Arthroplasty-Associated Infections

No Results

No Results

processing….

Infection, though an uncommon complication of arthroplasty, may be among the most devastating complications for the patient, as well as for the surgeon. The economic consequences associated with treating periprosthetic infections are substantial. [1, 2, 3]

Revision procedures for infection are associated with a longer operating time, greater blood loss, and more frequent complications, along with increases in the total number of hospitalizations, duration of hospitalization, total number of operations, total hospital costs, and total outpatient visits and charges. When compared with revisions for aseptic loosening or primary total hip arthroplasties (THAs), revisions for sepsis are associated with significantly greater use of hospital and physician resources. [3]

Currently, the reported infection rate after arthroplasty is 1%. [4]  Kurtz et al quantified the current and historical incidence of periprosthetic infection associated with hip and knee arthroplasty in the United States using the Nationwide Inpatient Sample, as well as corresponding hospitalization charges and length of stay, and found that the rate of infected knee arthroplasties was 0.92%, significantly greater than the rate of infected hip arthroplasties (0.88%). [5]

The number of primary and revision procedures has been projected to expand dramatically over the next 25 years [6] ; accordingly, the infection burden on patients, clinicians, and society as a whole will also increase. The estimated cost of infected revisions is projected to be as high as $1.6 billion by 2020. Methods of preventing, diagnosing, and treating infection must be continually improved in order to reduce the cost and complications of total joint arthroplasty.

There is a need for both improved diagnostic methods and more efficient treatment protocols. Molecular diagnostic methods, such as polymerase chain reaction (PCR) testing, have been associated with high false-positive rates and are still not recommended for routine clinical use. Addressing bone defects during reimplantation is an area that also requires further research.

The problems of conducting randomized studies in the setting of a septic prosthetic failure are a major deterrent to the evolution of treatment protocols. Foolproof intraoperative diagnostic techniques, improved implant designs, and better local antibiotic delivery systems must be developed to face the menace of infection associated with joint replacement surgery.

Gains may be achieved not only by developing newer approaches but also by using currently available approaches more effectively. For example, in one study, culture of samples obtained via sonication of prostheses was more sensitive than conventional periprosthetic-tissue culture for microbiologic diagnosis of prosthetic hip and knee infection, especially in patients who had received antimicrobial therapy within the 14 days preceding surgery. [7]

In a meta-analysis, antigranulocyte scintigraphy with monoclonal antibodies had a reasonably high discriminating ability with respect to identification of prosthesis infection in patients who underwent total joint arthroplasty. [8]

The use of cefuroxime-impregnated cement was shown to be effective in the prevention of early-to-intermediate deep infection after primary total knee arthroplasty (TKA) performed with perioperative systemic antibiotic prophylaxis but without any so-called clean-air measures. [9]  This measure may be particularly helpful in developing nations, where more and more arthroplasties are now being performed.

Additional pathogens are being found to cause prosthetic joint infections. A Swiss study drew attention toward infection by Propionibacterium acnes; a median of 10 biopsies, a 14-day incubation period, and histopathologic examination were needed to establish the association. [10]

Thus, the future of management of arthroplasty-associated infections lies in devising ways to prevent infections, developing investigations that allow early detection, and minimizing both the emergence of new pathogens and the spread of antibiotic resistance among existing pathogens.

Factors influencing the occurrence of arthroplasty-associated infections include the following [11] :

Debreuve-Theresette et al described the development of a score to asses the endogenous risk of surgical-site infection (SSI) after THA and TKA. [12] They found the score useful for identifying SSIs but noted that further validation in larger studies would be required.

Immunocompromised status, rheumatoid arthritis, and diabetes mellitus are some of the most important comorbid conditions associated with an increased risk of infection in a patient undergoing arthroplasty.

Malnutrition has been defined by many authors as a total white blood cell (WBC) count lower than 1500/µL and an albumin level lower than 3.5 mg/dL. [13] Malnourished patients have an increased chance of wound complications. [14] Hence, it is imperative to build up the patient’s nutritional status before the operation.

Obesity is another important factor to be considered. [15] One study found obesity to be an independent risk factor for the development of deep sepsis after hip arthroplasty. [16]

urinary tract infection (UTI) and ongoing sepsis in any other part of the body also increase the risk.

Smoking may increase the risk of SSI after total joint arthroplasty. [17]

Steroid use for an associated condition (eg, inflammatory arthritis or psoriasis) has been associated with increased susceptibility to infection. A previous surgical procedure on the same joint is an independent risk factor that doubles the risk of deep infection in the knee and triples the risk in the hip. [18, 19] Elderly patients and patients with comorbid conditions that require a long time for optimization before surgery are more susceptible to infection as well. [20]

The number of personnel and the amount of traffic in the OR exert an influence on the incidence of infection. Accordingly, changes in the OR environment have the potential to reduce infection. For example, some people shed a large number of bacteria; they can help decrease the risk of infection by using helmet aspirator suits.

Although various commercial preparations are available for preparing the surgical site, most surgeons prefer the iodophor compounds. Shaving the area is best avoided, but if it is considered essential, it should be done immediately before the procedure. The use of an iodophor-incorporated drape has been proved to decrease infection in arthroplasty patients and is now routine in this setting.

In one study, the use of an iodophor-incorporated drape during 649 TKAs was associated with an infection rate of only 0.5%. [21] In another study, the use of an iodophor-incorporated drape proved to be significantly better at preventing recolonization of the skin by bacteria than other methods of skin-site preparation were. [22]

Ultraviolet (UV) light has been employed to decrease the bacterial load in the OR. This measure adds to the cost of the procedure but has not been conclusively shown to produce a decrease in infection risk. [23]

Use of vertical laminar airflow has been found to yield a significant decrease in the bacterial load in the OR air and thereby decrease the infection rates with THAs. In an important study from the early 1980s, Lidwell et al concluded that laminar airflow systems and body exhaust suits independently reduced surgical infection risk by 50%. [24]

However, Miner et al, in a 2007 population survey designed to assess the efficacy of laminar flow and body exhaust suits, found no conclusive evidence to support this result. [25] The cost of laminar airflow systems and body exhaust suits is substantial, adding hundreds of dollars to the expense of each operation and complicating the environment in which the operating team works. The authors concluded that it would be worthwhile to obtain additional evidence whether these widely used clean-air practices have a meaningful clinical benefit in today’s OR.

A prolonged operating time increases the risk of infection. [26] In one population-based survey, a prolonged operating time was in fact the only statistically significant risk factor for infection. [25]

The type of implant used also influences the infection risk. For example, a large hinged knee implant increases the risk of infection. Materials such as polymethylmethacrylate (PMMA), steel, cobalt-chromium (CoCr), and polyethylene (PE) are susceptible to the formation of a biofilm by the infecting organism around the implant, which protects the pathogen from the action of antibiotics. [27]

The virulence of the infecting organisms is an important factor to consider in planning management. Staphylococcus aureus and Staphylococcus epidermidis are the most commonly isolated organisms. Gram-negative infections are resistant to treatment and are a frequent cause of recurrence after an exchange arthroplasty. [28] Organisms that can form glycocalyx, methicillin-resistant S aureus (MRSA), group D streptococci, and enterococci are considered highly virulent.

A frequent cause of inability to isolate the organism is empirical antibiotic therapy. Other causes are infections caused by anaerobic organisms and fungi. Trampuz et al reported the frequencies with which different pathogens cause prosthetic joint infections (see Table 1 below). [29]

Table 1. Microorganisms Causing Prosthetic Joint Infections (Open Table in a new window)

Microorganism

Frequency (%)

Coagulase-negative staphylococci

30-43

Staphylococcus aureus

12-23

Streptococci

9-10

Enterococci

3-7

Gram-negative bacilli

3-6

Anaerobes

2-4

Multiple pathogens (polymicrobial)

10-12

Unknown

10-11

Prosthetic joint infections are caused by pathogens living clustered together in biofilm, a highly hydrated extracellular matrix attached to the implant surface. Within the biofilm, the organisms grow either slowly or not at all; consequently, they are resistant to all growth-dependent antibiotics. The bacterial cells of the biofilm organize among themselves, communicate with each other, and behave like a multicellular organism. The biofilm helps the pathogens combat external and internal forces, whether from the host immune system or from antibiotics. [29]

There is some evidence to indicate that intracellular internalization of staphylococci may be a mechanism in the pathogenesis of infection and resistance to treatment. [30, 31]

The Surgical Infection Prevention Project and its Surgical Infection Prevention Guideline Writers Workgroup promoted the following three major interventions to prevent SSIs [32] :

With increasing frequency, patients are admitted to the hospital on the day of the operation and present to the OR just before their procedure. It is therefore essential to ensure that the institution of safeguards regarding the correct surgical site and the administration of prophylactic antibiotics no more than 1 hour before surgery are implemented as components of an institutional process. [33]

The cephalosporins cefazolin and cefuroxime are considered to have equal prophylactic efficacy. [34] Local guidelines that recommend beta-lactam agents as first-line prophylaxis should also recommend alternative drugs for those allergic to penicillin. Available evidence suggests that administering the first dose as near to the incision time as possible will reduce the likelihood of infection, whether superficial or deep.

There remains some controversy regarding the optimal duration of prophylaxis in connection with THA. The US advisory statement recommends that antimicrobial prophylaxis be administered no more than 1 hour before the incision and discontinued within 24 hours after the end of the operation. [32] However, European guidelines recommend administering a single dose no more than 30 minutes before the incision and advise considering prophylaxis for as long as 24 hours after the operation. [35, 36]

In a Dutch study, superficial and deep SSIs occurred in 2.6% of 1922 THA patients, and the highest odds ratios for infection were found in those who received prophylaxis after incision, those with an American Society of Anesthesiology score of 12, and those in whom the operating time was above the 75th percentile. [37] Prolonged prophylaxis after the end of the procedure and the use of antibiotic-impregnated cement did not contribute to fewer infections in this study.

Sculco TP. The economic impact of infected joint arthroplasty. Orthopedics. 1995 Sep. 18(9):871-3. [Medline].

Hebert CK, Williams RE, Levy RS, Barrack RL. Cost of treating an infected total knee replacement. Clin Orthop Relat Res. 1996 Oct. 140-5. [Medline].

Bozic KJ, Ries MD. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am. 2005 Aug. 87(8):1746-51. [Medline].

Springer BD, Cahue S, Etkin CD, Lewallen DG, McGrory BJ. Infection burden in total hip and knee arthroplasties: an international registry-based perspective. Arthroplast Today. 2017 Jun. 3 (2):137-140. [Medline].

Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty. 2008 Oct. 23(7):984-91. [Medline].

Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007 Apr. 89(4):780-5. [Medline].

Trampuz A, Piper KE, Jacobson MJ, Hanssen AD, Unni KK, Osmon DR, et al. Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med. 2007 Aug 16. 357 (7):654-63. [Medline].

Pakos EE, Trikalinos TA, Fotopoulos AD, Ioannidis JP. Prosthesis infection: diagnosis after total joint arthroplasty with antigranulocyte scintigraphy with 99mTc-labeled monoclonal antibodies–a meta-analysis. Radiology. 2007 Jan. 242(1):101-8. [Medline].

Chiu FY, Chen CM, Lin CF, Lo WH. Cefuroxime-impregnated cement in primary total knee arthroplasty: a prospective, randomized study of three hundred and forty knees. J Bone Joint Surg Am. 2002 May. 84-A(5):759-62. [Medline].

Zappe B, Graf S, Ochsner PE, Zimmerli W, Sendi P. Propionibacterium spp. in prosthetic joint infections: a diagnostic challenge. Arch Orthop Trauma Surg. 2008 Oct. 128(10):1039-46. [Medline].

Dunbar MJ, Richardson G. Minimizing infection risk: fortune favors the prepared mind. Orthopedics. 2011. 34(9):e467-9. [Medline].

Debreuve-Theresette A, Diallo S, Siboni R, Ohl X, Dehoux E, Bajolet O. Infections in Total Hip and Total Knee Arthroplasty: Development of a Score To Assess Endogenous Risk of Surgical Site Infections. Surg Infect (Larchmt). 2015 Dec. 16 (6):794-8. [Medline].

Smith TK. Nutrition: its relationship to orthopedic infections. Orthop Clin North Am. 1991 Jul. 22(3):373-7. [Medline].

Greene KA, Wilde AH, Stulberg BN. Preoperative nutritional status of total joint patients. Relationship to postoperative wound complications. J Arthroplasty. 1991 Dec. 6(4):321-5. [Medline].

Jung P, Morris AJ, Zhu M, Roberts SA, Frampton C, Young SW. BMI is a key risk factor for early periprosthetic joint infection following total hip and knee arthroplasty. N Z Med J. 2017 Sep 1. 130 (1461):24-34. [Medline].

Dowsey MM, Choong PF. Obesity is a major risk factor for prosthetic infection after primary hip arthroplasty. Clin Orthop Relat Res. 2008 Jan. 466(1):153-8. [Medline].

Sahota S, Lovecchio F, Harold RE, Beal MD, Manning DW. The Effect of Smoking on Thirty-Day Postoperative Complications After Total Joint Arthroplasty: A Propensity Score-Matched Analysis. J Arthroplasty. 2017 Aug 1. [Medline].

Surin VV, Sundholm K, Bäckman L. Infection after total hip replacement. With special reference to a discharge from the wound. J Bone Joint Surg Br. 1983 Aug. 65(4):412-8. [Medline].

Rand JA, Fitzgerald RH Jr. Diagnosis and management of the infected total knee arthroplasty. Orthop Clin North Am. 1989 Apr. 20(2):201-10. [Medline].

Cruse PJ, Foord R. A five-year prospective study of 23,649 surgical wounds. Arch Surg. 1973 Aug. 107(2):206-10. [Medline].

Ritter MA, Campbell ED. Retrospective evaluation of an iodophor-incorporated antimicrobial plastic adhesive wound drape. Clin Orthop Relat Res. 1988 Mar. (228):307-8. [Medline].

Johnston DH, Fairclough JA, Brown EM, Morris R. Rate of bacterial recolonization of the skin after preparation: four methods compared. Br J Surg. 1987 Jan. 74(1):64. [Medline].

Berg-Périer M, Cederblad A, Persson U. Ultraviolet radiation and ultra-clean air enclosures in operating rooms. UV-protection, economy, and comfort. J Arthroplasty. 1992 Dec. 7 (4):457-63. [Medline].

Lidwell OM, Lowbury EJ, Whyte W, Blowers R, Stanley SJ, Lowe D. Effect of ultraclean air in operating rooms on deep sepsis in the joint after total hip or knee replacement: a randomised study. Br Med J (Clin Res Ed). 1982 Jul 3. 285 (6334):10-4. [Medline]. [Full Text].

Miner AL, Losina E, Katz JN, Fossel AH, Platt R. Deep infection after total knee replacement: impact of laminar airflow systems and body exhaust suits in the modern operating room. Infect Control Hosp Epidemiol. 2007 Feb. 28(2):222-6. [Medline].

Fitzgerald RH Jr, Nolan DR, Ilstrup DM, Van Scoy RE, Washington JA 2nd, Coventry MB. Deep wound sepsis following total hip arthroplasty. J Bone Joint Surg Am. 1977 Oct. 59(7):847-55. [Medline].

Petty W, Spanier S, Shuster JJ, Silverthorne C. The influence of skeletal implants on incidence of infection. Experiments in a canine model. J Bone Joint Surg Am. 1985 Oct. 67 (8):1236-44. [Medline].

Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg Am. 1996 Apr. (4):512-23. [Medline].

Trampuz A, Zimmerli W. New strategies for the treatment of infections associated with prosthetic joints. Curr Opin Investig Drugs. 2005 Feb. 6(2):185-90. [Medline].

Ellington JK, Reilly SS, Ramp WK, Smeltzer MS, Kellam JF, MC. Mechanisms of Staphylococcus aureus invasion of cultured osteoblasts. Microb Pathog. 1999 Jun. 26(6):317-23. [Medline].

Jevon M, Guo C, Ma B, Mordan N, Nair SP, Harris M. Mechanisms of internalization of Staphylococcus aureus by cultured human osteoblasts. Infect Immun. 1999 May. 67(5):2677-81. [Medline].

Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004 Jun 15. 38 (12):1706-15. [Medline]. [Full Text].

Rosenberg AD, Wambold D, Kraemer L, et al. Ensuring appropriate timing of antimicrobial prophylaxis. J Bone Joint Surg Am. 2008 Feb. 90(2):226-32. [Medline].

Bosco JA, Bookman J, Slover J, Edusei E, Levine B. Principles of Antibiotic Prophylaxis in Total Joint Arthroplasty: Current Concepts. J Am Acad Orthop Surg. 2015 Aug. 23 (8):e27-35. [Medline].

[Guideline] Antibiotic prophylaxis in surgery. Scottish Intercollegiate Guidelines Network. Available at http://www.sign.ac.uk/assets/sign104.pdf. April 2014; Accessed: September 28, 2017.

van Kasteren ME, Gyssens IC, Kullberg BJ, Bruining HA, Stobberingh EE, Goris RJ. [Optimizing antibiotics policy in the Netherlands. V. SWAB guidelines for perioperative antibiotic prophylaxis. Foundation Antibiotics Policy Team]. Ned Tijdschr Geneeskd. 2000 Oct 21. 144 (43):2049-55. [Medline].

van Kasteren ME, Manniën J, Ott A, Kullberg BJ, de Boer AS, Gyssens IC. Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor. Clin Infect Dis. 2007 Apr 1. 44(7):921-7. [Medline].

Cuckler JM, Star AM, Alavi A, Noto RB. Diagnosis and management of the infected total joint arthroplasty. Orthop Clin North Am. 1991 Jul. 22 (3):523-30. [Medline].

Duff GP, Lachiewicz PF, Kelley SS. Aspiration of the knee joint before revision arthroplasty. Clin Orthop Relat Res. 1996 Oct. 132-9. [Medline].

[Guideline] The diagnosis of periprosthetic joint infections of the hip and knee. American Academy of Orthopaedic Surgeons. Available at https://www.aaos.org/research/guidelines/PJIguideline.pdf. June 18, 2010; Accessed: September 28, 2017.

[Guideline] Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013 Jan. 56 (1):e1-e25. [Medline].

Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011 Nov. 469(11):2992-4. [Medline].

Segawa H, Tsukayama DT, Kyle RF, Becker , Gustilo RB. Infection after total knee arthroplasty. A retrospective study of the treatment of eighty-one infections. J Bone Joint Surg Am. 1999 Oct. 81(10):1434-45. [Medline].

Spangehl MJ, Younger AS, Masri BA, Duncan CP. Diagnosis of infection following total hip arthroplasty. Instr Course Lect. 1998. 47:285-95. [Medline].

Spangehl MJ, Masri BA, O’Connell JX, Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am. 1999 May. 81(5):672-83. [Medline].

Greidanus NV, Masri BA, Garbuz DS, et al. Use of erythrocyte sedimentation rate and C-reactive protein level to diagnose infection before revision total knee arthroplasty. A prospective evaluation. J Bone Joint Surg Am. 2007 Jul. 89(7):1409-16. [Medline].

Shahi A, Kheir MM, Tarabichi M, Hosseinzadeh HRS, Tan TL, Parvizi J. Serum D-Dimer Test Is Promising for the Diagnosis of Periprosthetic Joint Infection and Timing of Reimplantation. J Bone Joint Surg Am. 2017 Sep 6. 99 (17):1419-1427. [Medline].

Fitzgerald RH Jr. Infected Total Hip Arthroplasty: Diagnosis and Treatment. J Am Acad Orthop Surg. 1995 Oct. 3 (5):249-262. [Medline].

Palestro CJ, Kim CK, Swyer AJ, Capozzi JD, Solomon RW, Goldsmith SJ. Total-hip arthroplasty: periprosthetic indium-111-labeled leukocyte activity and complementary technetium-99m-sulfur colloid imaging in suspected infection. J Nucl Med. 1990 Dec. 31(12):1950-5. [Medline].

Love C, Marwin SE, Tomas MB, Krauss ES, Tronco GG, Bhargava KK. Diagnosing infection in the failed joint replacement: a comparison of coincidence detection 18F-FDG and 111In-labeled leukocyte/99mTc-sulfur colloid marrow imaging. J Nucl Med. 2004 Nov. 45(11):1864-71. [Medline].

Mumme T, Reinartz P, Alfer J, Müller-Rath R, Buell U, Wirtz DC. Diagnostic values of positron emission tomography versus triple-phase bone scan in hip arthroplasty loosening. Arch Orthop Trauma Surg. 2005 Jun. 125(5):322-9. [Medline].

Reinartz P, Mumme T, Hermanns B, Cremerius U, Wirtz DC, Schaefer WM. Radionuclide imaging of the painful hip arthroplasty: positron-emission tomography versus triple-phase bone scanning. J Bone Joint Surg Br. 2005 Apr. 87(4):465-70. [Medline].

Parvizi J, Jacovides C, Antoci V, Ghanem E. Diagnosis of periprosthetic joint infection: the utility of a simple yet unappreciated enzyme. J Bone Joint Surg Am. 2011 Dec 21. 93(24):2242-8. [Medline].

Wyatt MC, Beswick AD, Kunutsor SK, Wilson MJ, Whitehouse MR, Blom AW. The Alpha-Defensin Immunoassay and Leukocyte Esterase Colorimetric Strip Test for the Diagnosis of Periprosthetic Infection: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am. 2016 Jun 15. 98 (12):992-1000. [Medline]. [Full Text].

Deirmengian C, Hallab N, Tarabishy A, Della Valle C, Jacobs JJ, Lonner J. Synovial fluid biomarkers for periprosthetic infection. Clin Orthop Relat Res. 2010 Aug. 468(8):2017-23. [Medline].

Xie K, Dai K, Qu X, Yan M. Serum and Synovial Fluid Interleukin-6 for the Diagnosis of Periprosthetic Joint Infection. Sci Rep. 2017 May 4. 7 (1):1496. [Medline]. [Full Text].

Yuan J, Yan Y, Zhang J, Wang B, Feng J. Diagnostic accuracy of alpha-defensin in periprosthetic joint infection: a systematic review and meta-analysis. Int Orthop. 2017 Sep 30. [Medline].

Bori G, Soriano A, García S, Mallofré C, Riba J, Mensa J. Usefulness of histological analysis for predicting the presence of microorganisms at the time of reimplantation after hip resection arthroplasty for the treatment of infection. J Bone Joint Surg Am. 2007 Jun. 89(6):1232-7. [Medline].

Malhotra R, Morgan . Role of core biopsy in diagnosing infection before revision hip arthroplasty. J Arthroplasty. 2004 Jan. 19 (1):-87. [Medline].

Nolan DR, Fitzgerald RH Jr, Beckenbaugh RD, Coventry MB. Complications of total hip arthroplasty treated by reoperation. J Bone Joint Surg Am. 1975 Oct. 57 (7):977-81. [Medline].

Nelson JP. Deep infection following total hip arthroplasty. J Bone Joint Surg Am. 1977 Dec. 59 (8):1042-4. [Medline].

Hunter G, Dandy D. The natural history of the patient with an infected total hip replacement. J Bone Joint Surg Br. 1977 Aug. 59(3):293-7. [Medline].

Canner GC, Steinberg ME, Heppenstall RB, Balderston R. The infected hip after total hip arthroplasty. J Bone Joint Surg Am. 1984 Dec. 66 (9):1393-9. [Medline].

Wroblewski BM. One-stage revision of infected cemented total hip arthroplasty. Clin Orthop Relat Res. 1986 Oct. 103-7. [Medline].

Ure KJ, Amstutz HC, Nasser S, Schmalzried TP. Direct-exchange arthroplasty for the treatment of infection after total hip replacement. An average ten-year follow-up. J Bone Joint Surg Am. 1998 Jul. 80(7):961-8. [Medline].

Bori G, Navarro G, Morata L, Fernández-Valencia JA, Soriano A, Gallart X. Preliminary Results After Changing From Two-Stage to One-Stage Revision Arthroplasty Protocol Using Cementless Arthroplasty for Infected Hip Replacements. J Arthroplasty. 2017 Sep 1. [Medline].

Hsieh PH, Shih CH, Chang YH, Lee MS, Shih HN, Yang WE. Two-stage revision hip arthroplasty for infection: comparison between the interim use of antibiotic-loaded cement beads and a spacer prosthesis. J Bone Joint Surg Am. 2004 Sep. 86-A(9):1989-97. [Medline].

Lai KA, Shen WJ, Yang CY, Lin RM, Lin CJ, Jou IM. Two-stage cementless revision THR after infection. 5 recurrences in 40 cases followed 2.5-7 years. Acta Orthop Scand. 1996 Aug. 67(4):325-8. [Medline].

Leunig M, Chosa E, Speck M, Ganz R. A cement spacer for two-stage revision of infected implants of the hip joint. Int Orthop. 1998. 22(4):209-14. [Medline].

Collins DN, McKenzie JM. Infections at the site of a hip implant. Successful and unsuccessful management. Clin Orthop Relat Res. 1991 Aug. (269):9-15. [Medline].

Hunter GA. The results of reinsertion of a total hip prosthesis after sepsis. J Bone Joint Surg Br. 1979 Nov. 61-B(4):422-3. [Medline].

James ET, Hunter GA, Cameron HU. Total hip revision arthroplasty: does sepsis influence the results?. Clin Orthop Relat Res. 1982 Oct. 88-94. [Medline].

Jupiter JB, Karchmer AW, Lowell JD, Harris WH. Total hip arthroplasty in the treatment of adult hips with current or quiescent sepsis. J Bone Joint Surg Am. 1981 Feb. 63 (2):194-200. [Medline].

McDonald DJ, Fitzgerald RH Jr, Ilstrup DM. Two-stage reconstruction of a total hip arthroplasty because of infection. J Bone Joint Surg Am. 1989 Jul. 71(6):828-34. [Medline].

Mirra JM, Amstutz HC, Matos M, Gold R. The pathology of the joint tissues and its clinical relevance in prosthesis failure. Clin Orthop Relat Res. 1976 Jun. 221-40. [Medline].

Clegg J. The results of the pseudarthrosis after removal of an infected total hip prosthesis. J Bone Joint Surg Br. 1977 Aug. 59(3):298-301. [Medline].

Johnston RC, Crowninshield RD. Roentgenologic results of total hip arthroplasty. A ten-year follow-up study. Clin Orthop Relat Res. 1983 Dec. 92-8. [Medline].

Powers KA, Terpenning MS, Voice RA, Kauffman CA. Prosthetic joint infections in the elderly. Am J Med. 1990 May. 88 (5N):9N-13N. [Medline].

Chiang ER, Su YP, Chen TH, Chiu FY, Chen WM. Comparison of articulating and static spacers regarding infection with resistant organisms in total knee arthroplasty. Acta Orthop. 2011 Aug. 82(4):460-4. [Medline].

Gruninger RP, Tsukayama DT, Wicklund B. Antibiotic impregnated PMMA beads in bone and prosthetic joint infections. Gustilo RB, Gruninger RP, Tsukayama DT, eds. Orthopaedic Infection: Diagnosis and Treatment. Philadelphia: WB Saunders; 1989. 66-74.

Yoo J, Lee S, Han C, Chang J. The modified static spacers using antibiotic-impregnated cement rod in two-stage revision for infected total knee arthroplasty. Clin Orthop Surg. 2011 Sep. 3(3):245-8. [Medline].

Dohmae Y, Bechtold JE, Sherman RE, Puno RM, Gustilo RB. Reduction in cement-bone interface shear strength between primary and revision arthroplasty. Clin Orthop Relat Res. 1988 Nov. (236):214-20. [Medline].

Engh GA, Ammeen DJ. Use of structural allograft in revision total knee arthroplasty in knees with severe tibial bone loss. J Bone Joint Surg Am. 2007 Dec. 89(12):2640-7. [Medline].

Sporer SM, O’Rourke M, Chong P, Paprosky WG. The use of structural distal femoral allografts for acetabular reconstruction. Average ten-year follow-up. J Bone Joint Surg Am. 2005 Apr. 87(4):760-5. [Medline].

Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969 Jun. 51(4):737-55. [Medline].

Weber FA, Lautenbach EE. Revision of infected total hip arthroplasty. Clin Orthop Relat Res. 1986 Oct. 211:108-15. [Medline].

Sanzén L, Carlsson AS, Josefsson G, Lindberg LT. Revision operations on infected total hip arthroplasties. Two- to nine-year follow-up study. Clin Orthop Relat Res. 1988 Apr. 165-72. [Medline].

Hope PG, Kristinsson KG, Norman P, Elson RA. Deep infection of cemented total hip arthroplasties caused by coagulase-negative staphylococci. J Bone Joint Surg Br. 1989 Nov. 71(5):851-5. [Medline].

Ariza J, Euba G, Murillo O. [Orthopedic device-related infections]. Enferm Infecc Microbiol Clin. 2008 Jun-Jul. 26(6):380-90. [Medline].

Choong PF, Dowsey MM, Carr D, Daffy J, Stanley P. Risk factors associated with acute hip prosthetic joint infections and outcome of treatment with a rifampinbased regimen. Acta Orthop. 2007 Dec. 78 (6):755-65. [Medline]. [Full Text].

Aboltins CA, Page MA, Buising KL, et al. Treatment of staphylococcal prosthetic joint infections with debridement, prosthesis retention and oral rifampicin and fusidic acid. Clin Microbiol Infect. 2007 Jun. 13(6):586-91. [Medline].

Drew RH, Perfect JR, Srinath L, Kurkimilis E, Dowzicky M, Talbot GH. Treatment of methicillin-resistant staphylococcus aureus infections with quinupristin-dalfopristin in patients intolerant of or failing prior therapy. For the Synercid Emergency-Use Study Group. J Antimicrob Chemother. 2000 Nov. 46(5):775-84. [Medline].

Carpenter CF, Chambers HF. Daptomycin: another novel agent for treating infections due to drug-resistant gram-positive pathogens. Clin Infect Dis. 2004 Apr 1. 38 (7):994-1000. [Medline].

Bressler AM, Zimmer SM, Gilmore JL, Somani J. Peripheral associated with prolonged use of linezolid. Lancet Infect Dis. 2004 Aug. 4(8):528-31. [Medline].

Latronico N, Guarneri B. Critical illness myopathy and neuropathy. Minerva Anestesiol. 2008 Jun. 74(6):319-23. [Medline].

Falahee MH, Matthews LS, Kaufer H. Resection arthroplasty as a salvage procedure for a knee with infection after a total arthroplasty. J Bone Joint Surg Am. 1987 Sep. 69(7):1013-21. [Medline].

Microorganism

Frequency (%)

Coagulase-negative staphylococci

30-43

Staphylococcus aureus

12-23

Streptococci

9-10

Enterococci

3-7

Gram-negative bacilli

3-6

Anaerobes

2-4

Multiple pathogens (polymicrobial)

10-12

Unknown

10-11

Status of Prosthetic Joint Infection

Treatment

Duration of symptoms <3 wk

and

stable implant

and

absence of sinus tract

and

susceptibility to antibiotics with activity against surface-adhering microorganisms

Débridement with retention

Intact or only slightly damaged soft tissue

1-stage exchange

Damaged soft tissue, abscess, or sinus tract

2-stage exchange with short interval (2-4 wk), spacer

Microorganism resistant or difficult to treat*

2-stage exchange with long interval (6-8 wk), no spacer

Inoperable, debilitated, or bedridden

Long-term suppressive antimicrobial treatment

No functional improvement by exchange of implant

Implant removal without replacement

Direct Exchange

Delayed Exchange

Advantages

• Less morbidity

• Reduced cost

• Improved mechanical stability

• Less complicated technique

• Shorter duration of disability

 

Disadvantages

• Inability to use sensitive antibiotic to mix with cement while fixation

 

Contraindications

• Immunocompromise

• Major soft tissue or skin defect

• Gram-negative organisms

• Actively discharging sinus or overt purulence

Advantages

• Ability to identify organisms, determine sensitivities, and give adequate antibiotics before reimplantation

• Ability to repeat debridement if necessary

• Ability to identify and correct other foci of infection and inciting factors

 

Disadvantages

• Technical difficulty resulting from extensive scarring and contracture

• Hardships of resection arthroplasty

• Increased cost and hospital stay

• Delayed rehabilitation

Microorganism

Antimicrobial Agent1

Dosage

Route

Staphylococcus aureus or coagulase-negative staphylococci

Methicillin-susceptible

Rifampin

plus

(flu)eloxacillin2

450 mg q12hr

2 g q6hr

PO/IV

IV

For 2 wk, followed by

Rifampin

plus

ciprofloxacin

or

levofloxacin

450 mg q12hr

750 mg q12hr

750 mg q24hr

to 500 mg q12hr

PO

PO

PO

PO

Methicillin-resistant

For 2 wk, followed by

 

Rifampin

plus

ciprofloxacin3

or

levofloxacin3

or

teicoplanin4

or

fusidic acid

or

trimethoprim-sulfamethoxazole

or

minocycline

450 mg q12hr

750 mg q12hr

750 mg q24hr

to 500 mg q12hr

400 mg q24hr

500 mg q8hr

1 forte tablet q8hr

100 mg q12hr

PO

PO

PO

IV/IM

PO

PO

PO

Streptococcus spp (except S agalactiae)

Penicillin G3

or

ceftriaxone

5 million U q6hr

2 g q24hr

IV

IV

For 2-4 wk, followed by

Amoxicillin

750-1000 mg q8hr

PO

Enterococcus spp (penicillin-susceptible) and S agalactiae

Penicillin G

or

ampicillin

or

amoxicillin

plus

aminoglycoside5

5 million U q6hr

2 g q4-6hr

IV

IV

For 2-4 wk, followed by

Amoxicillin

750-1000 mg q8hr

PO

Enterobacteriaceae (quinolone-susceptible)

Ciprofloxacin

750 g q12hr

PO

Nonfermenters (eg, Pseudomonas aeruginosa)

Cefepime

or

ceftazidime

plus

aminoglycoside5

2 g q8hr

IV

For 2-4 wk, followed by

Ciprofloxacin

750 g q12hr

PO

Anaerobes6

Clindamycin

600 mg q6hr

PO

For 2-4 wk, followed by

Clindamycin

300 mg q6hr

PO

Mixed infections

(without methicillin-resistant staphylococci)

Amoxicillin-clavulanate

or

piperacillin-tazobactam

or

imipenem

or

meropenem

2.2 g q8hr

4.5 g q8hr

500 mg q6hr

1 g q8hr

IV

IV

IV

IV

 

For 2-4 wk, followed by individual regimens according to antimicrobial susceptibility

PO= orally; IV= intravenously; IM= intramuscularly; forte tablet = trimethoprim 160 mg plus sulfamethoxazole 800 mg; MRSA = methicillin-resistant S aureus.

1. If implant retention or one-stage exchange is performed, the total duration of antimicrobial treatment is 3 months for hip prosthesis and 6 months for knee prosthesis.

2. In patients with delayed hypersensitivity, cefazolin (2 g IV q8hr) may be administered. In patients with immediate hypersensitivity, penicillin should be replaced with vancomycin (1 g q12hr).

3. MRSA should not be treated with quinolones, because antimicrobial resistance might emerge during treatment.

4. On the first day of treatment, the teicoplanin dose should be increased to 800 mg IV (loading dose).

5. Aminoglycosides can be administered in a single daily dose.

6. Alternatively, penicillin G (5 million U IV q6hr) or ceftriaxone (2 g IV q24hr) may be used for gram-positive anaerobes (eg, Propionibacterium acnes), and metronidazole (500 mg IV or PO q8hr) for gram-negative anaerobes (eg, Bacteroides spp).

Rajesh Malhotra, MBBS, MS Professor and Head, Department of Orthopedics, All India Institute of Medical Sciences; Chief, JPN Apex Trauma Centre, India

Disclosure: Nothing to disclose.

Karthik S Murugappan, MBBS, MS(Orth), DNB, MRCS Consulting Surgeon, Department of Orthopedics, Flinders Medical Center, Australia

Disclosure: Nothing to disclose.

William L Jaffe, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases

William L Jaffe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American College of Surgeons, Eastern Orthopaedic Association, New York Academy of Medicine

Disclosure: Received consulting fee from Stryker Orthopaedics for speaking and teaching.

James J McCarthy, MD, FAAOS, FAAP Associate Professor, Consulting Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health

James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Orthopaedic Association, Limb Lengthening and Reconstruction Society ASAMI-North America, Orthopaedics Overseas, Pediatric Orthopaedic Society of North America, Pennsylvania Medical Society, Pennsylvania Orthopaedic Society, and Philadelphia County Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Arthroplasty-Associated Infections

Research & References of Arthroplasty-Associated Infections|A&C Accounting And Tax Services
Source

One thought on “Arthroplasty-Associated Infections”


Leave a Reply