Implementation of a multidisciplinary infections conference affects the treatment plan in prosthetic joint infections of the hip: a retrospective study

Clinic of Hope: bridging infectious disease and orthopaedic surgery in prosthetic joint infection management

Prosthetic joint infections (PJIs) following total joint arthroplasty are a significant and costly complication. To address fragmented care typically seen with separate management, we established a combined infectious disease and orthopaedic surgery clinic at Duke Health in July 2020. This clinic focuses on patients experiencing acute deterioration or multiple PJI episodes, often at the stage where amputation is the only option offered. From July 2021 to March 2024, the clinic completed 974 visits with 319 unique patients. The clinic maintained a low no-show rate of 5.0%. Treatment plans included procedures such as debridement, antibiotics and implant retention (38%), as well as implant explantation and one-stage exchange (32% each), with amputation required in only 4% of cases. The integrated clinic model facilitated real-time, multidisciplinary care, improving patient outcomes and operational efficiency. This approach offers a promising model for managing complex infections.

Regional Spondylodiscitis Disparities: Impact on Pathogen Spectrum and Patients

Background: Spondylodiscitis is an infectious disease affecting an intervertebral disc and the adjacent vertebral bodies and is often the complication of a distant focus of infection. This study aims to ascertain the regional and hospital-specific disparities in bacterial patterns and resistance profiles in spontaneous and iatrogenic spondylodiscitis and their implications for patient treatment. Methods: We enrolled patients from two German hospitals, specifically comparing a university hospital (UVH) with a peripheral non-university hospital (NUH). We documented patient demographics, laboratory results, and surgical interventions. Microbiological assessments, antibiotic regimens, treatment durations, and resistance profiles were recorded. Results: This study included 135 patients. Upon admission, 92.4% reported pain, with 16.2% also presenting neurological deficits. The primary microbial species identified in both the UVH and NUH cohorts were S. aureus (37.3% vs. 31.3%) and cog. neg. staphylococci (28.8% vs. 34.4%), respectively. Notably, a higher prevalence of resistant bacteria was noted in the UVH group (p < 0.001). Additionally, concomitant malignancies were significantly more prevalent in the UVH cohort. Conclusion: Significant regional variations exist in bacterial prevalence and resistance profiles. Consequently, treatment protocols need to consider these nuances and undergo regular critical evaluation. Moreover, patients with concurrent malignancies face an elevated risk of spondylodiscitis.

Performance and Hypothetical Impact on Joint Infection Management of the BioFire Joint Infection Panel: a Retrospective Analysis

Pathogen identification is key in septic arthritis. Culture-based techniques are challenging, especially when patients have been pretreated with antibiotics or when difficult-to-culture bacteria are encountered. The BioFire joint infection assay (BJA) is a multiplex PCR panel which detects 31 of the most prevalent bacterial and fungal pathogens causing septic arthritis. Here, 123 cryoconserved contemporary synovial fluid samples from 120 patients underwent BJA analysis. Results were compared to those of culture-based diagnostics (standard of care [SOC]). Clinical data were collected, and the possible impact of the molecular diagnostic application on patient management was evaluated. Fifteen of 123 synovial fluid cultures grew bacterial pathogens. All on-panel pathogens (9/15) were correctly identified by the BJA. The BJA identified four additional bacterial pathogens in four SOC-negative cases. BJA sensitivity and specificity were 100% (95% confidence interval [CI], 69.2% to 100%) and 100% (95% CI, 96.8% to 100%), respectively. Compared to the SOC, the BJA would have resulted in faster provision of species identification and molecular susceptibility data by 49 h and 99 h, respectively. Clinical data analysis indicates that in BJA-positive cases, faster species ID could have led to timelier optimization of antibiotic therapy. This retrospective study demonstrates high sensitivity and specificity of the BJA to detect on-panel organisms in bacterial arthritis. The usefulness of the BJA in prosthetic-joint infections is limited, as important pathogens (i.e., coagulase negative staphylococci and Cutibacterium acnes) are not covered. Evidence from patient data analysis suggests that the assay might prove valuable for optimizing patient management in acute arthritis related to fastidious organisms or for patients who received antibiotics prior to specimen collection.

The Impact of a Dedicated Multidisciplinary Team Approach for Prosthetic Joint Infections of the Lower Limb

Introduction

Prosthetic joint infections (PJI) of the hip and knee have significant morbidity and mortality, and present with varying local, host and microbiological factors. Given the broad presentation and complexity of PJI’s, we developed a dedicated multidisciplinary team (MDT) to manage this complex patient cohort, and report on our early outcomes.

Methods

This was a retrospective observational study of all patients diagnosed with a prosthetic joint infection of the hip or knee (n = 71) at our institution during a 4.5-year period. Patients treated after development of the MDT (post-MDT) (n = 44), were compared to a control group prior establishment of the MDT (pre-MDT) (n = 27).

Results

85.2% of individuals in the pre-MDT, and 85.7% of individuals in the post-MDT group were considered cured at a minimum 2 years post-operatively according to the Delphi-based definition. The total number of admissions to hospital (2.44 vs. 1.84) and total number of antibiotics used (3.37 vs. 2.75) decreased in the post-MDT group; however, differences were not considered statistically significant.

Discussion

Implementation of a dedicated MDT in the management of individuals with PJI’s of the lower limb at our hospital has allowed early and effective collaboration between healthcare personnel, with early promising results. Given the broad nature of PJI, future studies are ongoing to determine modifiable risk factors to reduce the incidence and improve outcomes of individuals with PJI’s where systems can then be implemented into already established MDTs to achieve the best clinical outcome for our patients.

Epidemiology and outcomes of bone and joint infections in solid organ transplant recipients

Bone and joint infection (BJI) epidemiology and outcomes in solid organ transplant recipients (SOTr) remain largely unknown. We aim to describe BJI in a multi-center cohort of SOTr (Swiss Transplant Cohort Study). All consecutive SOTr with BJI (01.05.2008-31.12.2019) were included. A nested case-control study to identify risk factors for BJI was performed. Among 4482 patients, 61 SOTr with 82 BJI were included, at an incidence of 1.4% (95% CI 1.1-1.7), higher in heart and kidney-pancreas SOTr (Gray's test p < .01). Although BJI were predominately late events (median of 18.5 months post-SOT), most infections occurred during the first year post-transplant in thoracic SOTr. Diabetic foot osteomyelitis was the most frequent infection (38/82, 46.3%), followed by non-vertebral osteomyelitis (26/82, 31.7%). Pathogens included Gram-positive cocci (70/131, 53.4%), Gram-negative bacilli (34/131, 26.0%), and fungi (9/131, 6.9%). BJI predictors included male gender (OR 2.94, 95% CI 1.26-6.89) and diabetes (OR 2.97, 95% CI 1.34-6.56). Treatment failure was observed in 25.9% (21/81) patients and 1-year mortality post-BJI diagnosis was 14.8% (9/61). BJI remain a rare event in SOTr, associated with subtle clinical presentations, high morbidity and relapses, requiring additional studies in the future.

Do Multidisciplinary Spine Conferences Alter Management or Impact Outcome?

BACKGROUND

Multidisciplinary spine conferences (MSCs) are a strategy for discussing diagnostic and treatment aspects of patient care. Although they are becoming more common in hospitals, literature investigating how they impact patient care and outcomes is scarce. The aim of this study is to examine the impact of MSCs on surgical management and outcomes in elective spine surgical care.

METHODS

A systematic review of the literature was conducted to evaluate the impact of MSCs on patient management and outcomes. PubMed and Cochrane databases were searched using combinations and variations of search terms "Spine Conferences," "Multidisciplinary," and "Spine Team."

RESULTS

The literature search yielded 435 articles, of which 120 were selected for full-text review. Four articles (N = 529 patients) were included. Surgical plans were discussed in 211 patients. The decision was altered to conservative treatment in 70 patients (33.17%) and a different surgical strategy in 34 patients (16.11%). The differences were significant in 2 studies (P < 0.05). A 51% reduction in 30-day complications rates was observed when MSC was implemented in patients with adult complex scoliosis. Other spinal disorders showed a 30-day complication rate between 0% and 14% after MSC.

CONCLUSIONS

To our knowledge, this is the first systematic review of outcomes of MSCs in elective spine surgery and it confirms that MSCs impact management plan and outcomes. Consistent MSCs that include surgeons and nonsurgeons have the potential to enhance communication between specialists, standardize treatments, improve patient care, and encourage teamwork. More analysis is warranted to determine if patient outcomes are improved with these measures.

Management of Periprosthetic Joint Infections After Hemiarthroplasty of the Hip: A Critical Analysis Review

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Periprosthetic joint infection (PJI) following hip hemiarthroplasty (HA) is a devastating complication, incurring immense health-care costs associated with its treatment and placing considerable burden on patients and their families. These patients often require multiple surgical procedures, extended hospitalization, and prolonged antimicrobial therapy.

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Notable risk factors include older age, higher American Society of Anesthesiologists (ASA) score, inadequate antibiotic prophylaxis, non-antibiotic-loaded cementation of the femoral implant, longer duration of the surgical procedure, and postoperative drainage and hematoma.

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Although the most frequent infecting organisms are gram-positive cocci such as Staphylococcus aureus, there is a higher proportion of patients with gram-negative and polymicrobial infections after hip HA compared with patients who underwent total hip arthroplasty.

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Several surgical strategies exist. Regardless of the preferred surgical treatment, successful management of these infections requires a comprehensive surgical debridement focused on eradicating the biofilm followed by appropriate antibiotic therapy.

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A multidisciplinary approach led by surgeons familiar with PJI treatment and infectious disease specialists is recommended for all cases of PJI after hip HA to increase the likelihood of treatment success.

The Definition of the Term "Orthogeriatric Infection" for Periprosthetic Joint Infections

Introduction

In the background of the aging population, an increase of geriatric patients with specific age-related co-morbidities has already been seen over the years for proximal femur fractures in orthopaedic surgery as well as other medical disciplines. However, the geriatric aspect has not been well recognized in periprosthetic joint infection (PJI) patients so far. Therefore, this paper seeks to provide an overview on the co-morbidities of PJI patients with respect to the definition of geriatric patients.

Material and methods

In this single-center retrospective study, patients treated between 2007 and 2020 for PJI were included (n = 255). Patients were defined as geriatric according to the consensus definition criteria of the Federal Working Group of Clinical Geriatric Facilities e.V., the German Society for Geriatrics e.V. and the German Society for Gerontology and Geriatrics e.V. based on age (≤70 years), geriatric multimorbidity and the Barthel index (≤30).

Results

Applying the criteria defined 184 of the 255 (72.2%) PJI patients as geriatric infection patients. Regarding geriatric comorbidity, incontinence was most prevalent (38.1%), followed by immobility (25.6%). Comparing the geriatric infection patients with those classified as non-geriatric (n = 71) revealed that geriatric patients had a longer hospital stay and spent more days in the intensive care unit (ICU). Also, the amputation rate and the 5-year mortality rate was significantly increased (n = 15, 8.2% vs n = 1, 1.4%, P = .007 and n = 24, 13.0% vs n = 5, 7.0%, P = .005). The Barthel index showed a significant correlation with mortality (r = -.22, P = .011).

Discussion

We propose to use the term orthogeriatric infection patients in those cases in order to focus treatment not only on the orthopaedic infections but also on the important geriatric aspects.

Conclusion

The inclusion of geriatric physicians into the multidisciplinary team approach for PJI patients might be beneficial.

Introducing image-guided synovial aspiration and biopsy in assessing peri-prosthetic joint infection: an early single-centre experience

AIM

Synovial sampling can be used in the diagnosis of peri-prosthetic joint infection (PJI). The purpose of this study was to establish the role of simultaneous image-guided synovial aspiration and biopsy (SAB) during an initial 2-year experience at our institution.

METHODS

Retrospective review of consecutive SABs performed during 2014-2016 at a tertiary referral musculoskeletal centre. Radiological SAB microbiology culture results were compared with intra-operative surgical samples or multidisciplinary team (MDT) meeting outcome at 1-year follow-up if surgery was not undertaken. Sensitivity, specificity and accuracy of synovial aspiration (SA), synovial biopsy (SB) and simultaneous SAB were calculated.

RESULTS

103 patients (46 male, 57 female) totalling 111 procedures were analysed with mean age 65 years (range 31-83). Image-guided synovial procedures were performed on 52 (46.9%) hip and 59 (53.1%) knee joint prostheses. The mean combined sensitivity, specificity and accuracy for the entire cohort was 72.6%, 96.9% and 90%, respectively. When only SB was obtained, diagnostic accuracy (92.5%) was similar to SA alone (94.1%). In total, there were 21 (18.9%) true-positive, 80 (72.1%) true-negative, 2 (1.8%) false-positive and 8 (7.2%) false-negative cases (PPV 91.3% and NPV 90.9%). No post-procedural complications were recorded at 1-year follow-up.

CONCLUSION

Percutaneous image-guided SAB is a valuable technique in assessing suspected PJI, with most samples indicative of infective status and causative organisms when validated against intra-operative results and specialist MDT evaluation. Image-guided SB is a safe and useful additional procedure following failed SA with equivalent levels of diagnostic accuracy.

Comparison of patient reported outcome measures after single versus two-stage revision for chronic infection of total hip arthroplasty: a retrospective propensity score matched cohort study

INTRODUCTION

Two-stage revision is the current gold standard treatment for infected total hip arthroplasties (THA) with good clinical outcomes. Single-stage revision THA offers the advantage of only a single surgical intervention, potentially leading to improved functional outcomes. This study aimed to compare the differences in patient-reported outcome measures (PROMs) and complications between single and two-stage revision THA for chronic periprosthetic joint infection (PJI).

METHODS

A total of 159 consecutive revision THA patients for chronic PJI with complete pre-and post-operative patient-reported outcome measures (PROM) was investigated. A total of 46 patients with single-stage revision THA was matched to 92 patients following two-stage revision THA using propensity score matching, yielding a total of 136 propensity score-matched patients for analysis.

RESULTS

Single and two-stage revision THA improved PROM scores post-operatively, with significantly higher PROMs for single-stage revision THA (HOOS-PS: 50.7 vs 46.4, p = 0.04; Physical SF 10A: 42.1 vs 36.6, p < 0.001; PROMIS SF Physical: 41.4 vs 37.4, p < 0.001; PROMIS SF Mental: 52.8 vs 47.6, p < 0.001). There was no significant difference between both cohorts for reinfection rates (p = 0.81) and 90-day mortality rates (p = 1.0).

CONCLUSION

This study found a demonstrable functional benefit of single-stage revision compared to two-stage revision for THA with chronic periprosthetic joint infection, suggesting that single-stage revision THA may provide an effective alternative to two-stage revision in selected patients with chronic PJI.

LEVEL OF EVIDENCE

Level III, case-control retrospective analysis.

Improving outcomes in acute and chronic periprosthetic hip and knee joint infection with a multidisciplinary approach

AIMS

Periprosthetic hip and knee infection remains one of the most severe complications following arthroplasty, with an incidence between 0.5% to 1%. This study compares the outcomes of revision surgery for periprosthetic joint infection (PJI) following hip and knee arthroplasty prior to and after implementation of a specialist PJI multidisciplinary team (MDT).

METHODS

Data was retrospectively analyzed from a single centre. In all, 29 consecutive joints prior to the implementation of an infection MDT in November 2016 were compared with 29 consecutive joints subsequent to the MDT conception. All individuals who underwent a debridement antibiotics and implant retention (DAIR) procedure, a one-stage revision, or a two-stage revision for an acute or chronic PJI in this time period were included. The definition of successfully treated PJI was based on the Delphi international multidisciplinary consensus.

RESULTS

There were no statistically significant differences in patient demographics or comorbidities between the groups. There was also no significant difference in length of overall hospital stay (p = 0.530). The time taken for formal microbiology advice was significantly shorter in the post MDT group (p = 0.0001). There was a significant difference in failure rates between the two groups (p = 0.001), with 12 individuals (41.38%) pre-MDT requiring further revision surgery compared with one individual (6.67%) post-MDT inception.

CONCLUSION

Our standardized multidisciplinary approach for periprosthetic knee and hip joint infection shows a significant reduction in failure rates following revision surgery. Following implementation of our MDT, our success rate in treating PJI is 96.55%, higher than what current literature suggests. We advocate the role of a specialist infection MDT in the management of patients with a PJI to allow an individualized patient-centred approach and care plan, thereby reducing postoperative complications and failure rates. Cite this article: Bone Jt Open 2021;2(7):509-514.

Effect of a multidisciplinary team on the treatment of hip and knee prosthetic joint infections: a single-centre study of 154 infections

BACKGROUND

A multidisciplinary team responsible for the management plan of prosthetic joint infections (PJI) was founded in January 2008. The aim of this study was to investigate whether a decrease in the number of surgeries and length of stay (LOS) was seen in the management of PJI with the aid of the multidisciplinary team.

METHODS

This retrospective cohort study consisted of a total of 154 postoperative PJIs from three time periods: 21 PJIs from 2005 to 2007 (Group 1), 65 PJIs from 2011 to 2013 (Group 2), and 68 PJIs from 2015 to 2016 (Group 3). Successful outcome was classified as the retention of the original implant or revised implant and no infection-related death.

RESULTS

The median number of operations decreased from 2.0 operations (Group 1) to 1.0 operation (Group 3) (p = .023), and the median LOS was shortened from 49.0 days (Group 1) to 17.0 days (Group 3) (p = .000). The number of PJIs treated with two-stage exchange decreased from 52.4% (11/21, Group 1) to 16.2% (11/68, Group 3) (p = .004). Simultaneously, debridement, antibiotics, and implant retention (DAIR) as primary surgical treatment increased from 42.9% (9/21, Group 1) to 89.7% (61/68, Group 3) (p = .000). The successful outcome of DAIR improved from 55.6% (5/9, Group 1) to 85.2% (52/61, Group 3) (p = .077).

CONCLUSIONS

Treatment of PJI in a specialized centre with the aid of a multidisciplinary team lead to fewer surgeries and reduced LOS. Successful outcome of DAIR improved over time.

Implementation of a multidisciplinary infections conference improves the treatment of spondylodiscitis

Establishing a multidisciplinary approach regarding the treatment of spondylodiscitis and analyzing its effect compared to a single discipline approach. 361 patients diagnosed with spondylodiscitis were included in this retrospective pre-post intervention study. The treatment strategy was either established by a single discipline approach (n = 149, year 2003–2011) or by a weekly multidisciplinary infections conference (n = 212, year 2013–2018) consisting of at least an orthopedic surgeon, medical microbiologist, infectious disease specialist and pathologist. Recorded data included the surgical and antibiotic strategy, complications leading to operative revision, recovered microorganisms, as well as the total length of hospital and intensive care unit stay. Compared to a single discipline approach, performing the multidisciplinary infections conference led to significant changes in anti-infective and surgical treatment strategies. Patients discussed in the conference showed significantly reduced days of total antibiotic treatment (66 ± 31 vs 104 ± 31, p < 0.001). Moreover, one stage procedures and open transpedicular screw placement were more frequently performed following multidisciplinary discussions, while there were less involved spinal segments in terms of internal fixation as well as an increased use of intervertebral cages instead of autologous bone graft (p < 0.001). Staphylococcus aureus and Staphylococcus epidermidis were the most frequently recovered organisms in both patient groups. No significant difference was found comparing inpatient complications between the two groups or the total in-hospital stay. Implementation of a weekly infections conference is an effective approach to introduce multidisciplinarity into spondylodiscitis management. These conferences significantly altered the treatment plan compared to a single discipline approach. Therefore, we highly recommend the implementation to optimize treatment modalities for patients.

Failure analysis of infection persistence after septic revision surgery: a checklist algorithm for risk factors in knee and hip arthroplasty

PURPOSE

Several studies describe risk factors for primary periprosthetic joint infection (PJI) and general treatment outcome factors like microbe spectrum or patient-specific risk factors. However, these general and patient dependent findings cannot solely explain all cases of infection persistence after a prior septic revision. This study analyzes possible specific and patient independent reasons for failure after revisions for PJI in knee and hip arthroplasty.

METHODS

In a prospective analysis all patients were included that were treated: (1) at our department, (2) with a two-stage exchange, (3) between 2013 and 2017, (4) due to an infection persistence after a previous revision for PJI. Possible reasons for infection persistence were identified using a checklist algorithm, based on international guidelines.

RESULTS

70 patients with infection persistence could be included (44 knee joints, 26 hip joints). The average age was 71 years, the CCI (Charlson Comorbidity Index) 2.8 and the ASA (American Society of Anesthesiologists) score 2.7. In 85% at least one possible reason for patient independent infection persistence could be identified analyzing the previous infection therapy: (1) 50% inadequate therapy concept (n = 35), (2) 33% inadequate surgical debridement (n = 23), (3) 30% inadequate antimicrobial therapy (n = 21), (4) 13% missed external bacterial primary focus (n = 9). After the individual failure analysis, all 70 patients were treated with a two-stage exchange in our department and in 94.9% infection freedom could be achieved (34.3 ± 10.9 months follow-up).

CONCLUSIONS

In the majority of failed revisions with subsequent infection persistence at least one possible patient independent failure cause could be identified. The entire previous therapy should be critically reviewed following failing revisions to optimize the outcome of septic revisions. By using a checklist algorithm, high rates of infection freedom were achieved.

The global state of clinical research and trends in periprosthetic joint infection: A bibliometric analysis

OBJECTIVES

The purpose of this study was to estimate the trends and state of research in periprosthetic joint infection (PJI).

METHODS

Publications on PJI published between 1998 and 2018 were searched in the Web of Science database and analyzed using bibliometrics. The Altmetric score and Research Interest score were combined to provide a weighted count. The scope of the Altmetric score includes >16 weighted composite scores from websites such as Twitter, Facebook, and YouTube, whereas the Research Interest score is calculated from information derived from ResearchGate.

RESULTS

Total of 3245 published documents were identified. The largest contribution was made by the United States, with the institution contributing most being the Rothman Institute. The most relative articles were published by the Journal of Arthroplasty, whereas the highest citation frequency journal was Clinical Orthopaedics and Related Research. There was a positive correlation between citation counts and Research Interest scores, while the Altmetric Attention score showed a negative value for highly cited articles.

CONCLUSIONS

Based on the current trends of globalization, there is a rising trend in publications on PJI, with the largest annual contributions made by the United States. The most influential contributors are researchers from the United States and Europe. Twitter is used as a platform to communicate knowledge by most PJI researchers. The most recent research has focused on the diagnosis and risk factors of PJI.

Twenty common errors in the diagnosis and treatment of periprosthetic joint infection

Background

Misconceptions and errors in the management of periprosthetic joint infection (PJI) can compromise the treatment success. The goal of this paper is to systematically describe twenty common mistakes in the diagnosis and management of PJI, to help surgeons avoid these pitfalls.

Materials and methods

Common diagnostic and treatment errors are described, analyzed and interpreted.

Results

Diagnostic errors include the use of serum inflammatory biomarkers (such as C-reactive protein) to rule out PJI, incomplete evaluation of joint aspirate, and suboptimal microbiological procedures (such as using swabs or collection of insufficient number of periprosthetic samples). Further errors are missing possible sources of distant infection in hematogenous PJI or overreliance on suboptimal diagnostic criteria which can hinder or delay the diagnosis of PJI or mislabel infections as aseptic failure. Insufficient surgical treatment or inadequate antibiotic treatment are further reasons for treatment failure and emergence of antimicrobial resistance. Finally, wrong surgical indication, both underdebridement and overdebridement or failure to individualize treatment can jeopardize surgical results.

Conclusion

Multidisciplinary teamwork with infectious disease specialists and microbiologists in collaboration with orthopedic surgeons have a synergistic effect on the management of PJI. An awareness of the possible pitfalls can improve diagnosis and treatment results.