviews with 67 patients and 35 surgeons; a patient discrete choice questionnaire; and the INFORM (INFection ORthopaedic Management) randomised trial.
Review methods
Systematic reviews of studies reporting risk factors, diagnosis, treatment outcomes and cost comparisons. Individual patient data meta-analysis.
Results
In registry analyses, about 0.62% and 0.75% of patients with hip and knee replacement, respectively, had joint infection requiring surgery. Rates were four times greater after aseptic revision. The costs of inpatient and day-case admissions in people with hip prosthetic joint infection were about five times higher than those in people with no infection, an additional cost of > £30,000. People described devastating effects of hip and knee prosthetic joint infection and treatment. In the treatment of hip prosthetic joint infection, a two-stage procedure with or without a cement spacer had a greater negative impact on patient well-being than a single- or two-stage procedure with a custom-made articulating spacer. Surgeons described the significant emotional impact of hip and knee prosthetic joint infection and the importance of a supportive multidisciplinary team. In systematic reviews and registry analyses, the risk factors for hip and knee prosthetic joint infection included male sex, diagnoses other than osteoarthritis, high body mass index, poor physical status, diabetes, dementia and liver disease. Evidence linking health-care setting and surgeon experience with prosthetic joint infection was inconsistent. Uncemented fixation, posterior approach and ceramic bearings were associated with lower infection risk after hip replacement. In our systematic review, synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy for prosthetic joint infection. Systematic reviews and individual patient data meta-analysis showed similar reinfection outcomes in patients with hip or knee prosthetic joint infection treated with single- and two-stage revision. In registry analysis, there was a higher rate of early rerevision after single-stage revision for hip prosthetic joint infection, but, overall, 40% fewer operations are required as part of a single-stage procedure than as part of a two-stage procedure. The treatment of hip or knee prosthetic joint infection with early debridement and implant retention may be effective in > 60% of cases. In the INFORM randomised controlled trial, 140 patients with hip prosthetic joint infection were randomised to single- or two-stage revision. Eighteen months after randomisation, pain, function and stiffness were similar between the randomised groups (p = 0.98), and there were no differences in reinfection rates. Patient outcomes improved earlier in the single-stage than in the two-stage group. Participants randomised to a single-stage procedure had lower costs (mean difference –£10,055, 95% confidence interval –£19,568 to –£542) and higher quality-adjusted life-years (mean difference 0.06, 95% confidence interval –0.07 to 0.18) than those randomised to a two-stage procedure. Single-stage was the more cost-effective option, with an incremental net monetary benefit at a threshold of £20,000 per quality-adjusted life-year of £11,167 (95% confidence interval £638 to £21,696). In a discrete choice questionnaire completed by 57 patients 18 months after surgery to treat hip prosthetic joint infection, the most valued characteristics in decisions about revision were the ability to engage in valued activities and a quick return to normal activity.
Limitations
Some research was specific to people with hip prosthetic joint infection. Study populations in meta-analyses and registry analyses may have been selected for joint replacement and specific treatments. The INFORM trial was not powered to study reinfection and was limited to 18 months’ follow-up. The qualitative study subgroups were small.
Conclusions
We identified risk factors, diagnostic biomarkers, effective treatments and patient preferences for the treatment of hip and knee prosthetic joint infection. The risk factors include male sex, diagnoses other than osteoarthritis, specific comorbidities and surgical factors. Synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy. Infection is devastating for patients and surgeons, both of whom describe the need for support during treatment. Debridement and implant retention is effective, particularly if performed early. For infected hip replacements, single- and two-stage revision appear equally efficacious, but single-stage has better early results, is cost-effective at 18-month follow-up and is increasingly used. Patients prefer treatments that allow full functional return within 3–9 months.
Future work
For people with infection, develop information, counselling, peer support and care pathways. Develop supportive care and information for patients and health-care professionals to enable the early recognition of infections. Compare alternative and new treatment strategies in hip and knee prosthetic joint infection. Assess diagnostic methods and establish NHS diagnostic criteria.
Study registration
The INFORM randomised controlled trial is registered as ISRCTN10956306. All systematic reviews were registered in PROSPERO (as CRD42017069526, CRD42015023485, CRD42018106503, CRD42018114592, CRD42015023704, CRD42017057513, CRD42015016559, CRD42015017327 and CRD42015016664).
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ashley W Blom
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Fran E Carroll
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kirsty Garfield
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shaun Harris
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Setor K Kunutsor
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Athene Lane
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Charlotte Mallon
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew J Moore
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cecily K Palmer
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Ola Rolfson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Simon Strange
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Bouji N, Wen S, Dietz M. Intravenous antibiotic duration in the treatment of prosthetic joint infection: systematic review and meta-analysis. J Bone Jt Infect 2022; 7:191-202. [PMID: 36267262 PMCID: PMC9562697 DOI: 10.5194/jbji-7-191-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/20/2022] [Indexed: 08/22/2023] Open
Abstract
Introduction: Long antibiotic courses, including intravenous (IV) and oral administrations, are utilized in prosthetic joint infection (PJI) treatment. This meta-analysis examines the non-inferiority of short courses ( < 4 weeks) of IV antibiotics compared to long courses in treating PJI. Critical review of IV treatment is necessary due to the clinical, physical, and financial burden associated with it and its continued prolonged use in the US without much evidence to support the practice. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), databases were searched using predefined medical subject headings (MeSH). Results: The nine included studies reported 521 total hip arthroplasties (THAs) and 530 total knee arthroplasties (TKAs). There was no significant difference in the overall success rate in short- vs. long-duration IV antibiotics for PJI treatment: odds ratio (OR) of 1.65, 95 % confidence interval (CI) of 0.78-3.46, and p = 0 .18. However, due to the moderate to high heterogeneity (I 2 = 68 %, p < 0.01) amongst studies, an adjusted success rate was calculated after the exclusion of two studies. This showed a statistically significant difference between both groups (OR of 2.45, 95 % CI of 1.21-4.96, p < 0.001) favoring a short course of antibiotics and reflecting a more homogenous population (I 2 = 51 %, p = 0 .06). Conclusion: This study highlights the limited data available for evaluating IV antibiotic duration in the setting of PJI. We found that a shorter duration of IV antibiotics was non-inferior to a longer duration, with an improved OR of 2.45 for treatment success, likely shortening inpatient stay as well as lessening side effects and antimicrobial resistance with a lower cost to patients and overall healthcare.
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Affiliation(s)
- Nour Bouji
- Department of Orthopaedics, School of
Medicine, West Virginia University, Morgantown, WV 26506, USA
| | - Sijin Wen
- Department of Epidemiology and BioStatistics, School of Public Health, West Virginia University, Morgantown, WV 26506, USA
| | - Matthew J. Dietz
- Department of Orthopaedics, School of
Medicine, West Virginia University, Morgantown, WV 26506, USA
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Piovan G, Farinelli L, Screpis D, Marocco S, Motta L, Palazzolo G, Natali S, Zorzi C. The role of antibiotic calcium sulfate beads in acute periprosthetic knee infection: a retrospective cohort study. ARTHROPLASTY 2022; 4:42. [PMID: 36064753 PMCID: PMC9446807 DOI: 10.1186/s42836-022-00139-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 06/18/2022] [Indexed: 11/20/2022] Open
Abstract
Background The study aimed to compare debridement, antibiotics, and implant retention (DAIR) vs. debridement antibiotic bead and retention of the implant (DABRI) in terms of infection-free success rate and treatment cost for acute periprosthetic joint infections after total knee arthroplasty (TKA). Method Between 2017 and 2020, 32 patients with acute periprosthetic joint infection who were treated by total knee arthroplasty were retrospectively reviewed. The patients were divided into a DAIR group (n=15) and a DABRI group (n=17). During the DABRI, additional calcium ulphate antibiotic beads were used. Patient age, the Musculoskeletal Infection Society score, microorganisms involved, and success rate were assessed. Results The mean age of DAIR group (n=15) was 69 years, with 7 being male, and 8 female. The mean follow-up period lasted 30 months. The success rate was 80% (12/15). The mean age of DABRI group (n=17) was 64 years, with 10 patients being male and 7 female. The mean follow-up period was 16 months. The success rate was 88% (15/17). There were no significant differences in patient age (P>0.05), the Musculoskeletal Infection Society score (P>0.05), and success rate (P>0.05). A significant difference was found in the follow-up period between the two groups (P<0.05). Conclusion Both DAIR and DABRI could be used to treat acute periprosthetic joint infections and the outcomes and treatment costs of the two procedures were comparable. Additional use of calcium sulfate beads was safe, but might not improve the treatment result. Randomized controlled studies are warranted for the routine use.
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Mian HM, Lyons JG, Perrin J, Froehle AW, Krishnamurthy AB. A review of current practices in periprosthetic joint infection debridement and revision arthroplasty. ARTHROPLASTY 2022; 4:31. [PMID: 36045436 PMCID: PMC9434893 DOI: 10.1186/s42836-022-00136-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Humza M Mian
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St. Suite #2200, Dayton, OH, 45409, USA.
| | - Joseph G Lyons
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St. Suite #2200, Dayton, OH, 45409, USA
| | - Joshua Perrin
- Wright State University Boonshoft School of Medicine, Wright State Physicians Bldg, 725 University Blvd., Dayton, OH, 45435, USA
| | - Andrew W Froehle
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St. Suite #2200, Dayton, OH, 45409, USA
- School of Nursing, Kinesiology and Health, Wright State University, 3640 Colonel Glenn Hwy., Dayton, OH, 45435, USA
| | - Anil B Krishnamurthy
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St. Suite #2200, Dayton, OH, 45409, USA
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Shao H, Li R, Deng W, Yu B, Yang D, Zhou Y, Chen J. Symptom duration is associated with failure of periprosthetic joint infection treated with debridement, antibiotics and implant retention. Front Surg 2022; 9:913431. [PMID: 36117805 PMCID: PMC9470758 DOI: 10.3389/fsurg.2022.913431] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 08/11/2022] [Indexed: 11/29/2022] Open
Abstract
Background Debridement, antibiotics, and implant retention (DAIR) is an alternative treatment strategy for periprosthetic joint infection (PJI). However, no consensus exists regarding which patient population(s) may be most suitable for DAIR. This study aims to investigate the overall infection control rate and explore the prognostic factors associated with acute, hematogenous, and chronic PJIs treated with DAIR. Methods We retrospectively reviewed the included patients who were diagnosed with PJI and underwent DAIR at two institutions from 2009 to 2018 (n = 104). We collected the clinical data, including demographics, preoperative laboratory tests, Charlson Comorbidity Index, surgical information, and culture organism results. Treatment success was defined according to the criteria reported by Diaz-Ledezma. All patients were followed for at least one year unless failure preceded that time point. A multivariable analysis was utilized to identify prognostic factors associated with treatment, and a Kaplan-Meier survival analysis was used to depict the infection control rate. Results The overall treatment success rate in the current cohort of patients was 67.3% at a median 38.6 (interquartile range: 23.5, 90.7) months follow-up. Patients with a duration of infectious symptoms of more than ten days were more likely to fail (P = 0.035, hazard ratio 8.492, 95% confidence interval 1.159–62.212). There was no difference among acute, hematogenous, and chronic infections in terms of failure rate (P = 0.161). Conclusions DAIR is a reasonable treatment option for PJI, and its use in the setting of chronic infection does not appear to be a contraindication. Performing DAIR within ten days of the presentation of symptoms had a higher rate of treatment success.
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Affiliation(s)
- Hongyi Shao
- Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
| | - Rui Li
- Senior Department of Orthopedics, the Fourth Medical Center of PLA General Hospital, Beijing, China
- Department of Orthopedics, the First Medical Center of PLA General Hospital, Beijing, China
| | - Wang Deng
- Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
| | - Baozhan Yu
- Senior Department of Orthopedics, the Fourth Medical Center of PLA General Hospital, Beijing, China
- Department of Orthopaedics, No.2 Hospital of Baoding, Baoding, Hebei, China
| | - Dejin Yang
- Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
- Correspondence: Dejin Yang Yixin Zhou Jiying Chen
| | - Yixin Zhou
- Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
- Correspondence: Dejin Yang Yixin Zhou Jiying Chen
| | - Jiying Chen
- Senior Department of Orthopedics, the Fourth Medical Center of PLA General Hospital, Beijing, China
- Department of Orthopedics, the First Medical Center of PLA General Hospital, Beijing, China
- Correspondence: Dejin Yang Yixin Zhou Jiying Chen
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Jia Y, Chen J, Liang W, Xiong Y, Peng Z, Wang G. Differences in Efficacy between Short- and Long-Course Antibiotic Agents for Joint Prosthesis Infection: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2022; 23:616-624. [PMID: 35950957 DOI: 10.1089/sur.2022.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: To evaluate systematically the failure rate of short versus long courses of antibiotic agents for prosthetic joint infections (PJIs). Methods: PubMed, Embase, and Cochrane Library databases were searched for controlled studies of short- and long-course antibiotic agents for joint prosthesis infections, all from the time of database creation to April 2022. Literature search, quality evaluation, and data extraction were performed independently by two researchers, and the primary outcome was the rate of surgical failure after antibiotic treatment. Stata 11.0 software was then applied for meta-analysis. Publication bias was assessed using Begg test. Heterogeneity was assessed using the I2 test, and fixed or random effects models were used accordingly. Meta-regression was used to determine the causes of heterogeneity. Results: A total of 14 articles involving 1,971 participants met the inclusion criteria, including 12 observational studies and two randomized controlled trials. Meta-analysis showed no difference between short and long courses of antibiotic agents (relative risk, 1.08; 95% confidence interval [CI], 0.89-1.32). The results of the subgroup analysis showed no differences between the failure rates of patients with PJI treated with short and long courses of antibiotic agents in studies with different study areas, different treatment modalities, and different locations of the artificial joints. Conclusions: Patients with PJIs may not require long-term or lifelong antibiotic agents after surgical treatment, and short-term (four to six weeks) antibiotic therapy is usually safe.
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Affiliation(s)
- Yukun Jia
- The People's Hospital of Baoan Shenzhen
| | - Jie Chen
- The People's Hospital of Baoan Shenzhen
| | | | - Yu Xiong
- The People's Hospital of Baoan Shenzhen
| | - Zhan Peng
- The People's Hospital of Baoan Shenzhen
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Tai DBG, Berbari EF, Suh GA, Lahr BD, Abdel MP, Tande AJ. Truth in DAIR: Duration of Therapy and the Use of Quinolone/Rifampin-Based Regimens following Debridement and Implant Retention for Periprosthetic Joint Infections. Open Forum Infect Dis 2022; 9:ofac363. [PMID: 36072695 PMCID: PMC9439576 DOI: 10.1093/ofid/ofac363] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 07/21/2022] [Indexed: 11/17/2022] Open
Abstract
Background The optimal duration of antibiotic therapy after debridement and implant retention (DAIR) for periprosthetic joint infections (PJIs) is debated. Furthermore, the best antibiotic regimens for staphylococcal PJI are also unclear. In this study, we evaluated the impact of antibiotic therapy duration on the risk of failure. We assessed the utility of rifampin-based regimens for staphylococcal PJI managed with DAIR. Methods We performed a retrospective cohort study of patients 18 years and older diagnosed with hip and knee PJI who underwent DAIR between January 1, 2008 and 31 December 31, 2018 at Mayo Clinic, USA. The outcome was failure of DAIR. For statistical analysis, joint-stratified Cox regression models adjusted for age, sinus tract, symptom duration, and primary/revision arthroplasty were performed. Results We examined 247 cases of PJI with a median follow-up of 4.4 years (interquartile range [IQR], 2.3–7) after DAIR. The estimated 5-year cumulative incidence of failure was 28.1% (n = 65). There was no association between the duration of intravenous (IV) antibiotics (median 42 days; IQR, 38–42) and treatment failure (P = .119). A shorter duration of subsequent oral antibiotic therapy was associated with a higher risk of failure (P = .005; eg, 90-day vs 1-year duration; hazard ratio [HR], 3.50; 95% confidence interval [CI], 1.48–8.25). For staphylococcal knee PJI, both the use and longer duration of a rifampin-based regimen were associated with a lower risk of failure (both P = .025). There was no significant association between fluoroquinolone (FQ) use and failure (HR, 0.62; 95% CI, .31–1.24; P = .172). Conclusions The duration of initial IV antibiotic therapy did not correlate with treatment failure in this cohort of patients. Rifampin use is recommended for staphylococcal knee PJI. There was no apparent benefit of FQ use in staphylococcal PJI.
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Affiliation(s)
- Don Bambino Geno Tai
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine , Mayo Clinic , USA
| | - Elie F Berbari
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine , Mayo Clinic , USA
| | - Gina A Suh
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine , Mayo Clinic , USA
| | - Brian D Lahr
- Department of Quantitative Health Sciences , Mayo Clinic , USA
| | | | - Aaron J Tande
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine , Mayo Clinic , USA
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Does a New Antibiotic Scheme Improve the Outcome of Staphylococcus aureus-Caused Acute Prosthetic Joint Infections (PJI) Treated with Debridement, Antibiotics and Implant Retention (DAIR)? Antibiotics (Basel) 2022; 11:antibiotics11070922. [PMID: 35884176 PMCID: PMC9312051 DOI: 10.3390/antibiotics11070922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/03/2022] [Accepted: 07/05/2022] [Indexed: 12/04/2022] Open
Abstract
One of the most commonly used treatments for acute prosthetic joint infection (PJI) is DAIR (debridement, antibiotics and implant retention), which comprises the debridement and the retention of the implant, followed by antibiotic treatment. The efficacy of DAIR remains unclear, as the literature has demonstrated variable success rates, ranging from 26% to 92%. The Staphylococcus aureus is one of the most closely related causative microorganisms, especially with acute and late-acute PJI; it has been identified as one of the most significant predictors of DAIR failure. The current guidelines consider the use of vancomycin as the therapy of choice, but it requires the close control of possible side effects. The aim of this study is to determine if a new combination of antibiotics (a highly bactericidal initial combination followed by an antibiofilm scheme) decreases the failure of DAIR-treated acute prosthetic joint infection (PJI) caused by Staphylococcus aureus. A retrospective analysis of cases of orthopedic infections during a nine-year period (2011–2019) was performed. A total of 45 acute PJI cases caused by S. aureus were diagnosed. The results of two antibiotic schemes were compared: a novel scheme comprising 5 days of daptomycin (10 mg/kg/24 h) + cloxacillin (2 g/6 h) followed by levofloxacin (500 mg/24 h) + rifampicin (600 mg/24 h), versus a traditional, less bactericidal scheme of vancomycin (1000 mg/12 h) plus rifampicin (600 mg/24 h) or levofloxacin (500 mg/24 h) plus rifampicin (600 mg/24 h). Twenty-two out of the twenty-four patients treated with the new scheme (91.6%) were free of infection after 24.8 months of mean follow-up, whereas fourteen out of twenty-one patients (66.6%) were free of infection after 46.6 months of follow-up. This difference was statistically significant (p = 0.036). Demographic comparisons demonstrated homogeneous features, except the Charlson score, which was higher in the novel scheme group (p = 0.047). The combination of high-dose daptomycin and cloxacillin, followed by levofloxacin plus rifampicin, together with surgical treatment, shows better results when compared with other antibiotic schemes for treating acute PJI caused by S. aureus in which DAIR was performed.
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Characteristics, management and outcome of a large necrotising otitis externa case series: need for standardised case definition. J Laryngol Otol 2022; 136:604-610. [PMID: 35042578 PMCID: PMC9257435 DOI: 10.1017/s002221512100462x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractBackgroundNecrotising otitis externa is a severe ear infection for which there are no established diagnostic or treatment guidelines.MethodThis study described clinical characteristics, management and outcomes for patients managed as necrotising otitis externa cases at a UK tertiary referral centre.ResultsA total of 58 (63 per cent) patients were classified as definite necrotising otitis externa cases, 31 (34 per cent) as probable cases and 3 (3 per cent) as possible cases. Median duration of intravenous and oral antimicrobial therapy was 6.0 weeks (0.49–44.9 weeks). Six per cent of patients relapsed a median of 16.4 weeks (interquartile range, 23–121) after stopping antimicrobials. Twenty-eight per cent of cases had complex disease. These patients were older (p = 0.042), had a longer duration of symptoms prior to imaging (p < 0.0001) and higher C-reactive protein at diagnosis (p = 0.005). Despite longer courses of intravenous antimicrobials (23 vs 14 days; p = 0.032), complex cases were more likely to relapse (p = 0.016).ConclusionA standardised case-definition of necrotising otitis externa is needed to optimise diagnosis, management and research.
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Kherabi Y, Zeller V, Kerroumi Y, Meyssonnier V, Heym B, Lidove O, Marmor S. Streptococcal and Staphylococcus aureus prosthetic joint infections: are they really different? BMC Infect Dis 2022; 22:555. [PMID: 35715754 PMCID: PMC9206280 DOI: 10.1186/s12879-022-07532-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background Staphylococci and streptococci are the most frequent pathogens isolated from prosthetic joint infections (PJIs). The aim of this study was to analyze the outcome of streptococcal and methicillin-susceptible Staphylococcus aureus (MSSA) PJIs. Methods All monomicrobial streptococcal and MSSA PJIs managed in a French Referral Center (2010–2017) were sampled from the prospective PJIs cohort study. The primary outcome of interest was the cumulative reinfection-free survival at a 2-year follow-up. Results Two hundred and nine patients with 91 streptococcal and 132 staphylococcal infections were analyzed. Patients with streptococcal PJI were older, and infection was more frequently hematogenous. Reinfection-free survival rates at 2-years after all treatment strategies were higher for patients with streptococcal PJI (91% vs 81%; P = .012), but differed according to the strategy. After exchange arthroplasty, no outcome differences were observed (89% vs 93%; P = .878); after debridement, antibiotics and implant retention (DAIR), the reinfection-free survival rate was higher for patients with streptococcal PJI (87% vs 60%; P = .062). For patients managed with prolonged suppressive antibiotic therapy (SAT) alone, those with streptococcal PJIs had a 100% infection-free survival (100% vs 31%; P < .0001). Conclusions Reinfection-free survival after DAIR and SAT was better for patients with streptococcal than those with MSSA PJIs. No difference was observed after prosthesis exchange. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07532-x.
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Affiliation(s)
- Yousra Kherabi
- Centre de Référence des Infections Ostéo-Articulaires Complexes, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020, Paris, France. .,Service de Médecine Interne et Infectiologie, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020, Paris, France.
| | - Valérie Zeller
- Centre de Référence des Infections Ostéo-Articulaires Complexes, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020, Paris, France.,Service de Médecine Interne et Infectiologie, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020, Paris, France
| | - Younes Kerroumi
- Centre de Référence des Infections Ostéo-Articulaires Complexes, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020, Paris, France.,Service de Chirurgie Osseuse et Traumatologique, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020, Paris, France
| | - Vanina Meyssonnier
- Centre de Référence des Infections Ostéo-Articulaires Complexes, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020, Paris, France.,Service de Médecine Interne et Infectiologie, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020, Paris, France
| | - Beate Heym
- Centre de Référence des Infections Ostéo-Articulaires Complexes, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020, Paris, France.,Laboratoire des Centres de Santé et Hôpitaux d'Île-de-France, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020, Paris, France
| | - Olivier Lidove
- Service de Médecine Interne et Infectiologie, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020, Paris, France
| | - Simon Marmor
- Centre de Référence des Infections Ostéo-Articulaires Complexes, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020, Paris, France.,Service de Chirurgie Osseuse et Traumatologique, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020, Paris, France
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Wei J, Tong K, Wang H, Wen Y, Chen L. Intra-articular versus systemic vancomycin for the treatment of periprosthetic joint infection after debridement and spacer implantation in a rat model. Bone Joint Res 2022; 11:371-385. [PMID: 35708551 PMCID: PMC9233408 DOI: 10.1302/2046-3758.116.bjr-2021-0319.r3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aims Treatment outcomes for methicillin-resistant Staphylococcus aureus (MRSA) periprosthetic joint infection (PJI) using systemic vancomycin and antibacterial cement spacers during two-stage revision arthroplasty remain unsatisfactory. This study explored the efficacy and safety of intra-articular vancomycin injections for PJI control after debridement and cement spacer implantation in a rat model. Methods Total knee arthroplasty (TKA), MRSA inoculation, debridement, and vancomycin-spacer implantation were performed successively in rats to mimic first-stage PJI during the two-stage revision arthroplasty procedure. Vancomycin was administered intraperitoneally or intra-articularly for two weeks to control the infection after debridement and spacer implantation. Results Rats receiving intra-articular vancomycin showed the best outcomes among the four treatment groups, with negative bacterial cultures, increased weight gain, increased capacity for weightbearing activities, increased residual bone volume preservation, and reduced inflammatory reactions in the joint tissues, indicating MRSA eradication in the knee. The vancomycin-spacer and/or systemic vancomycin failed to eliminate the MRSA infections following a two-week antibiotic course. Serum vancomycin levels did not reach nephrotoxic levels in any group. Mild renal histopathological changes, without changes in serum creatinine levels, were observed in the intraperitoneal vancomycin group compared with the intra-articular vancomycin group, but no changes in hepatic structure or serum alanine aminotransferase or aspartate aminotransferase levels were observed. No local complications were observed, such as sinus tract or non-healing surgical incisions. Conclusion Intra-articular vancomycin injection was effective and safe for PJI control following debridement and spacer implantation in a rat model during two-stage revision arthroplasties, with better outcomes than systemic vancomycin administration. Cite this article: Bone Joint Res 2022;11(6):371–385.
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Affiliation(s)
- Jian Wei
- Department of Joint Surgery and Sports Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center of Wuhan University, Wuhan, China
| | - Kai Tong
- Department of Joint Surgery and Sports Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center of Wuhan University, Wuhan, China
| | - Hui Wang
- Department of Pharmacology, Department of Basic Medicine, Wuhan University, Wuhan, China
| | - Yinxian Wen
- Department of Joint Surgery and Sports Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center of Wuhan University, Wuhan, China
| | - Liaobin Chen
- Department of Joint Surgery and Sports Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center of Wuhan University, Wuhan, China
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Gilbertie JM, Schaer TP, Engiles JB, Seiler GS, Deddens BL, Schubert AG, Jacob ME, Stefanovski D, Ruthel G, Hickok NJ, Stowe DM, Frink A, Schnabel LV. A Platelet-Rich Plasma-Derived Biologic Clears Staphylococcus aureus Biofilms While Mitigating Cartilage Degeneration and Joint Inflammation in a Clinically Relevant Large Animal Infectious Arthritis Model. Front Cell Infect Microbiol 2022; 12:895022. [PMID: 35711655 PMCID: PMC9195519 DOI: 10.3389/fcimb.2022.895022] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/02/2022] [Indexed: 12/03/2022] Open
Abstract
The leading cause of treatment failure in Staphylococcus aureus infections is the development of biofilms. Biofilms are highly tolerant to conventional antibiotics which were developed against planktonic cells. Consequently, there is a lack of antibiofilm agents in the antibiotic development pipeline. To address this problem, we developed a platelet-rich plasma (PRP)-derived biologic, termed BIO-PLY (for the BIOactive fraction of Platelet-rich plasma LYsate) which has potent in vitro bactericidal activity against S. aureus synovial fluid free-floating biofilm aggregates. Additional in vitro studies using equine synoviocytes and chondrocytes showed that BIO-PLY protected these cells of the joint from inflammation. The goal of this study was to test BIO-PLY for in vivo efficacy using an equine model of infectious arthritis. We found that horses experimentally infected with S. aureus and subsequently treated with BIO-PLY combined with the antibiotic amikacin (AMK) had decreased bacterial concentrations within both synovial fluid and synovial tissue and exhibited lower systemic and local inflammatory scores compared to horses treated with AMK alone. Most importantly, AMK+BIO-PLY treatment reduced the loss of infection-associated cartilage proteoglycan content in articular cartilage and decreased synovial tissue fibrosis and inflammation. Our results demonstrate the in vivo efficacy of AMK+BIO-PLY and represents a new approach to restore and potentiate antimicrobial activity against synovial fluid biofilms.
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Affiliation(s)
- Jessica M. Gilbertie
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States
| | - Thomas P. Schaer
- Department of Clinical Studies New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States
| | - Julie B. Engiles
- Department of Clinical Studies New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States
- Department of Pathobiology New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States
| | - Gabriela S. Seiler
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Bennett L. Deddens
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Alicia G. Schubert
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Megan E. Jacob
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Darko Stefanovski
- Department of Clinical Studies New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States
| | - Gordon Ruthel
- Department of Pathobiology New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States
| | - Noreen J. Hickok
- Department of Orthopedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States
| | - Devorah M. Stowe
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Alexa Frink
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Lauren V. Schnabel
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States
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Walkay S, Wallace DT, Balasubramaniam VSC, Maheshwari R, Changulani M, Sarungi M. Outcomes of Debridement, Antibiotics and Implant Retention (DAIR) for Periprosthetic Joint Infection in a High-Volume Arthroplasty Centre. Indian J Orthop 2022; 56:1449-1456. [PMID: 35928667 PMCID: PMC9283628 DOI: 10.1007/s43465-022-00655-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/04/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Prosthetic joint infection (PJI) following total knee arthroplasty (TKA) and total hip arthroplasty (THA) can be a devastating diagnosis. Debridement, antibiotics and implant retention (DAIR) is a preferred treatment modality for acute PJI. A retrospective analysis of infected primary arthroplasties to evaluate the success of DAIR and factors influencing its outcomes. METHODS We retrospectively reviewed all patients who underwent DAIR for PJI at our unit between 2010 and 2018. Patients who underwent revision surgery as an index procedure, arthroscopic washout and those with less than two years of follow-up were excluded. Treatment failure was defined as revision arthroplasty for recurrence of infection within 2 years of the index procedure. Chi-square and Fischer's exact test were used to compare between patient factors and DAIR outcomes. Kaplan-Meier survival curve and log-rank test were used to analyse implant survivorship following DAIR. RESULTS Of the sixty patients (40 knees, 20 hips) who underwent DAIR, eighteen (13 knees, 5 hips) required revision arthroplasty within 2 years accounting for a success rate of 70%. Predictive factors for revision were American Society of Anaesthesiologist (ASA) score of greater than 2 (p = 0.021), BMI > 35 (p = 0.046), C Reactive protein (CRP) > 200 mg/L (p = 0.007) and Staphylococcus aureus growth (p = 0.012). The five-year survival rate for DAIR was 70%, which remained constant after two years from DAIR. CONCLUSION Success rate of DAIR in PJI was 70% which was comparable to similar studies in the literature. ASA > 2, BMI > 35, CRP > 200 and staphylococcus aureus growth were predictors for DAIR failure. Implant survival rate and duration were better following DAIR in early-onset PJI.
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Affiliation(s)
- Sriganesh Walkay
- grid.413157.50000 0004 0590 2070Department of Orthopaedics, Golden Jubilee National Hospital, Clydebank, Glasgow, Scotland, UK
| | - David Tran Wallace
- grid.413157.50000 0004 0590 2070Department of Orthopaedics, Golden Jubilee National Hospital, Clydebank, Glasgow, Scotland, UK
| | | | - Rohit Maheshwari
- grid.413157.50000 0004 0590 2070Department of Orthopaedics, Golden Jubilee National Hospital, Clydebank, Glasgow, Scotland, UK
| | - Manish Changulani
- grid.413157.50000 0004 0590 2070Department of Orthopaedics, Golden Jubilee National Hospital, Clydebank, Glasgow, Scotland, UK
| | - Martin Sarungi
- grid.413157.50000 0004 0590 2070Department of Orthopaedics, Golden Jubilee National Hospital, Clydebank, Glasgow, Scotland, UK
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Bradley AT, King CA, Lin Y, Sculco P, Balach T, Landy DC. Distinguishing Periprosthetic Crystalline Arthropathy from Infection in Total Knee Arthroplasty: A Systematic Review. J Knee Surg 2022; 35:668-675. [PMID: 32942331 DOI: 10.1055/s-0040-1716507] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Distinguishing periprosthetic crystalline arthropathy from periprosthetic joint infection (PJI) remains a diagnostic challenge as both symptom presentation and diagnostic tests overlap. Accurate differentiation is important as treatment plans vary significantly. We sought to systematically review all cases of total knee arthroplasty (TKA) periprosthetic crystalline arthropathy reported in the literature and summarize clinical, diagnostic, and operative findings in the context of guidelines for diagnosing PJI. The goal of this systematic review is to determine the amount of diagnostic overlap and to identify best practices for differentiating between these two diagnoses. MEDLINE and Google Scholar were searched to identify cases of crystalline arthropathy following TKA. Case reports were reviewed for patient characteristics, clinical symptoms, physical exam, laboratory results, and treatment outcomes. These findings were summarized across patients and dichotomized based on current thresholds for diagnosing PJI according to Musculoskeletal Infection Society criteria. Twenty-six articles were identified which included 42 cases of periprosthetic crystalline arthropathy (17 gout, 16 pseudogout, one both, and eight not specified). Of these cases, 25 presented over 1 year after their index arthroplasty and 15 had no prior history of crystalline arthropathy. Only six cases had a superimposed infection based on aspiration or intraoperative cultures. For cases without a culture-positive infection, several diagnostic tests overlap with PJI thresholds: 95% of patients had C-reactive protein greater than 1 mg/dL, 76% had an erythrocyte sedimentation rate greater than 30 mm/hour, 91% had a synovial white blood cell greater than 3,000 cells, and 76% had a synovial polymorphonuclear cells percent greater than 80%. Patients without co-infection were managed with non-steroidal anti-inflammatory drugs, colchicine, allopurinol, steroids, or a combination of these treatments and most had complete resolution of symptoms within 1 week. Commonly used markers of PJI fail to reliably distinguish periprosthetic crystalline arthropathy from infection. Though clinical judgement and consideration of the implications of delayed treatment for acute PJI remain paramount, in the setting of synovial crystals, surgeons may wish to consider this alternate etiology as the source of the patient's clinical symptoms.
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Affiliation(s)
- Alexander T Bradley
- Orthopaedic Surgery Department, Department 4B, University of Chicago, Chicago, Illinois
| | - Connor A King
- Orthopaedic Surgery Department, Department 4B, University of Chicago, Chicago, Illinois
| | - Ye Lin
- University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Peter Sculco
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Tessa Balach
- Orthopaedic Surgery Department, Department 4B, University of Chicago, Chicago, Illinois
| | - David C Landy
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York
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Gabrielli A, Wilson A, Wawrose R, Dombrowski M, O'Malley M, Klatt B. The presence of a draining sinus is associated with failure of re-implantation during two-stage exchange arthroplasty. J Bone Jt Infect 2022; 7:55-60. [PMID: 35402147 PMCID: PMC8985591 DOI: 10.5194/jbji-7-55-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/14/2022] [Indexed: 11/11/2022] Open
Abstract
Background: Reinfection rates after two-stage
exchange arthroplasty for prosthetic joint infection (PJI) have been
reported as high as 33 % in the literature. Understanding risk factors for
treatment failure will help to preoperatively counsel patients on the
likelihood of successful treatment and possibly influence the surgeon's
treatment algorithm. This study aimed to delineate whether the presence of a
draining sinus tract is associated with risk of failure of two-stage
exchange arthroplasty. Methods: We performed a single
institution, multi-center retrospective chart review of outcomes of patients
treated for PJI with two-stage exchange arthroplasty between June 2006 and
May 2016. For patients treated prior to 2011, PJI was defined based on the
preoperative work-up and intraoperative findings as determined by the
attending surgeon. After 2011, PJI was defined using MSIS consensus
criteria. All patients had a minimum of follow-up of 2 years or treatment
failure prior to 2 years. Treatment failure was defined as reinfection or
failure to complete two-stage exchange secondary to persistent infection or
other host factors. Operative reports and clinical notes were reviewed to
assess for presence of a draining sinus tract. Results: 240
patients were treated for PJI with intended two-stage exchange arthroplasty.
The overall rate of treatment failure was 29.6 % (71/240), while the
overall rate of reinfection was 13.3 % (32/240). A total of 39 patients did not
complete second stage revision; final treatment for these patients was
amputation, fusion, or chronic antibiotic suppression. A total of 52 of 240 patients
(21.7 %) had a draining sinus tract at presentation. Patients with a sinus
tract were significantly less likely to be replanted compared to those without a
sinus tract at presentation (13.3 % vs. 26.9 %, p=0.02). However, when
accounting for all mechanisms of treatment failure, including reinfection
following replantation, there was no statistically significant difference
detected between the sinus and no-sinus groups (27.7 % vs. 36.5 %, p=0.22). Discussion: A draining sinus tract represents a chronic,
deep infectious process with ultimate compromise of overlying soft tissues.
Thus we hypothesized it would be associated with failure in a two-stage
exchange arthroplasty. These data demonstrate that patients with a draining
sinus are significantly less likely to undergo re-implantation. This
provides evidence to the paucity of data surrounding draining sinuses and
two-stage PJI treatment.
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Pimentel de Araujo F, Pirolo M, Monaco M, Del Grosso M, Ambretti S, Lombardo D, Cassetti T, Gargiulo R, Riccobono E, Visca P, Pantosti A. Virulence Determinants in Staphylococcus aureus Clones Causing Osteomyelitis in Italy. Front Microbiol 2022; 13:846167. [PMID: 35308345 PMCID: PMC8927738 DOI: 10.3389/fmicb.2022.846167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
Staphylococcus aureus is the most common pathogen causing osteomyelitis (OM). The aim of this study was to explore the clonal complex (CC) distribution and the pattern of virulence determinants of S. aureus isolates from OM in Italy. Whole-genome sequencing was performed on 83 S. aureus isolates from OM cases in six hospitals. Antibiotic susceptibility tests showed that 30.1% of the isolates were methicillin-resistant S. aureus (MRSA). The most frequent CCs detected were CC22, CC5, CC8, CC30, and CC15, which represent the most common lineages circulating in Italian hospitals. MRSA were limited in the number of lineages (CC22, CC5, CC8, and CC1). Phylogenetic analysis followed the sequence type-CC groupings and revealed a non-uniform distribution of the isolates from the different hospitals. No significant difference in the mean number of virulence genes carried by MRSA or MSSA isolates was observed. Some virulence genes, namely cna, fib, fnbA, coa, lukD, lukE, sak, and tst, were correlated with the CC. However, different categories of virulence factors, such as adhesins, exoenzymes, and toxins, were frequently detected and unevenly distributed among all lineages. Indeed, each lineage carried a variable combination of virulence genes, likely reflecting functional redundancy, and arguing for the importance of those traits for the pathogenicity in OM. In conclusion, no specific genetic trait in the most frequent lineages could explain their high prevalence among OM isolates. Our findings highlight that CCs detected in OM isolates follow the epidemiology of S. aureus infections in the country. It is conceivable that any of the most common S. aureus CC can cause a variety of infections, including OM.
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Affiliation(s)
- Fernanda Pimentel de Araujo
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
- Department of Science, Roma Tre University, Rome, Italy
| | - Mattia Pirolo
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Monica Monaco
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Maria Del Grosso
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Simone Ambretti
- Unit of Microbiology, Policlinico S. Orsola, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Donatella Lombardo
- Unit of Microbiology, Policlinico S. Orsola, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Tiziana Cassetti
- Unit of Clinical Microbiology, S. Agostino-Estense Hospital Baggiovara, AUSL Modena, Modena, Italy
| | - Raffaele Gargiulo
- Unit of Clinical Microbiology, S. Agostino-Estense Hospital Baggiovara, AUSL Modena, Modena, Italy
| | - Eleonora Riccobono
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Paolo Visca
- Department of Science, Roma Tre University, Rome, Italy
- Santa Lucia Foundation (IRCCS), Rome, Italy
- *Correspondence: Paolo Visca,
| | - Annalisa Pantosti
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
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Exposure and Health Effects of Bacteria in Healthcare Units: An Overview. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12041958] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Healthcare units consist of numerous people circulating daily, such as workers, patients, and companions, and these people are vehicles for the transmission of microorganisms, such as bacteria. Bacteria species may have different allergenic, pathogenic, infectious, or toxic properties that can affect humans. Hospital settings foment the proliferation of bacteria due to characteristics present in the indoor hospital environment. This review article aims to identify the potential health effects caused by bacterial contamination in the context of healthcare units, both in patients and in workers. A search was carried out for articles published in PubMed, Web of Science and Scopus, between 1 January 2000 and 31 October 2021, using the descriptor hospital exposure assessment bacteria. This bibliographic research found a total of 13 articles. Bacteria transmission occurs mainly due to the contact between healthcare workers and patients or through the handling of/contact with contaminated instruments or surfaces. The most common bacterial contaminants are Escherichia coli, Pseudomonas aeruginosa, Staphylococcus spp., Staphylococcus aureus and Micrococcus luteus, and the principal health effects of these contaminants are hospital-acquired infections and infections in immunocompromised people. A tight control of the disinfection methods is thus required, and its frequency must be increased to remove the microbial contamination of wards, surfaces and equipment. A better understanding of seasonal variations is important to prevent peaks of contamination.
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Davis JS, Metcalf S, Clark B, Robinson JO, Huggan P, Luey C, McBride S, Aboltins C, Nelson R, Campbell D, Solomon LB, Schneider K, Loewenthal MR, Yates P, Athan E, Cooper D, Rad B, Allworth T, Reid A, Read K, Leung P, Sud A, Nagendra V, Chean R, Lemoh C, Mutalima N, Tran T, Grimwade K, Sehu M, Looke D, Torda A, Aung T, Graves S, Paterson DL, Manning L. Predictors of treatment success following peri-prosthetic joint infection: 24-month follow up from a multi-center prospective observational cohort study of 653 patients. Open Forum Infect Dis 2022; 9:ofac048. [PMID: 35233433 PMCID: PMC8882242 DOI: 10.1093/ofid/ofac048] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/30/2022] [Indexed: 12/05/2022] Open
Abstract
Background Periprosthetic joint infection (PJI) is a devastating condition and there is a lack of evidence to guide its management. We hypothesized that treatment success is independently associated with modifiable variables in surgical and antibiotic management. Methods The is a prospective, observational study at 27 hospitals across Australia and New Zealand. Newly diagnosed large joint PJIs were eligible. Data were collected at baseline and at 3, 12, and 24 months. The main outcome measures at 24 months were clinical cure (defined as all of the following: alive, absence of clinical or microbiological evidence of infection, and not requiring ongoing antibiotic therapy) and treatment success (clinical cure plus index prosthesis still in place). Results Twenty-four-month outcome data were available for 653 patients. Overall, 449 patients (69%) experienced clinical cure and 350 (54%) had treatment success. The most common treatment strategy was debridement and implant retention (DAIR), with success rates highest in early postimplant infections (119 of 160, 74%) and lower in late acute (132 of 267, 49%) and chronic (63 of 142, 44%) infections. Selected comorbidities, knee joint, and Staphylococcus aureus infections were independently associated with treatment failure, but antibiotic choice and duration (including rifampicin use) and extent of debridement were not. Conclusions Treatment success in PJI is associated with (1) selecting the appropriate treatment strategy and (2) nonmodifiable patient and infection factors. Interdisciplinary decision making that matches an individual patient to an appropriate management strategy is a critical step for PJI management. Randomized controlled trials are needed to determine the role of rifampicin in patients managed with DAIR and the optimal surgical strategy for late-acute PJI.
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Affiliation(s)
- Joshua S Davis
- Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
- Department of Infectious Diseases, John Hunter Hospital, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Sarah Metcalf
- Department of Infectious Diseases, Christchurch Hospital, Christchurch, New Zealand
| | - Benjamin Clark
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - J Owen Robinson
- Department of Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia
- College of Science, Health, Engineering and Education, Discipline of Health, Murdoch University, Perth Australia
| | - Paul Huggan
- Department of Infectious Diseases, Waikato Hospital, Hamilton, New Zealand
| | - Chris Luey
- Counties Manukau District Health Board, Auckland, NZ
| | - Stephen McBride
- Department of Infectious Diseases, Northern Health, Epping, Melbourne, Vic, Australia
| | - Craig Aboltins
- Department of Infectious Diseases, Northern Health, Epping, Melbourne, Vic, Australia
- Northern Clinical School, University of Melbourne, Melbourne, Vic, Australia
| | - Renjy Nelson
- Department of Infectious Diseases, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - David Campbell
- Department of Orthopaedic Surgery, Wakefield Orthopaedic Clinic and The University of Adelaide, Adelaide, SA, Australia
| | - L Bogdan Solomon
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital and The University of Adelaide, Adelaide, SA, Australia
| | - Kellie Schneider
- Department of Orthopaedic Surgery, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Mark R Loewenthal
- Department of Infectious Diseases, John Hunter Hospital, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Piers Yates
- Department of Orthopaedic Surgery, Fiona Stanley Hospital, Murdoch, WA, Australia
- Medical School, University of Western Australia, Perth, Australia
| | - Eugene Athan
- Department of Infectious Diseases, Barwon Health, Deakin University, Geelong, Vic, Australia
| | - Darcie Cooper
- Geelong Centre for Emerging Infectious Disease, Deakin University, Geelong, Vic, Australia
| | - Babak Rad
- Department of Infectious Diseases, Barwon Health, Deakin University, Geelong, Vic, Australia
| | - Tony Allworth
- Department of Infectious Diseases, St Vincent’s Private Hospital Northside, Chermside, QLD, Australia
| | - Alistair Reid
- Department of Infectious Diseases, Wollongong Hospital, Wollongong, NSW, Australia
| | - Kerry Read
- Department of Infectious Diseases, North Shore Hospital, Auckland, New Zealand
| | - Peter Leung
- Department of Microbiology and Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Archana Sud
- Department of Infectious Diseases, Nepean Hospital, Kingswood, NSW, Australia
| | - Vana Nagendra
- Department of Infectious Diseases, Liverpool Hospital, Liverpool, NSW, Australia
| | - Roy Chean
- Department of Infectious Diseases, Latrobe Regional Hospital, Traralgon, VIC, Australia
| | - Chris Lemoh
- Department of Infectious Diseases, Dandenong Hospital, Dandenong, VIC, Australia
| | - Nora Mutalima
- Department of Orthopaedic Surgery, Dandenong Hospital, Dandenong, VIC, Australia
| | - Ton Tran
- Department of Orthopaedic Surgery, Dandenong Hospital, Dandenong, VIC, Australia
| | - Kate Grimwade
- Department of Infectious Diseases, Tauranga Hospital, Tauranga, New Zealand
| | - Marjoree Sehu
- Infection Management Services, Princess Alexandra Hospital, QLD, Australia
| | - Davis Looke
- Infection Management Services, Princess Alexandra Hospital, QLD, Australia
| | - Adrienne Torda
- Faculty of Medicine and Health, UNSW Sydney, Randwick, NSW, Australia
| | - Thi Aung
- Department of Infectious Diseases, Redcliffe, Hospital, Redcliffe, QLD, Australia
| | - Steven Graves
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
- School of Surgery, University of South Australia, Adelaide, South Australia, Australia
| | - David L Paterson
- UQ Centre for Clinical Research, University of Queensland, Brisbane, QLD, Australia
| | - Laurens Manning
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia
- Medical School, University of Western Australia, Perth, Australia
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Vaz K, Taylor A, Kendrick B, Alvand A. A guide to debridement, antibiotics, and implant retention. ANNALS OF JOINT 2022; 7:5. [PMID: 38529146 PMCID: PMC10929291 DOI: 10.21037/aoj-20-89] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 09/01/2020] [Indexed: 03/27/2024]
Abstract
Debridement, antibiotics, and implant retention (DAIR) is an alternative management strategy for the treatment of periprosthetic joint infection (PJI). While infection eradication rates are lower with DAIR, the benefits including decreased morbidity, improved functional outcomes, and decreased cost may justify the risks when considering this form of treatment compared to traditional one or two stage exchange arthroplasty. Implant longevity in the setting of a successful DAIR is similar to matched patients who have not experienced a PJI. An experienced arthroplasty surgeon well versed in extensile exposure should perform the DAIR. This procedure should not be viewed as a simple "washout." While PJI may be considered a surgical urgency, DAIR can be performed on a planned list if it allows for appropriate staffing and implants for the procedure. Arthroscopic irrigation may be performed for a patient in extremis but it should not be viewed as a definitive procedure to address PJI. Keys to a successful DAIR include accurate tissue sampling to determine the infective organism, meticulous, radical debridement, and exchange of modular components if possible. A multidisciplinary team (MDT) including an infectious disease specialist should be involved prior to surgery in order to guide appropriate antimicrobial therapy throughout the patient's course of treatment. In the article below we present our indications, considerations, and technique for performing a DAIR for PJI for hip and knee arthroplasty.
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Affiliation(s)
- Kenneth Vaz
- Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Oxford, UK
| | - Adrian Taylor
- Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Oxford, UK
| | - Ben Kendrick
- Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Oxford, UK
| | - Abtin Alvand
- Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Oxford, UK
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48
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Middleton R, Price A, Alvand A. Contemporary outcomes of debridement, antibiotics and implant retention in knee arthroplasty. ANNALS OF JOINT 2022; 7:9. [PMID: 38529130 PMCID: PMC10929323 DOI: 10.21037/aoj-20-76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/11/2020] [Indexed: 03/27/2024]
Abstract
Periprosthetic joint infection (PJI) is a major complication after knee arthroplasty, with approximately a quarter of knee arthroplasty revisions citing PJI as an indication. With the demand for knee arthroplasty predicted to increase, coupled with a lack of evidence for decreasing PJI risk, an appreciation of the burdens of PJI on both patients and health care systems is vital. Patients with PJI can experience a reduced quality of life as well as increased morbidity, whilst the management of PJI has significant economic implications. Surgical options include debridement, antibiotics and implant retention (DAIR), single-stage revision, two-stage revision and salvage procedures. DAIR involves the systematic debridement of all infected and unhealthy tissues coupled with directed antibiotic therapy, with definitive infection clearance the objective. In contrast to single- and two-stage revision procedures for PJI, DAIR does not involve the removal of fixed implants, with only modular components exchanged. Potential benefits of DAIR include reduced tissue destruction, reduced morbidity and reduced healthcare burdens, but with a higher reinfection risk compared to staged revision techniques, and utility largely restricted to acute bacterial PJI. A review of contemporary DAIR outcomes is of value given advances in the understanding of PJI biology; the development of consensus-based definitions for PJI diagnosis and treatment outcomes; and evolution of DAIR indications and technique. This review discusses outcomes of DAIR for knee PJI, published over the last two decades.
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Affiliation(s)
- Robert Middleton
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
| | - Andrew Price
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
| | - Abtin Alvand
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
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Walmsley PJ. The '2-in-1' stage: indications, technique & results. ANNALS OF JOINT 2022; 7:7. [PMID: 38529137 PMCID: PMC10929305 DOI: 10.21037/aoj-20-83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 08/12/2020] [Indexed: 03/27/2024]
Abstract
Prosthetic joint infections remain an ongoing challenge for orthopaedic surgeons with an interest in knee arthroplasty, which relates to their often difficult diagnoses, need for multiple surgeries, increased technical and financial requirements. Peri-prosthetic joint infection is devastating complication for the patient and with the current literature unable to either demonstrate superiority of one or two stage revision then we should continue to assess on a case by case basis. The use of a '2 in 1' single-stage approach has been recently been promoted as a form of single stage revision for infection on account of the potential for reduction in risks, costs, and complications. Where it is safe to do so, a single stage procedure can avoid several of the drawbacks which may occur with a formal two stage approach. Particularly, it can reduce the risk of post-operative stiffness and arthrofibrosis which can be associated with two stage surgery. Use of a single stage may be more cost effective, by saving the patient having to undergo a second major procedure. This article reviews the indications for its use, technique and results. The use of '2-in-1' single-stage revision can be considered as an effective option for treating infection following TKR and cases with associated bone loss.
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Affiliation(s)
- Phil J. Walmsley
- Department of Orthopaedic Surgery, Victoria Hospital Kirkcaldy, Kirkcaldy, UK
- School of Medicine, University of St Andrews, North Haugh, St Andrews, Fife, UK
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Kiss C, Connoley D, Connelly K, Horne K, Korman T, Woolley I, Lau JSY. Long-Term Outcomes in Patients on Life-Long Antibiotics: A Five-Year Cohort Study. Antibiotics (Basel) 2022; 11:62. [PMID: 35052939 PMCID: PMC8772790 DOI: 10.3390/antibiotics11010062] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/16/2021] [Accepted: 12/24/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Little is known about the impacts at an individual level of long-term antibiotic consumption. We explored health outcomes of long-term antibiotic therapy prescribed to a cohort of patients to suppress infections deemed incurable. METHODS We conducted a 5-year longitudinal study of patients on long-term antibiotics at Monash Health, a metropolitan tertiary-level hospital network in Australia. Adults prescribed antibiotics for >12 months to suppress chronic infection or prevent recurrent infection were included. A retrospective review of medical records and a descriptive analysis was conducted. RESULTS Twenty-seven patients were followed up during the study period, from 29 patients originally identified in Monash Health in 2014. Seven of the 27 patients (26%) died from causes unrelated to the suppressed infection, six (22%) ceased long-term antibiotic therapy and two (7%) required treatment modification. Fifteen (56%) were colonised with multiresistant microorganisms, including vancomycin resistant Enterococci, methicillin resistant Staphylococcus aureus, and carbapenem resistant Enterobacteriaciae. CONCLUSIONS This work highlights the potential pitfalls of long-term antibiotic therapy, and the frailty of this cohort, who are often ineligible for definitive curative therapy.
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Affiliation(s)
- Christopher Kiss
- Monash Infectious Diseases, Monash Medical Centre, Monash Health, Clayton, VIC 3168, Australia; (C.K.); (D.C.); (K.C.); (K.H.); (T.K.); (I.W.)
| | - Declan Connoley
- Monash Infectious Diseases, Monash Medical Centre, Monash Health, Clayton, VIC 3168, Australia; (C.K.); (D.C.); (K.C.); (K.H.); (T.K.); (I.W.)
| | - Kathryn Connelly
- Monash Infectious Diseases, Monash Medical Centre, Monash Health, Clayton, VIC 3168, Australia; (C.K.); (D.C.); (K.C.); (K.H.); (T.K.); (I.W.)
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC 3800, Australia
| | - Kylie Horne
- Monash Infectious Diseases, Monash Medical Centre, Monash Health, Clayton, VIC 3168, Australia; (C.K.); (D.C.); (K.C.); (K.H.); (T.K.); (I.W.)
| | - Tony Korman
- Monash Infectious Diseases, Monash Medical Centre, Monash Health, Clayton, VIC 3168, Australia; (C.K.); (D.C.); (K.C.); (K.H.); (T.K.); (I.W.)
| | - Ian Woolley
- Monash Infectious Diseases, Monash Medical Centre, Monash Health, Clayton, VIC 3168, Australia; (C.K.); (D.C.); (K.C.); (K.H.); (T.K.); (I.W.)
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC 3800, Australia
| | - Jillian S. Y. Lau
- Monash Infectious Diseases, Monash Medical Centre, Monash Health, Clayton, VIC 3168, Australia; (C.K.); (D.C.); (K.C.); (K.H.); (T.K.); (I.W.)
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC 3800, Australia
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