Significant Difference in Antimicrobial Resistance of Coagulase Negative Periprosthetic Joint Infection in Septic Revision Total Knee Arthroplasty Between Two Major Orthopedic Centers

Clinical Outcomes and Complications of 2-Stage Septic Versus Aseptic Revision Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Although several studies have compared the clinical outcomes of septic and aseptic revision total knee arthroplasty (TKA), their results have been controversial. Therefore, this study aimed to compare clinical outcomes and complications of septic and aseptic revision TKA through a systematic review and meta-analysis.

METHODS

The PubMed (MEDLINE) and Embase databases were searched for studies evaluating the clinical outcomes and complications of 2-stage septic revision and aseptic revision TKAs. A systematic review of clinical outcomes (Knee Society Knee and Function Scores and range of motion) and complications (reoperation, infection, and failure rates) was conducted.

RESULTS

Thirteen studies were included in the systematic review. The mean MINORS (Methodological Index for NOn-Randomized Studies) score of the included studies was 20.5 (range, 18 to 22). The meta-analysis revealed higher reoperation (risk ratio [RR], 1.98; 95% confidence interval [CI], 1.50 to 2.62; p < 0.00001), infection (RR, 4.08; 95% CI, 2.94 to 5.64; p < 0.00001), and failure rates (RR, 2.88; 95% CI, 1.38 to 6.03; p = 0.005) in septic revision TKAs than in aseptic revision TKAs. Moreover, septic revision TKAs showed lower Knee Society Knee Scores compared with aseptic TKAs (mean difference [MD], -6.86; 95% CI, -11.80 to -1.92; p = 0.006). However, the Knee Society Function Score (MD, -1.84; 95% CI, -7.84 to 3.80; p = 0.52) and range of motion (MD, -6.96°; 95% CI, -16.23° to 2.31°; p = 0.14) were not significantly different between septic and aseptic revision TKAs.

CONCLUSIONS

Despite the heterogeneity of prosthesis designs and surgical protocols used in septic and aseptic revision TKAs, the results of this systematic review suggest that 2-stage septic revision TKAs have poorer clinical outcomes and higher complication rates than aseptic revision TKAs do.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Second-Line Antibiotic Agents in Patient-Reported Penicillin or Cephalosporin Allergy Have No Negative Impact on Antibiotic Resistance After Hip and Knee Arthroplasty

BACKGROUND

The aim of the present study was to compare causative bacteria and their antibiotic resistance profiles in patients developing a periprosthetic joint infection (PJI) based on preoperative prophylactic antibiotic regimens in primary total hip (THA) and primary total and unicompartmental knee arthroplasty (TKA/UKA).

METHODS

We reviewed all cases of PJI occurring after primary THA and primary TKA/UKA, between 2011 and 2020 in a tertiary referral hospital. The standard preoperative prophylactic antibiotic for primary joint arthroplasty was cefuroxime and recommended second-line agent was clindamycin. Patients were divided by the replaced joint and analyzed independently.

RESULTS

In the THA group, culture-positive PJI was detected in 61 of 3,123 (2.0%) cefuroxime-administered cases and 6 of 206 (2.9%) noncefuroxime-administered cases. In the TKA/UKA group, culture positive PJI was identified in 21 of 2,455 (0.9%) cefuroxime-administered cases and in 3 of 211 (1.4%) noncefuroxime administered cases. The most commonly isolated bacteria in both groups were coagulase negative staphylococci (CNS). There were no statistically significant differences of pathogen spectrum depending on the preoperative antibiotic regimen detected. Antibiotic resistance of isolated bacteria was significantly different in 4 of 27 (14.8%) analyzed antibiotics in THA and in 3 of 22 (13.6%) analyzed antibiotics in TKA/UKA. In all cohorts, a high occurrence of oxacillin-resistant CNS (50.0 to 100.0%) and clindamycin-resistant CNS (56.3 to 100.0%) has been observed.

CONCLUSION

The use of the second-line antibiotic did not influence the pathogen spectrum or antibiotic resistance. However, an alarmingly high proportion of CNS strains was resistant to clindamycin.

Two-Stage Revision Arthroplasty for Resistant Gram-Positive Periprosthetic Joint Infections Using an Oral Linezolid-Based Antibiotic Regime

BACKGROUND

Increasing antibiotic resistance has been reported as an issue in the systemic treatment of periprosthetic joint infection (PJI). Linezolid offers the advantages of high oral bioavailability and little resistance; however, efficacy in the treatment of PJI varies considerably, and studies reporting consistent surgical treatment are scarce.

METHODS

This is a retrospective, single-center analysis of two-stage revisions performed between 2008 and 2017. We identified 111 patients who met the inclusion criteria. Oral linezolid was given for 28 days following 14 days of intravenous tailored antibiotics in resistant gram-positive PJI. A total of 64% of the patients had methicillin-resistant coagulase-negative staphylococci. The median follow-up was 43 (interquartile range (IQR) 30-57) months.

RESULTS

22% (24/111) of the patients underwent surgery for subsequent infection. The 5-year infection-free survival probability was 77% (95% confidence interval (CI) 69-85). A total of 5% of the patients (6/111) had the same organism at the time of reinfection. The patients with infections caused by other organisms than Coagulase-negative staphylococci tended to have a worse reinfection-free survivorship at five years (70% vs. 81%, p = 0.09). Furthermore, the patients with obesity tended to have reduced reinfection-free survivorship at five years (69% vs. 84%, p = 0.08). Overall, 5% (6/111) of the patients had blood count abnormalities with no treatment discontinuations.

CONCLUSION

Two-stage revision arthroplasty with systemic oral linezolid treatment for resistant gram-positive PJI results in an infection control of 77% at the mid-term.

Hematogenous prosthetic knee joint infection with Klebsiella pneumoniae caused by asymptomatic gallbladder abscess: a case report and literature review

Klebsiella pneumoniae has the ability to form biofilm; therefore, the treatment of prosthetic joint infection involving K. pneumoniae is often challenging. This report describes the first case of acute hematogenous prosthetic knee joint infection with K. pneumoniae that occurred as a result of an asymptomatic gallbladder abscess. The patient was a 78-year-old man who underwent bilateral total knee arthroplasty 6 years ago. He had pain and swelling in his right knee. The synovial fluid culture of the right knee revealed K. pneumoniae and prosthetic joint infection was diagnosed. Computed tomography revealed a gallbladder abscess in the absence of right upper abdominal pain. The patient underwent simultaneous debridement of the knee and open cholecystectomy. The treatment was successful and the prosthesis was retained. In cases of hematogenous prosthetic joint infection with K. pneumoniae, other sources of infection should be suspected and investigated regardless of whether they are symptomatic.

International Survey of Practice for Prophylactic Systemic Antibiotic Therapy in Hip and Knee Arthroplasty

(1) Background: Prophylactic systemic antibiotics are acknowledged to be an important part of mitigating prosthetic joint infections. Controversy persists regarding optimal antibiotic regimes. We sought to evaluate current international antibiotics guidelines for total joint arthroplasty (TJA) of the hip and knee. (2) Methods: 42 arthroplasty societies across 6 continents were contacted and their published literature reviewed. (3) Results: 17 societies had guidelines; of which 11 recommended an antibiotic agent or antibiotic class (10—cephalosporin; 1—cloxacillin); 15 recommended antibiotic infusion within an hour of incision and 10 advised for post-operative doses (8—up to 24 h; 1—up to 36 h; 1—up to 48 h). (4) Conclusions: Prophylactic antibiotic guidelines for TJA are often absent or heterogenous in their advice.

The Impact of Patient-Reported Penicillin or Cephalosporin Allergy on the Occurrence of the Periprosthetic Joint Infection in Primary Knee and Hip Arthroplasty

Reducing the risk of periprosthetic joint infections (PJI) requires a multi-pronged strategy including usage of a prophylactic antibiotic. A history of penicillin or cephalosporin allergy often leads to a change in prophylactic antibiotic regimen to avoid serious side effects. The purpose of the present retrospective study was to determine incidence of PJI based on perioperative antibiotic regimen in total hip arthroplasty (THA), total knee arthroplasty (TKA) or unicompartmental knee arthroplasty (UKA). A review of all primary THAs, primary TKAs and primary UKAs, undertaken between 2011 and 2020 in a tertiary referral hospital, was performed. The standard perioperative antibiotic for joint arthroplasty (JA) in the analyzed tertiary hospital is cefuroxime. There were no differences in prophylactic antibiotic regimen over time. In 7.9% (211 of 2666) of knee arthroplasties and in 6.0% (206 of 3419) of total hip arthroplasties, a second-line prophylactic antibiotic was used. There was no statistically significant higher occurrence of PJI between the first-line and second-line prophylactic antibiotic in knee arthroplasties (p = 0.403) as well as in total hip arthroplasties (p = 0.309). No relevant differences in age, American Society of Anesthesiologists (ASA) score and body mass index (BMI) between the groups were observed.

Microbiological Trends and Antibiotic Susceptibility Patterns in Patients with Periprosthetic Joint Infection of the Hip or Knee over 6 Years

We sought to analyze trends of the causative pathogens and their antibiotic susceptibility patterns in patients with periprosthetic joint infections (PJI) of the hip and knee to get better insights and improve treatment. Retrospective evaluation of all consecutive patients with microbiological detection of a causative pathogen at a tertiary endoprothetic referral center between January 2016 and December 2021 in Germany was performed. Overall, 612 different microorganisms could be detected in 493 patients (hip: n = 293; knee: n = 200). Evaluation did not show a change in the relative abundance of pathogens detected, with coagulase-negative staphylococci (n = 275; 44.9%) found frequently, followed by S. aureus (n = 86; 14.1%), Enterococcus species (n = 57; 9.3%), Streptococcus species (n = 48; 7.8%), and Gram-negative bacteria (n = 80; 13.1%). Evaluation of the antibiotic susceptibilities showed increasing rates of oxacillin-resistant coagulase-negative staphylococci (60.4%; 46.8−76.7%) and piperacillin-tazobactam-resistant Gram-negative bacteria (26.5%; 0−57.1%), although statistically not significant. Resistance of Gram-positive bacteria to vancomycin (<1%) and Gram-negative microorganisms to meropenem (1.25%) remained an exception. In summary, coagulase-negative staphylococci, as the most frequent pathogen, displayed a continuously high rate of oxacillin resistance. For the highest antimicrobial coverage in the case of an empiric therapy/unknown pathogen, vancomycin might be chosen. Level of evidence: IV.