Role of Routine Suppressive Antibiotic Therapy After Debridement, Antibiotics, and Implant Retention for Acute Periprosthetic Joint Infections

Background

The first-line management strategy for acute periprosthetic joint infections (PJIs) is debridement, antibiotics, and implant retention (DAIR). Suppressive antibiotic therapy (SAT) after DAIR is proposed to improve outcomes, yet its efficacy remains under scrutiny.

Methods

We conducted a multicenter retrospective study in patients with acute PJI of the hip or knee who were treated with DAIR in centers from Europe and the United States. We analyzed the effect of SAT using a Cox model landmarked at 12 weeks. The primary covariate of interest was SAT, which was analyzed as a time-varying covariate. Patients who experienced treatment failure or were lost to follow-up within 12 weeks were excluded from the analysis.

Results

The study included 510 patients with 66 treatment failures with a median follow-up of 801 days. We did not find a statistically significant association between SAT and treatment failure (hazard ratio, 1.37; 95% CI, .79-2.39; P = .27). Subgroup analyses for joint, country cohort, and type of infection (early or late acute) did not show benefit for SAT. Secondary analysis of country cohorts showed a trend toward benefit for the US cohort (hazard ratio, 0.36; 95% CI, .11-1.15; P = .09), which also had the highest risk of treatment failure.

Conclusions

The utility of routine SAT as a strategy for enhancing DAIR's success in acute PJI remains uncertain. Our results suggest that SAT's benefits might be restricted to specific groups of patients, underscoring the need for randomized controlled trials. Identifying patients most likely to benefit from SAT should be a priority in future studies.

Concomitant Cement Spacer and Peri-spacer Fractures Seven Years After First-stage Revision Knee Arthroplasty: A Case Report

Introduction

Prosthetic joint infections (PJIs) remain an undesirable complication after total knee arthroplasties. Two-stage revision arthroplasty is the current standard of care for treating PJIs. However, the incidence of spacer retention for prolonged periods is increasing, with little known about its potential complications.

Case Report

We present a case of a 64-year-old female of Southeast Asian descent who had a cement spacer maintained in-situ for 7 years due to poor patient compliance with subsequent follow-up.

Conclusion

While patients have satisfactory functional outcomes with the cement spacer, it is not meant for permanent weight bearing. Two-stage revision arthroplasties are only as effective as patients' compliance with subsequent follow-up and surgery. Clinicians must discourage patients from forgoing subsequent follow-up visits and surgery despite satisfactory function and quality of life with the cement spacer in situ to prevent complications related to prolonged retention of cement spacers.

Debridement, Antibiotics, and Implant Retention for a Rare Serratia marcescens Infection after Total Knee Arthroplasty: A Case Report

Introduction

Recently, Serratia marcescens was reported to cause nosocomial infections.

Case Report

In this study, we report a case of S. marcescens infection occurring after total knee arthroplasty (TKA) in a 72-year-old woman. The patient had undergone TKA for knee osteoarthritis. She had a past medical history of diabetes mellitus, for which she was receiving cefazolin sodium. Six days after surgery, redness and effusion were observed in the wound, and post-operative infection was suspected. Thus, the patient was treated with linezolid, clindamycin, and tazobactam/piperacillin hydrate post-operatively. Twelve days after TKA, reinfection was suspected; hence, washing and debridement were repeated.

Conclusion

In this case, remission of S. marcescens infection was achieved without the need to remove the implant by cleaning, debridement, and the use of sensitive antimicrobial agents.

Acute Haematogenous Revision Total Knee Arthroplasty Infection by Streptococcus canis Treated by Debridement, Antibiotics, and Implant Retention: A Case Report

Prosthetic joint infections (PJIs) are one of the most feared complications by orthopaedic surgeons. Haematogenous PJI represents an important part of PJI cases. Streptococcus canis is an extremely rare cause of haematogenous PJI and its medical and surgical treatment and prognosis are not well established. We present a 79-year-old female patient who had a revision total knee arthroplasty (rTKA) surgery three years before. She was admitted to the hospital referring to three days of knee pain, restricted range of motion, and fever. Blood tests demonstrated leukocyte and C-reactive protein elevation. Joint fluid aspiration showed elevated white blood cell count with a high neutrophil differential and its conventional culture was positive for Streptococcus canis. She did not have pets but she took care of her daughter's dog. An acute haematogenous infection of the rTKA was diagnosed and treated with debridement, antibiotics (eight weeks of IV ceftriaxone), and implant retention (DAIR). After one year, the patient remains clinically asymptomatic without changes on X-rays and with normal serum levels of inflammatory blood markers. Streptococcus canis has to be kept in mind as a possible cause of haematogenous TKA infection in patients who have contact with domestic pets and patients should be asked for this contact. We recommend DAIR as a viable treatment option for this type of infection, which may show excellent results.

Removal of Spinal Instrumentation Is Not Required to Successfully Treat Postoperative Wound Infections in Most Cases

INTRODUCTION

Controversy exists regarding whether spinal implants need to be removed to treat postoperative deep wound infections (DWIs). This retrospective study aimed to determine whether the removal or retention of implants impacts the successful treatment of a DWI after spine surgery.

METHODS

Postoperative spine surgery patients presenting with signs of infection who underwent irrigation and debridement (I&D) at Twin Cities Spine Surgeons at Abbott Northwestern Hospital, Minnesota, USA, were studied. First, the persistence of infection when implants were retained or removed was assessed. Second, we analyzed the persistence of infection with respect to the number of I&D, the use of vacuum-assisted closure (VAC) treatment, pseudoarthrosis status, and functional outcomes.

RESULTS

One hundred thirty-five patients were included. Treatment of infection with retention of implants occurred in 64% (87/135); of these, 7% (6/87) had a persistent infection. Of patients with implant removal (36%, 48/135), 6% (3/48) had a persistent infection. Thus, we observed no difference between treatment with implants present compared to implants removed (p = 1.0). Fifty of the 135 patients (37%) received I&D and primary wound closure, and 85 (63%) patients received I&D and VAC treatment. There was no statistical difference between primary wound closure and VAC treatment (p = 0.15) with respect to persistence. Repeat I&D with VAC (three or more times) had a significantly lower rate of recurrence than those with two I&Ds. Pseudoarthrosis and persistent infection were unrelated. At minimum one-year follow-up, achieving a minimum clinically important difference in functional outcome was independent of persistent infection status.

CONCLUSION

Persistent infection was unrelated to the retention of implants. When VAC treatment was deemed necessary, more than two I&Ds resulted in a significantly better cure for infection. Those with a persistent infection were no more likely to exhibit pseudoarthrosis than those with no persistent infection. All patients showed improvement in functional outcomes at minimum one-year follow-up.

Outcomes After Successful Debridement, Antibiotic, and Implant Retention Therapy for Periprosthetic Joint Infection in Total Knee Arthroplasty

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.

Early Staphylococcal Periprosthetic Joint Infection (PJI) Treated with Debridement, Antibiotics, and Implant Retention (DAIR): Inferior Outcomes in Patients with Staphylococci Resistant to Rifampicin

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.

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

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.

Is There Harm in Debridement, Antibiotics, and Implant Retention Versus Two-Stage Revision in the Treatment of Periprosthetic Knee Infection? Experiences Within a Large US Health Care System

BACKGROUND

When faced with a periprosthetic joint infection (PJI) following total knee arthroplasty, the treating surgeon must determine whether 2-stage revision or "liner exchange," aka debridement, antibiotics, exchange of the modular polyethylene liner, and retention of fixed implants (DAIR), offers the best balance of infection eradication versus treatment morbidity. We sought to determine septic re-revision risk following DAIR compared to initial 2-stage revision.

METHODS

We conducted a cohort study using data from Kaiser Permanente's total joint replacement registry. Primary total knee arthroplasty patients who went on to have a PJI treated by DAIR or 2-stage revision were included (2005-2018). Propensity score-weighted Cox regression was used to evaluate risk for septic re-revision.

RESULTS

In total, 1,410 PJIs were included, 1,000 (70.9%) treated with DAIR. Applying propensity score weights, patients undergoing DAIR had a higher risk for septic re-revision compared to initial 2-stage procedures (hazard ratio 3.09, 95% CI 2.22-4.42). Of DAIR procedures, 150 failed (15%) and went on to subsequent 2-stage revision (DAIR-F). When compared to patients undergoing an initial 2-stage revision, we failed to observe a difference in septic re-revision risk following DAIR-F (hazard ratio 1.11, 95% CI 0.58-2.12).

CONCLUSION

Although DAIR had a higher risk of septic re-revision, we failed to observe a difference in risk following DAIR-F when compared to those who initially underwent 2-stage revision. Functional outcome, patient, and organism factors are important to consider when discussing PJI management options.

LEVEL OF EVIDENCE

Level III.

Fixation and Implant Retention of Extracapsular Femoral Neck Periprosthetic Fractures Around Hip Resurfacing Arthroplasty - A Case Series

BACKGROUND

Extracapsular femoral neck fractures in the presence of a resurfacing hip arthroplasty (RHA) appear to be independent of suboptimal technique during the initial implantation of the RHA and present with a similar etiology as native hip fractures - that is, a fragility fracture related to pathological or age-related osteoporosis, as a consequence of trauma. In the presence of a well-fixed and previously well-functioning RHA, the options for management include revision arthroplasty or open reduction and internal fixation (ORIF). In the absence of loosening through mechanisms of wear, infection, metallosis, or suboptimal prosthesis positioning, many authors have advocated ORIF with implant retention. However, there is often debate regarding the use of total hip arthroplasty in these cases.

CASE SERIES

The authors conducted a thorough assessment of the literature followed by a retrospective review of outcomes for three patients treated by ORIF with implant retention for extracapsular femoral neck fractures around a RHA, using a standardized technique. All patients were independently mobile and active with well-fixed and well-functioning RHAs before the date of injury. All patients suffered low-energy trauma resulting in the fracture. There were no intraoperative or perioperative complications. All patients achieved full weight-bearing status and independent mobility. Two patients achieved radiographic union and returned to full range of movement and independent mobilization comparable to their preoperative state. One patient was lost to follow-up.

CONCLUSION

The authors believe that fixation of extracapsular proximal femoral fractures distal to a well-fixed, well-functioning RHA is a good management option in an independent and active patient. A higher level of evidence is needed to investigate the surgical management options of these injuries comparing osteosynthesis with revision arthroplasty.

Daptomycin for the Treatment of Gram-Positive Periprosthetic Hip Infections: Can Daptomycin Prevent the Implant Removal?

Introduction

Management of periprosthetic hip infections (PHIs) generally consists of implant removal and thorough debridement, accompanied by appropriate antibiotic therapy. Daptomycin (DAP) is a novel antibiotic, which allowed for implant retention in several patients after treating their infected joints. However, there is no consensus about implant retention or removal during the treatment of PHIs. The aim of this study was to examine the effect of DAP and to determine a surgical treatment strategy.

Methods

This study retrospectively evaluated 20 patients between August 2014 and December 2018, divided into implant retention (n=9) and implant removal groups (n=11). Infection control and risk of recurrent infection were evaluated. Infection control was defined as not requiring implant removal after the final treatment.

Results

Infection control rates in implant retention and implant removal groups were 67% and 90%, respectively. All late chronic infections resulted in failure cases within the implant retention group. In the implant retention group, mean preoperative risk scores for successful cases were significantly higher than those for failure cases (p<0.05).

Conclusions

Patients with low risk did not require implant removal, suggesting that DAP may be a breakthrough alternative to traditional PHI management.

Risk Scores and Machine Learning to Identify Patients With Acute Periprosthetic Joints Infections That Will Likely Fail Classical Irrigation and Debridement

The most preferred treatment for acute periprosthetic joint infection (PJI) is surgical debridement, antibiotics and retention of the implant (DAIR). The reported success of DAIR varies greatly and depends on a complex interplay of several host-related factors, duration of symptoms, the microorganism(s) causing the infection, its susceptibility to antibiotics and many others. Thus, there is a great clinical need to predict failure of the “classical” DAIR procedure so that this surgical option is offered to those most likely to succeed, but also to identify those patients who may benefit from more intensified antibiotic treatment regimens or new and innovative treatment strategies. In this review article, the current recommendations for DAIR will be discussed, a summary of independent risk factors for DAIR failure will be provided and the advantages and limitations of the clinical use of preoperative risk scores in early acute (post-surgical) and late acute (hematogenous) PJIs will be presented. In addition, the potential of implementing machine learning (artificial intelligence) in identifying patients who are at highest risk for failure of DAIR will be addressed. The ultimate goal is to maximally tailor and individualize treatment strategies and to avoid treatment generalization.

Elevated ESR/CRP Ratio Is Associated With Reinfection After Debridement, Antibiotics, and Implant Retention in Chronic Periprosthetic Joint Infections

BACKGROUND

Ratios of established inflammatory markers, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), have been used for diagnostic purposes in the surgical field; however, the ESR:CRP ratio (ECR) has not been evaluated as a marker for predicting infection resolution in patients with periprosthetic joint infections (PJIs). This study aimed to evaluate the diagnostic accuracy of ECR in predicting postoperative reinfection in patients who underwent debridement, antibiotics, and implant retention (DAIR).

METHODS

This is a retrospective review of 179 consecutive patients who underwent DAIR revision total joint arthroplasty for PJI. Patients were stratified by acuity of their infection: acute PJI, acute hematogenous PJI, and chronic PJI. The area under the receiver operating characteristic curve was calculated to evaluate ECR as diagnostic marker for predicting postoperative reinfection in patients who underwent DAIR.

RESULTS

Statistically significant differences in ECR were found in patients who underwent DAIR revision total joint arthroplasty for chronic infection (1.23 vs 2.33; P = .04). There was no significant difference in ECR in patients who underwent DAIR for acute infection (P = .70) and acute hematogenous infection (P = .56). In patients who underwent DAIR for chronic PJI, ECR demonstrated a sensitivity and specificity of 75% and 84%, respectively, for the prediction of postoperative reinfection, which was significantly higher than that of ESR (sensitivity, 67%; specificity, 47%; P < .001) and CRP (sensitivity, 50%; specificity, 26%; P < .001).

CONCLUSION

Elevated ECR was associated with an increased reinfection risk in patients who underwent DAIR for chronic PJI, suggesting that preoperative ECR may be a useful predictor to identify patients at increased risk of reinfection after DAIR for chronic PJIs.

Implant Retention or Removal for Management of Surgical Site Infection After Spinal Surgery

STUDY DESIGN

A literature review.

OBJECTIVE

To summarize the implant removal rate, common bacterial organisms found, time of onset, ratio of superficial to deep infection, and regurgitating the prevalence among all the retrospective and prospective studies on management and characterization of surgical site infections (SSIs).

METHODS

PubMed was searched for articles published between 2000 and 2018 on the management or characterization of SSIs after spinal surgery. Only prospective and retrospective studies were included.

RESULTS

A total of 49 articles were found relevant to the objective. These studies highlighted the importance of implant removal to avoid recurrence of SSI. The common organisms detected were methicillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus epidermis, Staphylococcus epidermis, Staphylococcus aureus, and Propionibacterium acnes, with prevalence of 1% to 15%. A major proportion of all were deep SSI, with minority reporting on late-onset SSI.

CONCLUSION

Long-term antibiotics administration, and continuous irrigation and debridement were common suggestion among the authors; however, the key measure undertaken or implied by most authors to avoid risk of recurrence was removal or replacement of implants for late-onset SSI.

Assessing the Role of Daptomycin as Antibiotic Therapy for Staphylococcal Prosthetic Joint Infection

Background: The role of daptomycin, a potent, safe, convenient anti-staphylococcal antibiotic, in treatment of prosthetic joint infection (PJI) is unclear. We evaluated our experience with the largest cohort of patients with staphylococcal PJI managed with daptomycin. Methods: A cohort of staphylococcal hip and knee PJI treated with daptomycin was identified by hospital records from 2009 to 2016. All cases met Musculoskeletal Infection Society International Consensus criteria for PJI. The primary endpoint was 2 year prosthesis retention. Univariate analyses and regression statistics were calculated. Results: 341 patients with staphylococcal PJI were analyzed. 154 two-stages (77%) and 74 DAIR procedures (52%) met criteria for treatment success at 2 years. 77 patients were treated with daptomycin, of which 34 two-stages (68%) and 15 DAIRs (56%) achieved treatment success. Pairwise and regression analysis found no association between treatment success and daptomycin use. Organism (DAIR only) and Charlson Comorbidity Index scores (DAIR and two-stage) were significantly associated with treatment outcome. Six daptomycin patients (7.8%) had adverse side effects. Discussion: Daptomycin fared no better or worse than comparable antibiotics in a retrospective cohort of staphylococcal hip and knee PJI patients, regardless of surgical strategy. Conclusion: The convenient dosing, safety, and potency of daptomycin make it an attractive antibiotic for staphylococcal PJI. However, these advantages must be weighed against higher costs and rare, but serious side effects.

State-of-the-art diagnosis and surgical treatment of acute peri-prosthetic joint infection following primary total hip arthroplasty

Acute peri-prosthetic joint infection (PJI) following total hip arthroplasty (THA) is a potentially devastating and undesired complication, with a prevalence of 0.3% to 2.9%. Its suspicion begins with a meticulous physical examination and anamnesis. Diagnosis should be made on the basis of the Musculoskeletal Infection Society criteria. Serum and synovial biomarkers are very useful tools when major criteria are absent.Although sometimes not possible due to medical conditions, surgery is usually the first line of treatment. Although its outcome is highly correlated with the isolated microorganism, irrigation and debridement with implant retention (DAIR) is the gold standard for treatment. Ideally, the prior approach should be proximally and distally extended to augment the field of view and remove all of the prosthetic modular components, that is, femoral head and acetabular insert.Given DAIR's unclear control of infection, with successful outcomes in the range of 30% to 95%, one- or two-stage revision protocols may play a role in certain cases of acute infections; nonetheless, further prospective, randomized studies are necessary to compare long-term outcomes between DAIR and revision surgeries.Following surgical treatment, length of antibiotherapy is in the range of six weeks to six months, without any difference in outcomes between short and long protocols. Treatment should be adjusted to the isolated bacteria and controlled further with post-operative serum biomarker levels. Cite this article: EFORT Open Rev 2018;3:434-441. DOI: 10.1302/2058-5241.3.170032.

Refabrication of an implant-retained auricular prosthesis using clip attachment pickup technique

Increased patient acceptance and widespread use have led to a greater demand for refabrication of existing maxillofacial prostheses exhibiting wear and tear. Refabricating an osseointegrated implant-retained silicone auricular prosthesis on the existing Hader bar is a challenging task if it is performed without removing it. Therefore, an attachment level impression method is utilized for the refabrication of a new prosthesis on an existing Hader bar framework without removing it from the patient's defect. This case report discusses a modification of the Mahidol University technique. This modification provides a simple, speedy, and convenient method through which the relation between the metal framework and attachments could be obtained precisely. This precision allowed for easy fabrication of the acrylic housing, which in turn results in better adaptation of the auricular prosthesis to the patient's face. Therefore, this technique offers advantages to both the prosthetist in fabrication and the patient in facilitating him continue to wear his existing implant-retained prosthesis during refabrication process.