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El Haj C, Murillo O, Ribera A, Garcia-Somoza D, Tubau F, Cabellos C, Cabo J, Ariza J. The anti-biofilm effect of macrolides in a rat model of S. aureus foreign-body infection: Might it be of clinical relevance? Med Microbiol Immunol 2016; 206:31-39. [DOI: 10.1007/s00430-016-0479-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 09/10/2016] [Indexed: 01/22/2023]
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202
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Lora-Tamayo J, Euba G, Cobo J, Horcajada JP, Soriano A, Sandoval E, Pigrau C, Benito N, Falgueras L, Palomino J, Del Toro MD, Jover-Sáenz A, Iribarren JA, Sánchez-Somolinos M, Ramos A, Fernández-Sampedro M, Riera M, Baraia-Etxaburu JM, Ariza J. Short- versus long-duration levofloxacin plus rifampicin for acute staphylococcal prosthetic joint infection managed with implant retention: a randomised clinical trial. Int J Antimicrob Agents 2016; 48:310-6. [PMID: 27524103 DOI: 10.1016/j.ijantimicag.2016.05.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/04/2016] [Accepted: 05/28/2016] [Indexed: 02/08/2023]
Abstract
Levofloxacin plus rifampicin (L+R) is the treatment of choice for acute staphylococcal prosthetic joint infection (PJI) managed with debridement and implant retention (DAIR). Long courses have been empirically recommended, but some studies have suggested that shorter treatments could be as effective. Our aim was to prove that a short treatment schedule was non-inferior to the standard long schedule. An open-label, multicentre, randomised clinical trial (RCT) was performed. Patients with an early post-surgical or haematogenous staphylococcal PJI, managed with DAIR and initiated on L+R were randomised to receive 8 weeks of treatment (short schedule) versus a long schedule (3 months or 6 months for hip or knee prostheses, respectively). The primary endpoint was cure rate. From 175 eligible patients, 63 were included (52% women; median age, 72 years): 33 patients (52%) received the long schedule and 30 (48%) received the short schedule. There were no differences between the two groups except for a higher rate of polymicrobial infection in the long-schedule group (27% vs. 7%; P = 0.031). Median follow-up was 540 days. In the intention-to-treat analysis, cure rates were 58% and 73% in patients receiving the long and short schedules, respectively (difference -15.7%, 95% CI -39.2% to 7.8%). Forty-four patients (70%) were evaluable per-protocol: cure rates were 95.0% and 91.7% for the long and short schedules, respectively (difference 3.3%, 95% CI -11.7% to 18.3%). This is the first RCT suggesting that 8 weeks of L+R could be non-inferior to longer standard treatments for acute staphylococcal PJI managed with DAIR.
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Affiliation(s)
- Jaime Lora-Tamayo
- Unidad de Enfermedades Infecciosas, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre "i+12", Madrid, Spain.
| | - Gorane Euba
- Servicio de Enfermedades Infecciosas, Hospital Universitario de Bellvitge, Barcelona, Spain
| | - Javier Cobo
- Servicio de Enfermedades Infecciosas, IRYCIS, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Juan Pablo Horcajada
- Servicio de Enfermedades Infecciosas, Hospital del Mar, IMIM, CEXS-UPF, Barcelona, Spain
| | - Alex Soriano
- Servicio de Enfermedades Infecciosas, Hospital Clínic i Provincial, IDIBAPS, Barcelona, Spain
| | - Enrique Sandoval
- Servicio de Traumatología, Fundación Jiménez Díaz, Madrid, Spain
| | - Carles Pigrau
- Servicio de Enfermedades Infecciosas, Hospital Universitario Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Natividad Benito
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Falgueras
- Servicio de Enfermedades Infecciosas, Corporació Sanitària Parc Taulí, Sabadell, Spain
| | - Julián Palomino
- Servicio de Enfermedades Infecciosas, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - María Dolores Del Toro
- Unidad Clínica Intercentros de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío, Seville, Spain
| | - Alfredo Jover-Sáenz
- Unidad Funcional de Infección Nosocomial y Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Lleida, Spain
| | - José Antonio Iribarren
- Servicio de Enfermedades Infecciosas, Hospital Universitario Donostia, San Sebastián, Spain
| | - Mar Sánchez-Somolinos
- Servicio de Microbiología y Enfermedades Infecciosas, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Antonio Ramos
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Marta Fernández-Sampedro
- Servicio de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Melchor Riera
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | | | - Javier Ariza
- Servicio de Enfermedades Infecciosas, Hospital Universitario de Bellvitge, Barcelona, Spain
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203
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Zmistowski BM, Manrique J, Patel R, Chen AF. Recurrent Periprosthetic Joint Infection After Irrigation and Debridement With Component Retention Is Most Often Due to Identical Organisms. J Arthroplasty 2016; 31:148-51. [PMID: 27378647 DOI: 10.1016/j.arth.2016.05.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 05/13/2016] [Accepted: 05/17/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Irrigation and debridement with prosthetic retention (I&D) is an oft-utilized treatment option for PJI, despite its known limited success. While it is known that nearly half of all patients treated with I&D have recurrent infection, the organism persistence between infection events remains unreported. In addition, identifying those cases in which I&D routinely failed to eradicate the infection (not simply prevent recurrent infection) may allow improved patient selection for this less morbid procedure-a difficult task to date. METHODS Using an institutional database, 146 patients (153 joints) undergoing I&D between April 2000 and July 2013 were identified. There were 60 hips (40%). The overall success rate of I&D in this group was 52% (80/153). The failure group was limited to those patients with growth on culture at both initial failure and recurrent failure (46 cases). Analyses were performed to identify potential predictors of failed I&D and organism persistence in those cases. RESULTS In the study group, 83.7% (36/43) of cases failed with the same organism. Knees with failed I&D had an organism persistence of 92.3% (24/26) compared with 70.5% (12/17; P = .09) for the hip. Patients initially infected with Staphylococcus aureus (specifically methicillin-resistant [13/13]) had a higher risk of persistent PJI (96%; 24/25) compared to other organisms (66.7%; 12/18; P = .01). CONCLUSION I&D had a success rate of approximately 50% and typically failed due to organism persistence rather than a new infection. Given that persistent infection was most common in knees and S aureus, I&D should have a limited role in treating PJI, especially in these cases.
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Affiliation(s)
- Benjamin M Zmistowski
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jorge Manrique
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ripal Patel
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Antonia F Chen
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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204
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Mühlhofer HML, Suren C, Feihl S, Schauwecker J, von Eisenhart-Rothe R, Banke IJ. [Implant-associated infections - diagnostics and therapy]. MMW Fortschr Med 2016; 158:45-49. [PMID: 27596194 DOI: 10.1007/s15006-016-8660-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Heinrich M L Mühlhofer
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, D-81675, München, Deutschland.
| | - Christian Suren
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, D-81675, München, Deutschland
| | - Susanne Feihl
- Institut für Medizinische Mikrobiologie, Immunologie und Hygiene, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Johannes Schauwecker
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, D-81675, München, Deutschland
| | - Rüdiger von Eisenhart-Rothe
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, D-81675, München, Deutschland
| | - Ingo J Banke
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, D-81675, München, Deutschland
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205
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Ravi S, Zhu M, Luey C, Young SW. Antibiotic resistance in early periprosthetic joint infection. ANZ J Surg 2016; 86:1014-1018. [DOI: 10.1111/ans.13720] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/20/2016] [Accepted: 07/03/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Saiprasad Ravi
- School of Medicine; The University of Auckland; Auckland New Zealand
| | - Mark Zhu
- Department of Orthopaedic Surgery; North Shore Hospital; Auckland New Zealand
| | - Christopher Luey
- Department of Infectious Diseases; Middlemore Hospital; Auckland New Zealand
| | - Simon W. Young
- School of Medicine; The University of Auckland; Auckland New Zealand
- Department of Orthopaedic Surgery; North Shore Hospital; Auckland New Zealand
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206
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Tasse J, Croisier D, Badel-Berchoux S, Chavanet P, Bernardi T, Provot C, Laurent F. Preliminary results of a new antibiotic susceptibility test against biofilm installation in device-associated infections: the Antibiofilmogram®. Pathog Dis 2016; 74:ftw057. [PMID: 27316688 DOI: 10.1093/femspd/ftw057] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2016] [Indexed: 12/17/2022] Open
Abstract
Biofilms are complex communities of microorganisms embedded in an extracellular matrix and adherent to a surface. The development was described as a four-stage process leading to the formation of a mature biofilm which was resistant to immune system and antibiotic actions. In bone and joint infections (BJIs), the formation of biofilms is a leading cause of treatment failure. Here we study the capacity of 11 antibiotics commonly used in the treatment of BJIs to inhibit the biofilm formation on 29 clinical Staphylococcus aureus isolates by a new test called Antibiofilmogram(®) The minimal inhibitory concentration (MIC) and biofilm MIC (bMIC) were determined in vitro and showed similar values for clindamycin, fusidic acid, linezolid and rifampin. Reversely, daptomycin, fosfomycin, gentamicin and ofloxacin showed a bMIC distribution different from MIC with bMIC above breakpoint. Finally, cloxacillin, teicoplanin and vancomycin revealed an intermediate bMIC distribution with a strain-dependent pattern. A murine in vivo model of catheter-associated S. aureus infection was made and showed a significant reduction, but not total prevention, of catheter colonization with cloxacillin at bMIC, and no or limited reduction with cloxacillin at MIC. Antibiofilmogram(®) could be of great interest after surgical operations on contaminated prostheses and after bacteremia in order to prevent the colonization of the device.
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Affiliation(s)
- Jason Tasse
- BioFilm Control, Saint-Beauzire 63360, France French National Reference Centre for Staphylococci, International Centre for Infectiology Research - Inserm U1111, Hospices Civils de Lyon, Lyon 69000, France
| | | | | | - Pascal Chavanet
- Vivexia Laboratory, Dijon, France Department of Infectious Disease, Dijon University Hospital, Dijon 21000, France
| | | | | | - Frédéric Laurent
- French National Reference Centre for Staphylococci, International Centre for Infectiology Research - Inserm U1111, Hospices Civils de Lyon, Lyon 69000, France
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207
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Ertapenem Articulating Spacer for the Treatment of Polymicrobial Total Knee Arthroplasty Infection. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2016; 2016:5753489. [PMID: 27366173 PMCID: PMC4904593 DOI: 10.1155/2016/5753489] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 05/02/2016] [Accepted: 05/11/2016] [Indexed: 12/29/2022]
Abstract
Introduction. Periprosthetic joint infections (PJIs) are the primary cause of early failure of the total knee arthroplasty (TKA). Polymicrobial TKA infections are often associated with a higher risk of treatment failure. The aim of the study was to assess the efficacy of ertapenem loaded spacers in the treatment of polymicrobial PJI. Methods. There were 18 patients enrolled; nine patients with polymicrobial PJI treated with ertapenem loaded articulating spacers were compared to the group of 9 patients treated with vancomycin or ceftazidime loaded spacers. Results. Successful reimplantation with revision implants was possible in 66.67%. Ertapenem spacers were used in 6 cases in primary two-stage procedure and in 3 cases in secondary spacer exchange. Successful infection eradication was achieved in all cases; final reimplantation with revision knee arthroplasty implants was possible in 6 cases. Conclusion. Ertapenem can be successfully used as antimicrobial addition to the cement spacers in two-stage revision treatment of polymicrobial PJIs. However, this type of spacer may also be useful in the treatment of infections caused by monomicrobial extended spectrum beta-lactamases producing gram-negative bacilli. Further clinical studies are required to evaluate the efficacy and safety of ertapenem spacers in the treatment of polymicrobial and monomicrobial PJIs.
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208
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Perez-Jorge C, Gomez-Barrena E, Horcajada JP, Puig-Verdie L, Esteban J. Drug treatments for prosthetic joint infections in the era of multidrug resistance. Expert Opin Pharmacother 2016; 17:1233-46. [PMID: 27054293 DOI: 10.1080/14656566.2016.1176142] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Despite many advances, the management of prosthetic joint infection is still a complex issue. Moreover, in recent years the problem of antimicrobial resistance has emerged as an important challenge. AREAS COVERED We analysed recent advances in different aspects of prosthetic joint infections. The importance of biofilms needs to be considered for antibiotic selection because, when embedded in these structures, bacteria acquire resistant behaviour. Moreover, the presence of resistance mechanisms in some species of organisms increases the difficulty of management. In this sense, the growing importance of methicillin-resistant staphylococci, multidrug-resistant Enterobacteriaceae or Pseudomonas aeruginosa is of increasing concern. Together with these organisms, others with constitutive resistance against most antibiotics (like Enterococcus sp., mycobacteria or fungi) represent a similar problem for selection of therapy. Research into new materials that can be used as drug carriers opens a new field for management of these infections and will likely come to the front line in the coming years. EXPERT OPINION Individualised therapies should carefully consider the aetiology, pathogenesis and antimicrobial susceptibility. Satisfactory clinical outcome could be further fostered by enhancing the multidisciplinary approach, with better collaboration in the antibiotic selection and the surgical management.
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Affiliation(s)
- Concepcion Perez-Jorge
- a Bone and Joint Infection Unit, Department of Clinical Microbiology , IIS-Fundacion Jimenez Diaz, UAM , Madrid , Spain
| | - Enrique Gomez-Barrena
- b Department of Orthopaedic Surgery , IdiPaz-Hospital La Paz Institute for Health Research, UAM , Madrid , Spain
| | - Juan-Pablo Horcajada
- c Service of Infectious Diseases, Hospital del Mar, CEXS Universitat Pompeu Fabra , Institut Hospital del Mar d'Investigacions Mèdiques , Barcelona , Spain
| | - Lluis Puig-Verdie
- d Department of Orthopaedic Surgery , Hospital del Mar, Institut Hospital del Mar d'Investigacions Mèdiques , Barcelona , Spain
| | - Jaime Esteban
- a Bone and Joint Infection Unit, Department of Clinical Microbiology , IIS-Fundacion Jimenez Diaz, UAM , Madrid , Spain
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209
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Rodríguez-Pardo D, Pigrau C, Corona PS, Almirante B. An update on surgical and antimicrobial therapy for acute periprosthetic joint infection: new challenges for the present and the future. Expert Rev Anti Infect Ther 2016; 13:249-65. [PMID: 25578886 DOI: 10.1586/14787210.2015.999669] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Periprosthetic joint infection (PJI) is a devastating complication that can occur following any arthroplasty procedure. Approximately half of these infections develop within the first year after arthroplasty, mainly in the first 1 to 3 months. These infections are known as early PJI. It is widely accepted that many early PJIs can be successfully managed by debridement, irrigation, and prosthetic retention, followed by a course of biofilm-effective antibiotics (debridement, antibiotics, implant retention procedure), but candidate patients should meet the requirements set down in Zimmerli's algorithm. The best antibiotic regimen for acute PJI treated without implant removal remains uncertain. Rifampin-containing regimens, when feasible, are recommended in gram-positive infections, and fluoroquinolones in gram-negative cases. The duration, dosage, and administration route of antibiotics and the use of combined therapy are matters that requires further clarification, as the current level of evidence is low and most recommendations are based on experimental data, studies in small series, and expert experience.
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210
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Aboltins C, Dowsey M, Peel T, Lim WK, Choong P. Good quality of life outcomes after treatment of prosthetic joint infection with debridement and prosthesis retention. J Orthop Res 2016; 34:898-902. [PMID: 26517733 DOI: 10.1002/jor.23089] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 10/26/2015] [Indexed: 02/04/2023]
Abstract
Patients treated for early prosthetic joint infection (PJI) with surgical debridement and prosthesis retention have a rate of successful infection eradication that is similar to patients treated with the traditional approach of prosthesis exchange. It is therefore important to consider other outcomes after prosthetic joint infection treatment that may influence management decisions, such as quality of life (QOL). Our aim was to describe infection cure rates and quality of life for patients with prosthetic joint infection treated with debridement and prosthesis retention and to determine if treatment with this approach was a risk factor for poor quality of life outcomes. Prospectively collected pre and post-arthroplasty data were available for 2,134 patients, of which PJI occurred in 41. For patients treated for prosthetic joint infection, the 2-year survival free of treatment failure was 87% (95%CI 84-89). Prosthetic joint infection cases treated with debridement and retention had a similar improvement from pre-arthroplasty to 12-months post-arthroplasty as patients without PJI in QOL according to the SF-12 survey. Prosthetic joint infection treated with debridement and retention was not a risk factor for poor quality of life on univariate or multivariate analysis. Prosthetic joint infection treated with debridement and prosthesis retention results in good cure rates and quality of life. Further studies are required that directly compare quality of life for different surgical approaches for prosthetic joint infection to better inform management decisions. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:898-902, 2016.
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Affiliation(s)
- Craig Aboltins
- Department of Infectious Diseases, St Vincent's Hospital, 41 Victoria Pde Fitzroy, Victoria, 3065, Australia.,Northwest Academic Centre, Univeristy of Melbourne, 185 Cooper St Epping, Victoria, 3076, Australia
| | - Michelle Dowsey
- Department of Orthopaedic Surgery, St Vincent's Hospital, 41 Victoria Pde Fitzroy, Victoria, 3065, Australia.,The University of Melbourne Department of Surgery, St Vincent's Hospital, 41 Victoria Pde Fitzroy, Victoria, 3065, Australia
| | - Trish Peel
- Department of Orthopaedic Surgery, St Vincent's Hospital, 41 Victoria Pde Fitzroy, Victoria, 3065, Australia.,The University of Melbourne Department of Surgery, St Vincent's Hospital, 41 Victoria Pde Fitzroy, Victoria, 3065, Australia
| | - Wen K Lim
- Northwest Academic Centre, Univeristy of Melbourne, 185 Cooper St Epping, Victoria, 3076, Australia.,Department of Medicine, Northern Health, 185 Cooper St Epping, Victoria, 3076, Australia
| | - Peter Choong
- Department of Orthopaedic Surgery, St Vincent's Hospital, 41 Victoria Pde Fitzroy, Victoria, 3065, Australia.,The University of Melbourne Department of Surgery, St Vincent's Hospital, 41 Victoria Pde Fitzroy, Victoria, 3065, Australia
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211
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Tschudin-Sutter S, Frei R, Dangel M, Jakob M, Balmelli C, Schaefer D, Weisser M, Elzi L, Battegay M, Widmer A. Validation of a treatment algorithm for orthopaedic implant-related infections with device-retention—results from a prospective observational cohort study. Clin Microbiol Infect 2016; 22:457.e1-9. [DOI: 10.1016/j.cmi.2016.01.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 12/28/2015] [Accepted: 01/03/2016] [Indexed: 11/28/2022]
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212
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de Vries LMA, van der Weegen W, Neve WC, Das HPW, Ridwan BU, Steens J. The Effectiveness of Debridement, Antibiotics and Irrigation for Periprosthetic Joint Infections after Primary Hip and Knee Arthroplasty. A 15 Years Retrospective Study in Two Community Hospitals in the Netherlands. J Bone Jt Infect 2016; 1:20-24. [PMID: 28529848 PMCID: PMC5423563 DOI: 10.7150/jbji.14075] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The aim of our study was to evaluate the effectiveness of debridement, antibiotics, irrigation and retention (DAIR) in patients who developed a periprosthetic joint infection (PJI) after primary hip or knee arthroplasty in two community hospitals in the Netherlands. We retrospectively collected data in two hospitals in the Netherlands on all episodes of PJI after primary hip (THA) and knee arthroplasty (TKA) from 1998-2012. In 109 of 8234 THA (1.32%) and 65 of 5752 TKA (1.13%) a PJI developed. DAIR was used as treatment in 84 patients after THA (77.1%) and 56 patients after TKA (86.2%). 34 Patients only received antibiotics or were immediately revised. After 1 year follow-up, prosthesis retention was achieved in 81 THA patients (74.3%) and 48 TKA patients (73.8%). Acute infections showed a better survival compared to late infections (84.0% vs 46.6% respectively; p<0.01). Furthermore, a young age was associated with an increased revision risk (p<0.01). In conclusion, debridement, antibiotics and irrigation in acute PJI may lead to retention of the prosthesis in a majority of cases. Large patient cohort studies can provide data on PJI outcome, complementing National Registries which have limited detail.
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Affiliation(s)
- LMA de Vries
- Department of Orthopaedics, Westfriesgasthuis, Hoorn, the Netherlands
| | - W van der Weegen
- Department of Orthopaedics, St Anna Hospital, Geldrop, the Netherlands
| | - WC Neve
- Department of Orthopaedics, Westfriesgasthuis, Hoorn, the Netherlands
| | - HPW Das
- Department of Orthopaedics, St Anna Hospital, Geldrop, the Netherlands
| | - BU Ridwan
- Department of Medical Microbiology, Westfriesgasthuis, Hoorn, the Netherlands
| | - J Steens
- Department of Orthopaedics, Westfriesgasthuis, Hoorn, the Netherlands
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213
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Moriarty TF, Kuehl R, Coenye T, Metsemakers WJ, Morgenstern M, Schwarz EM, Riool M, Zaat SA, Khana N, Kates SL, Richards RG. Orthopaedic device-related infection: current and future interventions for improved prevention and treatment. EFORT Open Rev 2016; 1:89-99. [PMID: 28461934 PMCID: PMC5367564 DOI: 10.1302/2058-5241.1.000037] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Orthopaedic and trauma device-related infection (ODRI) remains one of the major complications in modern trauma and orthopaedic surgery.Despite best practice in medical and surgical management, neither prophylaxis nor treatment of ODRI is effective in all cases, leading to infections that negatively impact clinical outcome and significantly increase healthcare expenditure.The following review summarises the microbiological profile of modern ODRI, the impact antibiotic resistance has on treatment outcomes, and some of the principles and weaknesses of the current systemic and local antibiotic delivery strategies.The emerging novel strategies aimed at preventing or treating ODRI will be reviewed. Particular attention will be paid to the potential for clinical impact in the coming decades, when such interventions are likely to be critically important.The review focuses on this problem from an interdisciplinary perspective, including basic science innovations and best practice in infectious disease. Cite this article: Moriarty TF, Kuehl R, Coenye T, et al. Orthopaedic device related infection: current and future interventions for improved prevention and treatment. EFORT Open Rev 2016;1:89-99. DOI: 10.1302/2058-5241.1.000037.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Nina Khana
- University Hospital of Basel, Switzerland
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214
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Investigation on rifampicin administration from the standpoint of pharmacokinetics/pharmacodynamics in a neutropenic murine thigh infection model. J Infect Chemother 2016; 22:387-94. [PMID: 27029221 DOI: 10.1016/j.jiac.2016.02.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 02/22/2016] [Accepted: 02/28/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND The purpose of this study was to examine the pharmacokinetics/pharmacodynamics of rifampicin against methicillin-susceptible Staphylococcus aureus (MSSA), methicillin-resistant S. aureus (MRSA), and vancomycin-intermediate S. aureus (VISA) in a neutropenic murine thigh infection model. METHODS Three S. aureus isolates (MSSA [ATCC 25923], MRSA and VISA [Mu50]) with rifampicin MIC 0.06 to >256 μg/mL were tested. The efficacy was calculated as the change in bacterial density. A maximum effect model was used to determine the PK/PD index that best described the dose-response data. RESULTS The area under the curve (AUC)/MIC and maximum concentration of drug in serum (Cmax/MIC) were the best correlated with in vivo efficacy (AUC/MIC, R(2) = 0.96; Cmax/MIC, R(2) = 0.97) for S. aureus ATCC 25923 strain, and the dose fractionation-response study did not show significantly different antimicrobial activity (p = 0.10). The AUC/MIC values associated with stasis and 1-log kill for the S. aureus ATCC 25923 strain were 386 and 952, respectively. On the other hand, no antimicrobial efficacy was observed against two strains (MRSA and VISA) with MIC of 128 μg/mL or more. CONCLUSION Rifampicin demonstrated concentration-dependent killing. The AUC/MIC was a predictive PK/PD index.
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Tornero E, Morata L, Martínez-Pastor JC, Angulo S, Combalia A, Bori G, García-Ramiro S, Bosch J, Mensa J, Soriano A. Importance of selection and duration of antibiotic regimen in prosthetic joint infections treated with debridement and implant retention. J Antimicrob Chemother 2016; 71:1395-401. [DOI: 10.1093/jac/dkv481] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 12/15/2015] [Indexed: 12/26/2022] Open
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Park KH, Cho OH, Lee JH, Park JS, Ryu KN, Park SY, Lee YM, Chong YP, Kim SH, Lee SO, Choi SH, Bae IG, Kim YS, Woo JH, Lee MS. Optimal Duration of Antibiotic Therapy in Patients With Hematogenous Vertebral Osteomyelitis at Low Risk and High Risk of Recurrence. Clin Infect Dis 2016; 62:1262-1269. [DOI: 10.1093/cid/ciw098] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 01/05/2016] [Indexed: 11/13/2022] Open
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Mühlhofer HML, Gollwitzer H, Lenze F, Feihl S, Pohlig F, von Eisenhart-Rothe R, Schauwecker J. [Periprosthetic infections of the hip joint : Clinical approach]. DER ORTHOPADE 2016; 44:357-65. [PMID: 25800463 DOI: 10.1007/s00132-015-3084-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Increasing rates of periprosthetic joint infections (PJI) will present orthopedic surgeons and the health care system with challenges in the next few years. New concepts in diagnostic and surgical pathways allow specialized centers to offer differentiated therapy of PJI. AIM This article presents an overview of recent treatment concepts for PJI of the hip emphasizing diagnosis and the clinical approach. METHOD A selective literature search was performed focusing on evidence-based concepts including diagnostics, surgical treatment, and biofilm active antibiotics. RESULTS PJI of the hip are classified as mature biofilm or immature biofilm infections. The most important step in the diagnostic procedure is to identify the pathogen and its antimicrobial susceptibility. Preoperative joint aspiration and leukocyte count, differentiation, and microbiological culture should be standard. Arthroscopic biopsy may be necessary to identify the pathogen. Depending on the biofilm maturity and the antimicrobial susceptibility, implant retention or two-stage revisions should be performed. Combination of surgical therapy and biofilm-active antibiotics are of utmost importance for successful treatment. DISCUSSION PJI represents a significant challenge for the orthopedic surgeon. Evidence-based and standardized clinical pathways are necessary for accurate and rapid diagnosis as well as patient-specific treatment concepts.
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Affiliation(s)
- H M L Mühlhofer
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland,
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218
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Abstract
Periprosthetic joint infections are a devastating complication after arthroplasty and are associated with substantial patient morbidity. More than 25% of revisions are attributed to these infections, which are expected to increase. The increased prevalence of obesity, diabetes, and other comorbidities are some of the reasons for this increase. Recognition of the challenge of surgical site infections in general, and periprosthetic joint infections particularly, has prompted implementation of enhanced prevention measures preoperatively (glycaemic control, skin decontamination, decolonisation, etc), intraoperatively (ultraclean operative environment, blood conservation, etc), and postoperatively (refined anticoagulation, improved wound dressings, etc). Additionally, indications for surgical management have been refined. In this Review, we assess risk factors, preventive measures, diagnoses, clinical features, and treatment options for prosthetic joint infection. An international consensus meeting about such infections identified the best practices and further research needs. Orthopaedics could benefit from enhanced preventive, diagnostic, and treatment methods.
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Affiliation(s)
- Bhaveen H Kapadia
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Richard A Berg
- Department of Infectious Disease, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Jacqueline A Daley
- Infection Prevention and Control, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Jan Fritz
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anil Bhave
- Department of Rehabilitation, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA.
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219
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Abstract
Periprosthetic joint infection (PJI) is one of the most feared and challenging complications following total knee arthroplasty. We provide a detailed description of our current understanding regarding the management of PJI of the knee, including diagnostic aids, pre-operative planning, surgical treatment, and outcome.
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Affiliation(s)
- T Gehrke
- Helios Endo-Klinik, Holstenstr.2, 22767 Hamburg, Germany
| | - P Alijanipour
- Rothman Institute, 125 S 9th St Ste 1000, Philadelphia, PA 19107, USA
| | - J Parvizi
- Rothman Institute, 125 S 9th St Ste 1000, Philadelphia, PA 19107, USA
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220
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Inzana JA, Schwarz EM, Kates SL, Awad HA. Biomaterials approaches to treating implant-associated osteomyelitis. Biomaterials 2015; 81:58-71. [PMID: 26724454 DOI: 10.1016/j.biomaterials.2015.12.012] [Citation(s) in RCA: 184] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 12/06/2015] [Accepted: 12/13/2015] [Indexed: 12/13/2022]
Abstract
Orthopaedic devices are the most common surgical devices associated with implant-related infections and Staphylococcus aureus (S. aureus) is the most common causative pathogen in chronic bone infections (osteomyelitis). Treatment of these chronic bone infections often involves combinations of antibiotics given systemically and locally to the affected site via a biomaterial spacer. The gold standard biomaterial for local antibiotic delivery against osteomyelitis, poly(methyl methacrylate) (PMMA) bone cement, bears many limitations. Such shortcomings include limited antibiotic release, incompatibility with many antimicrobial agents, and the need for follow-up surgeries to remove the non-biodegradable cement before surgical reconstruction of the lost bone. Therefore, extensive research pursuits are targeting alternative, biodegradable materials to replace PMMA in osteomyelitis applications. Herein, we provide an overview of the primary clinical treatment strategies and emerging biodegradable materials that may be employed for management of implant-related osteomyelitis. We performed a systematic review of experimental biomaterials systems that have been evaluated for treating established S. aureus osteomyelitis in an animal model. Many experimental biomaterials were not decisively more efficacious for infection management than PMMA when delivering the same antibiotic. However, alternative biomaterials have reduced the number of follow-up surgeries, enhanced the antimicrobial efficacy by delivering agents that are incompatible with PMMA, and regenerated bone in an infected defect. Understanding the advantages, limitations, and potential for clinical translation of each biomaterial, along with the conditions under which it was evaluated (e.g. animal model), is critical for surgeons and researchers to navigate the plethora of options for local antibiotic delivery.
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Affiliation(s)
- Jason A Inzana
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos, Switzerland; Center for Musculoskeletal Research, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, United States; Department of Biomedical Engineering, University of Rochester, 207 Robert B. Goergen Hall, Rochester, NY 14642, United States.
| | - Edward M Schwarz
- Center for Musculoskeletal Research, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, United States; Department of Biomedical Engineering, University of Rochester, 207 Robert B. Goergen Hall, Rochester, NY 14642, United States; Department of Orthopedics, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, United States
| | - Stephen L Kates
- Center for Musculoskeletal Research, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, United States; Department of Orthopedics, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, United States
| | - Hani A Awad
- Center for Musculoskeletal Research, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, United States; Department of Biomedical Engineering, University of Rochester, 207 Robert B. Goergen Hall, Rochester, NY 14642, United States; Department of Orthopedics, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, United States
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221
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Jacquot A, Sirveaux F, Roche O, Favard L, Clavert P, Molé D. Surgical management of the infected reversed shoulder arthroplasty: a French multicenter study of reoperation in 32 patients. J Shoulder Elbow Surg 2015; 24:1713-22. [PMID: 25957111 DOI: 10.1016/j.jse.2015.03.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 03/02/2015] [Accepted: 03/07/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND In a retrospective multicenter study, we evaluated the efficiency and outcomes of the different therapeutic options for infection after reversed shoulder arthroplasty. METHODS Thirty-two patients were reoperated on for infection after reversed shoulder arthroplasty between 1996 and 2011. The mean age was 71 (55-83) years. The involved implants were primary prostheses in 23 cases and revision prostheses in 9 cases. The average preoperative Constant score was 34 (11-69). Six of these patients needed 2 successive procedures. A total of 38 procedures were performed: débridement (13), 1-stage (5) or 2-stage revision (14), or implant removal (6). At last follow-up (mean, 36 months; range, 12-137 months), every patient had clinical, biologic, and radiographic evaluation. RESULTS Infections were largely caused by coagulase-negative staphylococci (56%) and Propionibacterium acnes (59%). The complication rate was 26%. At last follow-up, 26 patients were free of infection (81%). The final Constant score was 46 (12-75). After débridement with implant retention, the mean Constant score was 51 (29-75), but the healing rate was only 54%. Implant revision (1 or 2 stage) led to better functional results than implant removal (46 vs. 25; P = .001), with similar healing rates (73% and 67%, respectively). Patients with low initial impairment (Constant score > 30) were not significantly improved by surgical treatment. CONCLUSION Débridement is the less aggressive option but exposes patients to healing failure. It should be proposed as a first treatment attempt. Revision of the implant is technically challenging but preserves shoulder function, with no higher rate of residual infection compared with implant removal.
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Affiliation(s)
- Adrien Jacquot
- Orthopaedic & Traumatologic Surgery Department, Centre Chirurgical E. Gallé, Nancy, France.
| | - François Sirveaux
- Orthopaedic & Traumatologic Surgery Department, Centre Chirurgical E. Gallé, Nancy, France
| | - Olivier Roche
- Orthopaedic & Traumatologic Surgery Department, Centre Chirurgical E. Gallé, Nancy, France
| | - Luc Favard
- Orthopaedic & Traumatologic Surgery Department, Hopital Trousseaux, Tours, France
| | - Philippe Clavert
- Orthopaedic Surgery and Hand Surgery Center, Illkirch Graffenstaden, Strasbourg, France
| | - Daniel Molé
- Orthopaedic & Traumatologic Surgery Department, Centre Chirurgical E. Gallé, Nancy, France
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Vu DL, Uçkay I, Gonzalez A, Rohner P, Hoffmeyer P, Lübbeke A. Factors related to outcome of early and delayed prosthetic joint infections. J Infect 2015; 72:255-7. [PMID: 26481057 DOI: 10.1016/j.jinf.2015.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 10/10/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Diem-Lan Vu
- Service of Infectious Diseases, Geneva University Hospitals & Faculty of Medicine, University of Geneva, Switzerland
| | - Ilker Uçkay
- Service of Infectious Diseases, Geneva University Hospitals & Faculty of Medicine, University of Geneva, Switzerland; Orthopaedic Surgery Service, Geneva University Hospitals & Faculty of Medicine, University of Geneva, Switzerland.
| | - Amanda Gonzalez
- Orthopaedic Surgery Service, Geneva University Hospitals & Faculty of Medicine, University of Geneva, Switzerland
| | - Peter Rohner
- Coding Office, Geneva University Hospitals & Faculty of Medicine, University of Geneva, Switzerland
| | - Pierre Hoffmeyer
- Orthopaedic Surgery Service, Geneva University Hospitals & Faculty of Medicine, University of Geneva, Switzerland
| | - Anne Lübbeke
- Orthopaedic Surgery Service, Geneva University Hospitals & Faculty of Medicine, University of Geneva, Switzerland
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223
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Improved identification of polymicrobial infection in total knee arthroplasty through sonicate fluid cultures. Arch Orthop Trauma Surg 2015; 135:1453-7. [PMID: 26350385 DOI: 10.1007/s00402-015-2317-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) is the leading cause for early failure of total knee arthroplasty (TKA). An insufficient diagnosis of the involved bacterial species can be a possible cause for this high failure rate. Sonicate fluid cultures (SFC) have been shown to increase the detection rate of PJI in comparison to the use of conventional microbiological methods. The hypothesis of this study is that sonication will improve not only the detection rate of PJI, but also the detection rate of polymicrobial infection in patients with TKA revision surgery. MATERIALS AND METHODS 109 patients, undergoing TKA revision surgery, were enrolled in this prospective cohort study and received a synovial aspiration, intraoperative tissue cultures, histological sampling of the periprosthetic membrane (PM), and sonication of the explanted endoprosthesis. A PJI was defined according to the following criteria: presence of intraarticular pus or a sinus tract, positive isolation of the same bacterial species in ≥2 microbiological samples or a PM indicative of infection. RESULTS 31 patients had a defined PJI according to the above-mentioned criteria. SFC achieved the highest sensitivity (74 %) of all microbiological methods. The PM achieved a sensitivity of 87 %. When the results of the SFC and the PM were combined, it was possible to further increase the sensitivity to 94 %. The utilization of SFC doubled the number of polymicrobial bacterial isolations in our patient collective. There were 12 cases of polymicrobial bacterial isolations, six were detectable through conventional microbiological methods, four were detectable through SFC and two were identifiable as polymicrobial through the isolation of an additional bacterial species in the SFC. CONCLUSIONS In our study, SFC were the most sensitive microbiological method and were surpassed only by the histology. The use of SFC doubled the detection rate of polymicrobial isolations, which would be missed with conventional microbiological methods alone.
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Debridement with prosthesis retention and antibiotherapy vs. two-stage revision for periprosthetic knee infection within 3 months after arthroplasty: a case–control study. Clin Microbiol Infect 2015; 21:851.e11-7. [DOI: 10.1016/j.cmi.2015.05.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 05/19/2015] [Accepted: 05/21/2015] [Indexed: 12/16/2022]
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El Haj C, Murillo O, Ribera A, Vivas M, Garcia-Somoza D, Tubau F, Cabellos C, Cabo J, Ariza J. Daptomycin combinations as alternative therapies in experimental foreign-body infection caused by meticillin-susceptible Staphylococcus aureus. Int J Antimicrob Agents 2015; 46:189-95. [DOI: 10.1016/j.ijantimicag.2015.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 03/30/2015] [Accepted: 04/11/2015] [Indexed: 11/15/2022]
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226
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Polymicrobial infections reduce the cure rate in prosthetic joint infections: outcome analysis with two-stage exchange and follow-up ≥two years. INTERNATIONAL ORTHOPAEDICS 2015; 40:1367-73. [DOI: 10.1007/s00264-015-2871-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 04/26/2015] [Indexed: 02/07/2023]
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227
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Puhto AP, Puhto T, Niinimäki T, Ohtonen P, Leppilahti J, Syrjälä H. Predictors of treatment outcome in prosthetic joint infections treated with prosthesis retention. INTERNATIONAL ORTHOPAEDICS 2015; 39:1785-91. [DOI: 10.1007/s00264-015-2819-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 05/08/2015] [Indexed: 01/27/2023]
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228
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Tong SYC, Davis JS, Eichenberger E, Holland TL, Fowler VG. Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management. Clin Microbiol Rev 2015; 28:603-61. [PMID: 26016486 PMCID: PMC4451395 DOI: 10.1128/cmr.00134-14] [Citation(s) in RCA: 2733] [Impact Index Per Article: 303.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Staphylococcus aureus is a major human pathogen that causes a wide range of clinical infections. It is a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections. This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of each of these clinical entities. The past 2 decades have witnessed two clear shifts in the epidemiology of S. aureus infections: first, a growing number of health care-associated infections, particularly seen in infective endocarditis and prosthetic device infections, and second, an epidemic of community-associated skin and soft tissue infections driven by strains with certain virulence factors and resistance to β-lactam antibiotics. In reviewing the literature to support management strategies for these clinical manifestations, we also highlight the paucity of high-quality evidence for many key clinical questions.
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Affiliation(s)
- Steven Y C Tong
- Global and Tropical Health, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Joshua S Davis
- Global and Tropical Health, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Emily Eichenberger
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Thomas L Holland
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Vance G Fowler
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
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229
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Jiranek WA, Waligora AC, Hess SR, Golladay GL. Surgical Treatment of Prosthetic Joint Infections of the Hip and Knee: Changing Paradigms? J Arthroplasty 2015; 30:912-8. [PMID: 25922125 DOI: 10.1016/j.arth.2015.03.014] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 02/26/2015] [Accepted: 03/13/2015] [Indexed: 02/07/2023] Open
Abstract
Prosthetic joint infection (PJI) of the hip and knee remains one of the most common and feared arthroplasty complications. The impact and cost of PJI is significant, both to the patient and to the health care system. Recent reports of results of different treatment strategies have led many surgeons to modify their approach to management of PJI. This paper will explore apparent paradigm shifts, both to indications and technique, including the importance of waiting for bacterial identification, the decreasing role for irrigation and debridement (I&D) with retention of components, the increased utilization of single stage revision, and conversely a decreasing role for two-stage exchange. Strategies for treating drug-resistant organisms and management of failed treatment will also be examined.
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Affiliation(s)
- William A Jiranek
- Department of Orthopaedic Surgery, VCU School of Medicine, Richmond, Virginia
| | - Andrew C Waligora
- Department of Orthopaedic Surgery, VCU School of Medicine, Richmond, Virginia
| | - Shane R Hess
- Department of Orthopaedic Surgery, VCU School of Medicine, Richmond, Virginia
| | - Gregory L Golladay
- Department of Orthopaedic Surgery, VCU School of Medicine, Richmond, Virginia
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Influence of daily dosage and frequency of administration of rifampicin–levofloxacin therapy on tolerance and effectiveness in 154 patients treated for prosthetic joint infections. Eur J Clin Microbiol Infect Dis 2015; 34:1675-82. [DOI: 10.1007/s10096-015-2404-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 05/05/2015] [Indexed: 10/23/2022]
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231
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KLIC-score for predicting early failure in prosthetic joint infections treated with debridement, implant retention and antibiotics. Clin Microbiol Infect 2015; 21:786.e9-786.e17. [PMID: 25959106 DOI: 10.1016/j.cmi.2015.04.012] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 04/13/2015] [Accepted: 04/14/2015] [Indexed: 01/22/2023]
Abstract
Debridement, irrigation and antibiotic treatment form the current approach in early prosthetic joint infection (PJI). Our aim was to design a score to predict patients with a higher risk of failure. From 1999 to 2014 early PJIs were prospectively collected and retrospectively reviewed. The primary end-point was early failure defined as: 1) the need for unscheduled surgery, 2) death-related infection within the first 60 days after debridement or 3) the need for suppressive antibiotic treatment. A score was built-up according to the logistic regression coefficients of variables available before debridement. A total of 222 patients met the inclusion criteria. The most frequently isolated microorganisms were coagulase-negative staphylococci (95 cases, 42.8%) and Staphylococcus aureus (81 cases, 36.5%). Treatment of 52 (23.4%) cases failed. Independent predictors of failure were: chronic renal failure (OR 5.92, 95% CI 1.47-23.85), liver cirrhosis (OR 4.46, 95% CI 1.15-17.24), revision surgery (OR 4.34, 95% CI 1.34-14.04) or femoral neck fracture (OR 4.39, 95% CI1.16-16.62) compared with primary arthroplasty, C reactive protein >11.5 mg/dL (OR 12.308, 95% CI 4.56-33.19), cemented prosthesis (OR 8.71, 95% CI 1.95-38.97) and when all intraoperative cultures were positive (OR 6.30, 95% CI 1.84-21.53). A score for predicting the risk of failure was designed using preoperative factors (KLIC-score: Kidney, Liver, Index surgery, Cemented prosthesis and C-reactive protein value) and it ranged between 0 and 9.5 points. Patients with scores of ≤2, >2-3.5, 4-5, >5-6.5 and ≥7 had failure rates of 4.5%, 19.4%, 55%, 71.4% and 100%, respectively. The KLIC-score was highly predictive of early failure after debridement. In the future, it would be necessary to validate our score using cohorts from other institutions.
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Abstract
Prosthetic joint infection (PJI) still remains a significant problem. In line with the forecasted rise in joint replacement procedures, the number of cases of PJI is also anticipated to rise. The formation of biofilm by causative pathogens is central to the occurrence and the recalcitrance of PJI. The subject of microbial biofilms is receiving increasing attention, probably as a result of the wide acknowledgement of the ubiquity of biofilms in the natural, industrial, and clinical contexts, as well as the notorious difficulty in eradicating them. In this review, we discuss the pertinent issues surrounding PJI and the challenges posed by biofilms regarding diagnosis and treatment. In addition, we discuss novel strategies of prevention and treatment of biofilm-related PJI.
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Affiliation(s)
| | | | - Jason C Webb
- Avon Orthopedic Centre, Southmead Hospital,University of Bristol
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233
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Rafii F, Hart ME. Antimicrobial resistance in clinically important biofilms. World J Pharmacol 2015; 4:31-46. [DOI: 10.5497/wjp.v4.i1.31] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 10/22/2014] [Accepted: 12/17/2014] [Indexed: 02/06/2023] Open
Abstract
A biofilm contains a consortium of cohesive bacterial cells forming a complex structure that is a sedentary, but dynamic, community. Biofilms adhere on biotic and abiotic surfaces, including the surfaces of practically all medical devices. Biofilms are reported to be responsible for approximately 60% of nosocomial infections due to implanted medical devices, such as intravenous catheters, and they also cause other foreign-body infections and chronic infections. The presence of biofilm on a medical device may result in the infection of surrounding tissues and failure of the device, necessitating the removal and replacement of the device. Bacteria from biofilms formed on medical devices may be released and disperse, with the potential for the formation of new biofilms in other locations and the development of a systemic infection. Regardless of their location, bacteria in biofilms are tolerant of the activities of the immune system, antimicrobial agents, and antiseptics. Concentrations of antimicrobial agents sufficient to eradicate planktonic cells have no effect on the same microorganism in a biofilm. Depending on the microbial consortium or component of the biofilm that is involved, various combinations of factors have been suggested to explain the recalcitrant nature of biofilms toward killing by antibiotics. In this mini-review, some of the factors contributing to antimicrobial resistance in biofilms are discussed.
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234
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Holmberg A, Thórhallsdóttir VG, Robertsson O, W-Dahl A, Stefánsdóttir A. 75% success rate after open debridement, exchange of tibial insert, and antibiotics in knee prosthetic joint infections. Acta Orthop 2015; 86:457-62. [PMID: 25753311 PMCID: PMC4513601 DOI: 10.3109/17453674.2015.1026756] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 02/03/2015] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Prosthetic joint infection (PJI) is a leading cause of early revision after total knee arthroplasty (TKA). Open debridement with exchange of tibial insert allows treatment of infection with retention of fixed components. We investigated the success rate of this procedure in the treatment of knee PJIs in a nationwide material, and determined whether the results were affected by microbiology, antibiotic treatment, or timing of debridement. PATIENTS AND METHODS 145 primary TKAs revised for the first time, due to infection, with debridement and exchange of the tibial insert were identified in the Swedish Knee Arthroplasty Register (SKAR). Staphylococcus aureus was the most common pathogen (37%) followed by coagulase-negative staphylococci (CNS) (23%). Failure was defined as death before the end of antibiotic treatment, revision of major components due to infection, life-long antibiotic treatment, or chronic infection. RESULTS The overall healing rate was 75%. The type of infecting pathogen did not statistically significantly affect outcome. Staphylococcal infections treated without a combination of antibiotics including rifampin had a higher failure rate than those treated with rifampin (RR = 4, 95% CI: 2-10). In the 16 cases with more than 3 weeks of symptoms before treatment, the healing rate was 62%, as compared to 77% in the other cases (p = 0.2). The few patients with a revision model of prosthesis at primary operation had a high failure rate (5 of 8). INTERPRETATION Good results can be achieved by open debridement with exchange of tibial insert. It is important to use an antibiotic combination including rifampin in staphylococcal infections.
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Affiliation(s)
- Anna Holmberg
- Division of Infection Medicine, Department of Clinical Sciences, Lund University , Lund
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Valour F, Rasigade JP, Trouillet-Assant S, Gagnaire J, Bouaziz A, Karsenty J, Lacour C, Bes M, Lustig S, Bénet T, Chidiac C, Etienne J, Vandenesch F, Ferry T, Laurent F. Delta-toxin production deficiency in Staphylococcus aureus: a diagnostic marker of bone and joint infection chronicity linked with osteoblast invasion and biofilm formation. Clin Microbiol Infect 2015; 21:568.e1-11. [PMID: 25677632 DOI: 10.1016/j.cmi.2015.01.026] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 01/21/2015] [Accepted: 01/24/2015] [Indexed: 11/29/2022]
Abstract
Biofilm formation, intra-osteoblastic persistence, small-colony variants (SCVs) and the dysregulation of agr, the major virulence regulon, are possibly involved in staphylococcal bone and joint infection (BJI) pathogenesis. We aimed to investigate the contributions of these mechanisms among a collection of 95 Staphylococcus aureus clinical isolates from 64 acute (67.4%) and 31 chronic (32.6%) first episodes of BJI. The included isolates were compared for internalization rate, cell damage and SCV intracellular emergence using an ex vivo model of human osteoblast infection. Biofilm formation was assessed in a microbead immobilization assay (BioFilm Ring test). Virulence gene profiles were assessed by DNA microarray. Seventeen different clonal complexes were identified among the screened collection. The staphylococcal internalization rate in osteoblasts was significantly higher for chronic than acute BJI isolates, regardless of the genetic background. Conversely, no differences regarding cytotoxicity, SCV emergence, biofilm formation and virulence gene distribution were observed. Additionally, agr dysfunction, detected by the lack of delta-toxin production using whole-cell matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) analysis (n = 15; 15.8%), was significantly associated with BJI chronicity, osteoblast invasion and biofilm formation. These findings provide new insights into MSSA BJI pathogenesis, suggesting the correlation between chronicity and staphylococcal osteoblast invasion. This adaptive mechanism, along with biofilm formation, is associated with agr dysfunction, which can be routinely assessed by delta-toxin detection using MALDI-TOF spectrum analysis, possibly providing clinicians with a diagnostic marker of BJI chronicity at the time of diagnosis.
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Affiliation(s)
- F Valour
- Department of Infectious Diseases, Hospices Civils de Lyon, France; Department of Microbiology, French National Reference Centre for Staphylococci, Hospices Civils de Lyon, France; INSERM U1111, International Centre for Infectiology Research, France; Claude Bernard Lyon 1 University, France.
| | - J-P Rasigade
- Department of Microbiology, French National Reference Centre for Staphylococci, Hospices Civils de Lyon, France; INSERM U1111, International Centre for Infectiology Research, France; Claude Bernard Lyon 1 University, France
| | | | - J Gagnaire
- Department of Microbiology, French National Reference Centre for Staphylococci, Hospices Civils de Lyon, France
| | - A Bouaziz
- Department of Infectious Diseases, Hospices Civils de Lyon, France
| | - J Karsenty
- Department of Infectious Diseases, Hospices Civils de Lyon, France
| | - C Lacour
- Department of Microbiology, French National Reference Centre for Staphylococci, Hospices Civils de Lyon, France
| | - M Bes
- Department of Microbiology, French National Reference Centre for Staphylococci, Hospices Civils de Lyon, France; INSERM U1111, International Centre for Infectiology Research, France
| | - S Lustig
- INSERM U1111, International Centre for Infectiology Research, France; Claude Bernard Lyon 1 University, France; Orthopaedic Surgery department, Hospices Civils de Lyon, France
| | - T Bénet
- Department of Infection Control and Epidemiology, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - C Chidiac
- Department of Infectious Diseases, Hospices Civils de Lyon, France; INSERM U1111, International Centre for Infectiology Research, France; Claude Bernard Lyon 1 University, France
| | - J Etienne
- Department of Microbiology, French National Reference Centre for Staphylococci, Hospices Civils de Lyon, France; INSERM U1111, International Centre for Infectiology Research, France; Claude Bernard Lyon 1 University, France
| | - F Vandenesch
- Department of Microbiology, French National Reference Centre for Staphylococci, Hospices Civils de Lyon, France; INSERM U1111, International Centre for Infectiology Research, France; Claude Bernard Lyon 1 University, France
| | - T Ferry
- Department of Infectious Diseases, Hospices Civils de Lyon, France; INSERM U1111, International Centre for Infectiology Research, France; Claude Bernard Lyon 1 University, France
| | - F Laurent
- Department of Microbiology, French National Reference Centre for Staphylococci, Hospices Civils de Lyon, France; INSERM U1111, International Centre for Infectiology Research, France; Claude Bernard Lyon 1 University, France
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Park KH, Cho OH, Lee YM, Moon C, Park SY, Moon SM, Lee JH, Park JS, Ryu KN, Kim SH, Lee SO, Choi SH, Lee MS, Kim YS, Woo JH, Bae IG. Therapeutic outcomes of hematogenous vertebral osteomyelitis with instrumented surgery. Clin Infect Dis 2015; 60:1330-8. [PMID: 25663159 DOI: 10.1093/cid/civ066] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 01/24/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Patients with hematogenous vertebral osteomyelitis (HVO) occasionally require instrumentation for spinal stabilization. However, placing instrumentation in the setting of spinal infection raises concerns about recurrent infection due to bacteria adhering to the foreign material. In this study, we evaluated the therapeutic outcomes of patients with HVO who underwent instrumented surgery. METHODS We conducted a retrospective chart review of adult patients with microbiologically diagnosed HVO who underwent surgical intervention in 5 tertiary care hospitals over an 8-year period. RESULTS A total of 153 patients with HVO underwent surgical management for their infections. Of these 153 patients, 94 (61.4%) underwent surgical debridement alone (noninstrumented surgery) and 59 (38.6%) underwent surgical debridement and instrumentation (instrumented surgery). The median durations of antibiotic therapy were 66 and 80 days for the noninstrumentation and instrumentation groups, respectively (P = .22). Clinical outcomes were similar between the groups, including rates of infection-related death (2.1% vs 0%; P = .52), primary failure (1.1% vs 5.1%; P = .30), and recurrence (4.8% vs 6.8%; P = .72). Among the instrumentation group, there was a significant decreasing trend for recurrence according to total duration of antibiotic therapy: 22.2% (4-6 weeks), 9.1% (6-8 weeks), and 2.6% (≥ 8 weeks; P = .04). Duration of pre-instrumentation antibiotic therapy and single-stage operation (vs 2-stage operation) were not risk factors for recurrence. CONCLUSIONS Spinal instrumentation in patients with HVO may be safe with pathogen-directed prolonged antibiotic therapy and should not be abandoned or delayed solely because of the risk of recurrence.
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Affiliation(s)
- Ki-Ho Park
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul
| | - Oh-Hyun Cho
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju
| | - Yu-Mi Lee
- Department of Infectious Diseases, Busan Paik Hospital, Inje University College of Medicine, Busan
| | - Chisook Moon
- Department of Infectious Diseases, Busan Paik Hospital, Inje University College of Medicine, Busan
| | - Seong Yeon Park
- Department of Internal Medicine, Dongguk University Ilsan Hospital, University of Dongguk College of Medicine, Goyang-si
| | - Song Mi Moon
- Department of Infectious Diseases, Gachon University Gil Medical Center, Incheon
| | | | - Ji Seon Park
- Department of Radiology, Kyung Hee University Hospital, Kyung Hee University School of Medicine
| | - Kyung Nam Ryu
- Department of Radiology, Kyung Hee University Hospital, Kyung Hee University School of Medicine
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi Suk Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - In-Gyu Bae
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju
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Risk factors for failure in early prosthetic joint infection treated with debridement. Influence of etiology and antibiotic treatment. J Appl Biomater Funct Mater 2014; 12:129-34. [PMID: 25199072 DOI: 10.5301/jabfm.5000209] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2013] [Indexed: 11/20/2022] Open
Abstract
PURPOSES The aim of the present study was to evaluate the importance of isolated microorganisms according to the Gram stain and the type of antibiotic received on the outcome of early prosthetic joint infection (PJI) treated with debridement, antibiotics and implant retention (DAIR). METHODS From January 1999 to December 2009, all patients with an early PJI were prospectively registered in a database and they were retrospectively reviewed for this study. RESULTS During the study period, 160 patients met the inclusion criteria of the study. After a mean (SD) post-debridement follow-up of 5.2 (2.5) years, 117 patients (73.1%) were considered to be in remission and 43 (26.9%) were classified as failure. Variables associated with failure were liver cirrhosis (66.7% vs. 22.8%, p=0.001), diagnosis within the first 30 days from arthroplasty (30.4% vs. 8.0%, p=0.020), C-reactive protein (CRP) >12 mg/dl (46.7% vs. 21.2%, p=0.005), microorganism isolated in all deep samples (31.1% vs. 16.0%, p=0.047) and Gram-negative (GN) infection not treated with a fluoroquinolone (57.1% vs. 20.0%, P=0.004). Gram-positive (GP) infection not treated with rifampin was close to be statistically significantly associated with failure (34.4% vs. 19.2%, p=0.067). A multivariate analysis identified liver cirrhosis (OR: 12.4 CI95%: 3.1-49.7, p<0.001), CRP-value (OR: 1.06 CI95%: 1.0-1.11, p=0.049), and when a GN-infection was not treated with a fluoroquinolone (OR: 6.5, CI95%: 1.8-23.8, p=0.005) as independent predictors of failure. CONCLUSION The remission rate of PJI treated with DAIR after 3 years of follow-up was 73%. The main predictors of failure were liver cirrhosis, the selected antibiotic most specially fluoroquinolones for GN and rifampin for GP infections, the C-reactive protein and the number of samples culture positive as a potential surrogate markers of bacterial density.
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238
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Kuiper JWP, Willink RT, Moojen DJF, Bekerom MPJVD, Colen S. Treatment of acute periprosthetic infections with prosthesis retention: Review of current concepts. World J Orthop 2014; 5:667-676. [PMID: 25405096 PMCID: PMC4133475 DOI: 10.5312/wjo.v5.i5.667] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 04/28/2014] [Accepted: 06/03/2014] [Indexed: 02/06/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty, occurring in approximately 1%-2% of all cases. With growing populations and increasing age, PJI will have a growing effect on health care costs. Many risk factors have been identified that increase the risk of developing PJI, including obesity, immune system deficiencies, malignancy, previous surgery of the same joint and longer operating time. Acute PJI occurs either postoperatively (4 wk to 3 mo after initial arthroplasty, depending on the classification system), or via hematogenous spreading after a period in which the prosthesis had functioned properly. Diagnosis and the choice of treatment are the cornerstones to success. Although different definitions for PJI have been used in the past, most are more or less similar and include the presence of a sinus tract, blood infection values, synovial white blood cell count, signs of infection on histopathological analysis and one or more positive culture results. Debridement, antibiotics and implant retention (DAIR) is the primary treatment for acute PJI, and should be performed as soon as possible after the development of symptoms. Success rates differ, but most studies report success rates of around 60%-80%. Whether single or multiple debridement procedures are more successful remains unclear. The use of local antibiotics in addition to the administration of systemic antibiotic agents is also subject to debate, and its pro’s and con’s should be carefully considered. Systemic treatment, based on culture results, is of importance for all PJI treatments. Additionally, rifampin should be given in Staphylococcal PJIs, unless all foreign material is removed. The most important factors contributing to treatment failure are longer duration of symptoms, a longer time after initial arthroplasty, the need for more debridement procedures, the retention of exchangeable components, and PJI caused by Staphylococcus (aureus or coagulase negative). If DAIR treatment is unsuccessful, the following treatment option should be based on the patient health status and his or her expectations. For the best functional outcome, one- or two-stage revision should be performed after DAIR failure. In conclusion, DAIR is the obvious choice for treatment of acute PJI, with good success rates in selected patients.
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Rodríguez-Pardo D, Pigrau C, Lora-Tamayo J, Soriano A, del Toro MD, Cobo J, Palomino J, Euba G, Riera M, Sánchez-Somolinos M, Benito N, Fernández-Sampedro M, Sorli L, Guio L, Iribarren JA, Baraia-Etxaburu JM, Ramos A, Bahamonde A, Flores-Sánchez X, Corona PS, Ariza J. Gram-negative prosthetic joint infection: outcome of a debridement, antibiotics and implant retention approach. A large multicentre study. Clin Microbiol Infect 2014; 20:O911-9. [PMID: 24766536 DOI: 10.1111/1469-0691.12649] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 04/07/2014] [Accepted: 04/18/2014] [Indexed: 02/05/2023]
Abstract
We aim to evaluate the epidemiology and outcome of gram-negative prosthetic joint infection (GN-PJI) treated with debridement, antibiotics and implant retention (DAIR), identify factors predictive of failure, and determine the impact of ciprofloxacin use on prognosis. We performed a retrospective, multicentre, observational study of GN-PJI diagnosed from 2003 through to 2010 in 16 Spanish hospitals. We define failure as persistence or reappearance of the inflammatory joint signs during follow-up, leading to unplanned surgery or repeat debridement>30 days from the index surgery related death, or suppressive antimicrobial therapy. Parameters predicting failure were analysed with a Cox regression model. A total of 242 patients (33% men; median age 76 years, interquartile range (IQR) 68-81) with 242 episodes of GN-PJI were studied. The implants included 150 (62%) hip, 85 (35%) knee, five (2%) shoulder and two (1%) elbow prostheses. There were 189 (78%) acute infections. Causative microorganisms were Enterobacteriaceae in 78%, Pseudomonas spp. in 20%, and other gram-negative bacilli in 2%. Overall, 19% of isolates were ciprofloxacin resistant. DAIR was used in 174 (72%) cases, with an overall success rate of 68%, which increased to 79% after a median of 25 months' follow-up in ciprofloxacin-susceptible GN-PJIs treated with ciprofloxacin. Ciprofloxacin treatment exhibited an independent protective effect (adjusted hazard ratio (aHR) 0.23; 95% CI, 0.13-0.40; p<0.001), whereas chronic renal impairment predicted failure (aHR, 2.56; 95% CI, 1.14-5.77; p 0.0232). Our results confirm a 79% success rate in ciprofloxacin-susceptible GN-PJI treated with debridement, ciprofloxacin and implant retention. New therapeutic strategies are needed for ciprofloxacin-resistant PJI.
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Affiliation(s)
- D Rodríguez-Pardo
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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Dastgheyb S, Parvizi J, Shapiro IM, Hickok NJ, Otto M. Effect of biofilms on recalcitrance of staphylococcal joint infection to antibiotic treatment. J Infect Dis 2014; 211:641-50. [PMID: 25214518 DOI: 10.1093/infdis/jiu514] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The pathogenesis of joint infections is not well understood. In particular, we do not know why these infections respond poorly to antibiotic treatment. Here we show that methicillin-resistant Staphylococcus aureus, a major cause of joint infections, forms exceptionally strong biofilmlike aggregates in human synovial fluid (SF), to an extent significantly exceeding biofilm formation observed in growth medium or serum. Screening a transposon bank identified bacterial fibronectin- and fibrinogen-binding proteins as important for the formation of macroscopic clumps in SF, suggesting an important role of fibrin-containing clots in the formation of bacterial aggregates during joint infection. Pretreatment of SF with plasmin led to a strongly reduced formation of aggregates and increased susceptibility to antibiotics. These results give important insight into the pathogenesis of staphylococcal joint infection and the mechanisms underlying resistance to treatment. Furthermore, they point toward a potential novel approach for treating joint infections.
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Affiliation(s)
- Sana Dastgheyb
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland Department of Orthopedic Surgery, Thomas Jefferson University
| | | | | | - Noreen J Hickok
- Department of Orthopedic Surgery, Thomas Jefferson University
| | - Michael Otto
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
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Aboltins C, Daffy J, Choong P, Stanley P. Current concepts in the management of prosthetic joint infection. Intern Med J 2014; 44:834-40. [DOI: 10.1111/imj.12510] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 06/03/2014] [Indexed: 01/28/2023]
Affiliation(s)
- C. Aboltins
- Department of Infectious Diseases; Northern Health; Melbourne Victoria Australia
- Northwest Academic Centre; The University of Melbourne; Melbourne Victoria Australia
| | - J. Daffy
- Department of Infectious Diseases; St Vincent's Hospital Melbourne; Melbourne Victoria Australia
| | - P. Choong
- Department of Surgery; The University of Melbourne; Melbourne Victoria Australia
- Department of Orthopaedics; St Vincent's Hospital Melbourne; Melbourne Victoria Australia
| | - P. Stanley
- Department of Infectious Diseases; Northern Health; Melbourne Victoria Australia
- Northwest Academic Centre; The University of Melbourne; Melbourne Victoria Australia
- Department of Infectious Diseases; St Vincent's Hospital Melbourne; Melbourne Victoria Australia
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High doses of daptomycin (10 mg/kg/d) plus rifampin for the treatment of staphylococcal prosthetic joint infection managed with implant retention: a comparative study. Diagn Microbiol Infect Dis 2014; 80:66-71. [DOI: 10.1016/j.diagmicrobio.2014.05.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 05/26/2014] [Accepted: 05/27/2014] [Indexed: 11/19/2022]
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Morata L, Senneville E, Bernard L, Nguyen S, Buzelé R, Druon J, Tornero E, Mensa J, Soriano A. A Retrospective Review of the Clinical Experience of Linezolid with or Without Rifampicin in Prosthetic Joint Infections Treated with Debridement and Implant Retention. Infect Dis Ther 2014; 3:235-43. [PMID: 25139552 PMCID: PMC4269635 DOI: 10.1007/s40121-014-0032-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Indexed: 11/26/2022] Open
Abstract
Introduction Debridement and prosthesis retention, combined with a prolonged antibiotic regimen including rifampicin, is an accepted therapeutic approach when the duration of symptoms is less than 4 weeks and there are no radiological signs of loosening. The outcome of patients managed with this strategy has been previously assessed in several articles with success rates of 60–90%. This study aims to review the clinical experience with linezolid in 3 different hospitals from Spain and France in patients with prosthetic joint infection (PJI) managed with debridement, retention of the implant and treated with linezolid with or without rifampicin. Methods Patients with an acute PJI who underwent open debridement with implant retention treated with linezolid for more than 7 days in 3 hospitals from Barcelona, Tours and Lille between 2005 and 2011 were retrospectively reviewed. Relevant information about demographics, co-morbidity, type of implant, surgical treatment, microorganism isolated, antimicrobial therapy, adverse events (AEs) and outcomes were recorded from patients. Results A total of 39 patients were retrospectively reviewed. The mean age (SD) was 70.5 (8.8) years and 9 patients had diabetes mellitus (23%). There were 25 (64%) knee prostheses, 13 (33%) hips and 1 shoulder (3%). The median interquartile range (IQR) days from arthroplasty to infection diagnosis was 17 (19–48) and 33 (85%) cases were diagnosed within the first 60 days. The median (IQR) duration of antibiotic treatment was 70.5 (34–96) days and the median (IQR) number of days on linezolid treatment was 44.5 (30–81). AEs were observed in 15 patients (38%), with gastrointestinal complaints in 8 cases and anemia in 5 being the most frequent. After a median (IQR) follow-up of 2.5 (1.8–3.6) years, there were 11 failures (28%) (8 relapses and 3 new infections). The failure rate was higher in the rifampicin group (36% vs. 18%) mainly due to a higher relapse rate (27% vs. 12%) although differences were not statistically significant. Conclusion Management of acute PJIs with debridement and retention of the implant linezolid, with or without rifampicin, is associated with a high remission rate and it is an alternative treatment for infections due to fluoroquinolone and/or rifampicin-resistant staphylococci. Electronic supplementary material The online version of this article (doi:10.1007/s40121-014-0032-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Laura Morata
- Bone and Joint Infection Unit, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain.
| | - Eric Senneville
- Lille-Tourcoing French Referent Center for Osteo-articular Infection, Lille University Hospital, Lille, France
| | - Louis Bernard
- Infectious Diseases Unit, Tours University Hospital, Tours Cedex, France
| | - Sophie Nguyen
- Lille-Tourcoing French Referent Center for Osteo-articular Infection, Lille University Hospital, Lille, France
| | - Rodolphe Buzelé
- Infectious Diseases Unit, Tours University Hospital, Tours Cedex, France
| | - Jérome Druon
- Regional French Referent Center for Osteo-articular Infection, Tours Cedex, France
| | - Eduard Tornero
- Bone and Joint Infection Unit, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Josep Mensa
- Bone and Joint Infection Unit, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Alex Soriano
- Bone and Joint Infection Unit, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
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Anagnostakos K, Schmitt C. Can periprosthetic hip joint infections be successfully managed by debridement and prosthesis retention? World J Orthop 2014; 5:218-224. [PMID: 25035823 PMCID: PMC4095013 DOI: 10.5312/wjo.v5.i3.218] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 03/02/2014] [Accepted: 04/11/2014] [Indexed: 02/06/2023] Open
Abstract
To evaluate the current literature about how successfully periprosthetic hip joint infections can be managed by debridement and prosthesis retention. A literature search was performed through PubMed until September 2013. Search terms were “DAIR (debridement, antibiotics, irrigation, and retention)” alone and in combination with “hip” as well as “hip infection + prosthesis retention”. A total of 11 studies reporting on 292 cases could be identified. Five different treatment modalities have been described with varying success rates (debridement-21% infection eradication rate; debridement + lavage-75% infection eradication rate; debridement, lavage, with change of modular prosthesis components-70.4% infection eradication rate; debridement, lavage, change of modular prosthesis components + vacuum-assisted closure-92.8% infection eradication rate; acetabular cup removal + spacer head onto retained stem-89.6% infection eradication rate). With regard to the postoperative antibiotic therapy, no general consensus could be drawn from the available data. Debridement, antibiotic therapy, irrigation, and prosthesis retention is an acceptable solution in the management of early and acute hematogenous periprosthetic hip joint infections. The current literature does not allow for generalization of conclusions with regard to the best treatment modality. A large, multi-center study is required for identification of the optimal treatment of these infections.
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245
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Barbero Allende JM, Romanyk Cabrera J, Montero Ruiz E, Vallés Purroy A, Melgar Molero V, Agudo López R, Gete García L, López Álvarez J. [Eradication of Staphylococcus aureus in carrier patients undergoing joint arthroplasty]. Enferm Infecc Microbiol Clin 2014; 33:95-100. [PMID: 24880651 DOI: 10.1016/j.eimc.2014.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 02/25/2014] [Accepted: 03/03/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Prosthetic joint infection (PJI) is a complication with serious repercussions and its main cause is Staphylococcus aureus. The purpose of this study is to determine whether decolonization of S.aureus carriers helps to reduce the incidence of PJI by S.aureus. MATERIAL AND METHODS An S.aureus screening test was performed on nasal carriers in patients undergoing knee or hip arthroplasty between January and December 2011. Patients with a positive test were treated with intranasal mupirocin and chlorhexidine soap 5 days. The incidence of PJI was compared with patients undergoing the same surgery between January and December 2010. RESULTS A total of 393 joint replacements were performed in 391 patients from the control group, with 416 joint replacements being performed in the intervention group. Colonization study was performed in 382 patients (91.8%), of which 102 were positive (26.7%) and treated. There was 2 PJI due S.aureus compared with 9 in the control group (0.5% vs 2.3%, odds ratio [OR]: 0.2, 95% confidence interval [CI]: 0.4 to 2.3, P=.04). CONCLUSIONS In our study, the detection of colonization and eradication of S.aureus carriers achieved a significant decrease in PJI due to S.aureus compared to a historical group.
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Affiliation(s)
| | - Juan Romanyk Cabrera
- Servicio de Microbiología, Hospital Príncipe de Asturias, Alcalá de Henares, España
| | - Eduardo Montero Ruiz
- Servicio de Medicina Interna, Hospital Príncipe de Asturias, Alcalá de Henares, España
| | - Alfonso Vallés Purroy
- Servicio de Cirugía Ortopédica y Traumatológica, Hospital Príncipe de Asturias, Alcalá de Henares, España
| | | | - Rosa Agudo López
- Servicio de Medicina Interna, Hospital Príncipe de Asturias, Alcalá de Henares, España
| | - Luis Gete García
- Servicio de Medicina Interna, Hospital Príncipe de Asturias, Alcalá de Henares, España
| | - Joaquín López Álvarez
- Servicio de Medicina Interna, Hospital Príncipe de Asturias, Alcalá de Henares, España
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Ceftriaxone for Methicillin-Sensitive Staphylococcus aureus Osteoarticular Infections. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2014. [DOI: 10.1097/ipc.0000000000000109] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Prosthetic joint infection (PJI) is a tremendous burden for individual patients as well as the global health care industry. While a small minority of joint arthroplasties will become infected, appropriate recognition and management are critical to preserve or restore adequate function and prevent excess morbidity. In this review, we describe the reported risk factors for and clinical manifestations of PJI. We discuss the pathogenesis of PJI and the numerous microorganisms that can cause this devastating infection. The recently proposed consensus definitions of PJI and approaches to accurate diagnosis are reviewed in detail. An overview of the treatment and prevention of this challenging condition is provided.
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Affiliation(s)
- Aaron J. Tande
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Robin Patel
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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248
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Scherr TD, Heim CE, Morrison JM, Kielian T. Hiding in Plain Sight: Interplay between Staphylococcal Biofilms and Host Immunity. Front Immunol 2014; 5:37. [PMID: 24550921 PMCID: PMC3913997 DOI: 10.3389/fimmu.2014.00037] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 01/22/2014] [Indexed: 12/21/2022] Open
Abstract
Staphylococcus aureus and Staphylococcus epidermidis are notable for their propensity to form biofilms on implanted medical devices. Staphylococcal biofilm infections are typified by their recalcitrance to antibiotics and ability to circumvent host immune-mediated clearance, resulting in the establishment of chronic infections that are often recurrent in nature. Indeed, the immunomodulatory lifestyle of biofilms seemingly shapes the host immune response to ensure biofilm engraftment and persistence in an immune competent host. Here, we provide a brief review of the mechanisms whereby S. aureus and S. epidermidis biofilms manipulate host–pathogen interactions and discuss the concept of microenvironment maintenance in infectious outcomes, as well as speculate how these findings pertain to the challenges of staphylococcal vaccine development.
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Affiliation(s)
- Tyler D Scherr
- Department of Pathology and Microbiology, University of Nebraska Medical Center , Omaha, NE , USA
| | - Cortney E Heim
- Department of Pathology and Microbiology, University of Nebraska Medical Center , Omaha, NE , USA
| | - John M Morrison
- Department of Pathology and Microbiology, University of Nebraska Medical Center , Omaha, NE , USA
| | - Tammy Kielian
- Department of Pathology and Microbiology, University of Nebraska Medical Center , Omaha, NE , USA
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249
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O'Toole P, Osmon D, Soriano A, Berdal JE, Bostrum M, Franco-Cendejas R, Huang D, Nelson C, Nishisaka F, Salgado CD, Sawyer R, Segreti J, Senneville E, Zhang XL. Oral antibiotic therapy. J Arthroplasty 2014; 29:115-8. [PMID: 24360497 DOI: 10.1016/j.arth.2013.09.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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250
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Haasper C, Buttaro M, Hozack W, Aboltins CA, Borens O, Callaghan JJ, de Carvalho PI, Chang Y, Corona P, Da Rin F, Esposito S, Fehring TK, Sanchez XF, Lee GC, Martinez-Pastor JC, Mortazavi SMJ, Noiseux NO, Peng KT, Schutte HD, Schweitzer D, Trebše R, Tsiridis E, Whiteside L. Irrigation and debridement. J Arthroplasty 2014; 29:100-3. [PMID: 24360491 DOI: 10.1016/j.arth.2013.09.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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