Prosthetic joint infections in the elderly

Periprosthetic joint infection of the hip

Aims

The number of revision arthroplasties being performed in the elderly is expected to rise, including revision for infection. The primary aim of this study was to measure the treatment success rate for octogenarians undergoing revision total hip arthroplasty (THA) for periprosthetic joint infection (PJI) compared to a younger cohort. Secondary outcomes were complications and mortality.

Methods

Patients undergoing one- or two-stage revision of a primary THA for PJI between January 2008 and January 2021 were identified. Age, sex, BMI, American Society of Anesthesiologists grade, Charlson Comorbidity Index (CCI), McPherson systemic host grade, and causative organism were collated for all patients. PJI was classified as 'confirmed', 'likely', or 'unlikely' according to the 2021 European Bone and Joint Infection Society criteria. Primary outcomes were complications, reoperation, re-revision, and successful treatment of PJI. A total of 37 patients aged 80 years or older and 120 patients aged under 80 years were identified. The octogenarian group had a significantly lower BMI and significantly higher CCI and McPherson systemic host grades compared to the younger cohort.

Results

The majority of patients were planned to undergo two-stage revision, although a significantly higher proportion of the octogenarians did not proceed with the second stage (38.7% (n = 12) vs 14.8% (n = 16); p = 0.003). Although there was some evidence of a lower complication rate in the younger cohort, this did not reach statistical significance (p = 0.065). No significant difference in reoperation (21.6% (n = 8) vs 25.0% (n = 30); p = 0.675) or re-revision rate (8.1% (n = 3) vs 16.7% (n = 20); p = 0.288) was identified between the groups. There was no difference in treatment success between groups (octogenarian 89.2% (n = 33) vs control 82.5% (n = 99); p = 0.444).

Conclusion

When compared to a younger cohort, octogenarians did not show a significant difference in complication, re-revision, or treatment success rates. However, given they are less likely to be eligible to proceed with second stage revision, consideration should be given to either single-stage revision or use of an articulated spacer to maximize functional outcomes.

Outpatient Parenteral Antibiotic Therapy in Older Adults

Outpatient parenteral antimicrobial therapy (OPAT) for older adults is a complex process that involves multiple stakeholders and care coordination, but it is a useful and patient-centered tool with opportunities for the treatment of complicated infections, improved patient satisfaction, and reduced health-care costs. Older age should not be an exclusion for OPAT but rather prompt the OPAT provider to thoroughly evaluate candidacy and safety. Amid the on-going COVID-19 pandemic, innovations in OPAT are needed to shepherd OPAT care into a more patient-centered, thoughtful practice, whereas minimizing harm to older patients from unnecessary health-care exposure and thus health-care associated infections.

Prosthetic Joint Infections of the Hip and Knee Among the Elderly: A Retrospective Study

BACKGROUND

As the population ages and demand for total joint arthroplasty increases, rates of periprosthetic joint infection are expected to increase in the geriatric population. Studies comparing prevalence of risk factors, etiology, management, and mortality of prosthetic joint infection in older patients are lacking.

METHODS

We compared clinical characteristics, management, and mortality of patients <75 vs ≥75 years of age with first prosthetic joint infection of the hip or knee admitted to a tertiary medical center between September 2017 and December 2019.

RESULTS

Ninety-eight patients (<75 years of age [n = 63]; ≥75 years of age (n = 35) were studied. Groups were similar in terms of etiology, culture-directed therapy, antibiotic suppression, and length of stay. There was no difference in surgical management, performed in almost 97% of cases in both groups. Arrhythmia and heart failure were more prevalent in those aged ≥75 years. Readmission related to prosthetic joint infection occurred less often in older individuals (P = .005). Deaths within 1 year of diagnosis were rare (n = 4; 4.1%), occurring in older patients and resulting mostly from sepsis.

CONCLUSION

In our single-center study, patients with first prosthetic joint infection had similar management, regardless of age. We identified cardiac history as one of the host factors for prosthetic joint infection most seen in patients ≥75 years of age. Although deaths were rare, 1-year mortality was higher in patients aged ≥75. Prospective, multicenter studies are needed to explore risk factors and management strategies of prosthetic joint infection among elderly populations.

Nanomaterial-Based Antimicrobial Coating for Biomedical Implants: New Age Solution for Biofilm-Associated Infections

Recently, the upsurge in hospital-acquired diseases has put global health at risk. Biomedical implants being the primary source of contamination, the development of biomedical implants with antimicrobial coatings has attracted the attention of a large group of researchers from around the globe. Bacteria develops biofilms on the surface of implants, making it challenging to eradicate them with the standard approach of administering antibiotics. A further issue of current concern is the fast resurgence of resistance to conventional antibiotics. As nanotechnology continues to advance, various types of nanomaterials have been created, including 2D nanoparticles and metal and metal oxide nanoparticles with antimicrobial properties. Researchers from all over the world are using these materials as a coating agent for biomedical implants to create an antimicrobial environment. This comprehensive and contemporary review summarizes various metals, metal oxide nanoparticles, 2D nanomaterials, and their composites that have been used or may be used in the future as an antimicrobial coating agent for biomedical implants, as well as their succinct mode of action to combat biofilm-associated infection and diseases.

Effectiveness of Extended Infection Control Measures on Methicillin-Resistant Staphylococcus aureus Infection Among Orthopaedic Patients

Purpose

The purpose of the study was to find the effectiveness of Extended Infection Control Measures (EICM) in reducing the rate of methicillin-resistant Staphylococcus aureus (MRSA) infection among orthopaedic surgery patients.

Methods

The study adopted a quasi-experimental design and was conducted in the orthopaedic units of a tertiary care hospital. This study recruited 168 orthopaedic patients and 154 healthcare professionals (HCPs). EICM included hand hygiene, decolonizing the patients and HCPS, staff education, feedback of surveillance data, treatment of high-risk and MRSA-infected patients, having separate equipment for MRSA-infected patients, and appropriate cleaning of patient's unit.

Results

The EICM effectively reduced MRSA infection from 21.2 to 6% (p < 0.001). It also resulted in improving the knowledge of HCPs in the prevention and management of MRSA infection (p < 0.001), and all colonized HCPs were successfully (100%) decolonized.

Conclusion

EICM is a promising intervention to combat MRSA infection among orthopaedic wards. Hence, it can be executed in orthopaedic wards, thereby improving the treatment quality and reducing the infection-related consequences.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-022-00713-5.

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.

Chitosan and Hydroxyapatite Based Biomaterials to Circumvent Periprosthetic Joint Infections

Every year, worldwide, millions of people suffering from joint pain undergo joint replacement. For most patients, joint arthroplasty reduces pain and improve function, though a small fraction will experience implant failure. One of the main reasons includes prosthetic joint infection (PJI), involving the prosthesis and adjacent tissues. Few microorganisms (MO) are required to inoculate the implant, resulting in the formation of a biofilm on its surface. Standard treatment includes not only removal of the infected prosthesis but also the elimination of necrotic bone fragments, local and/or systemic administration of antibiotics, and revision arthroplasty with a new prosthesis, immediately after the infection is cleared. Therefore, an alternative to the conventional therapeutics would be the incorporation of natural antimicrobial compounds into the prosthesis. Chitosan (Ch) is a potential valuable biomaterial presenting properties such as biocompatibility, biodegradability, low immunogenicity, wound healing ability, antimicrobial activity, and anti-inflammatory potential. Regarding its antimicrobial activity, Gram-negative and Gram-positive bacteria, as well as fungi are highly susceptible to chitosan. Calcium phosphate (CaP)-based materials are commonly utilized in orthopedic and dentistry for their excellent biocompatibility and bioactivity, particularly in the establishment of cohesive bone bonding that yields effective and rapid osteointegration. At present, the majority of CaP-based materials are synthetic, which conducts to the depletion of the natural resources of phosphorous in the future due to the extensive use of phosphate. CaP in the form of hydroxyapatite (HAp) may be extracted from natural sources as fish bones or scales, which are by-products of the fish food industry. Thus, this review aims to enlighten the fundamental characteristics of Ch and HAp biomaterials which makes them attractive to PJI prevention and bone regeneration, summarizing relevant studies with these biomaterials to the field.

Serine Protease Inhibitors-New Molecules for Modification of Polymeric Biomaterials

Three serine protease inhibitors (AEBSF, soy inhibitor, α₁-antitrypsin) were covalently immobilized on the surface of three polymer prostheses with the optimized method. The immobilization efficiency ranged from 11 to 51%, depending on the chosen inhibitor and biomaterial. The highest activity for all inhibitors was observed in the case of immobilization on the surface of the polyester Uni-Graft prosthesis, and the preparations obtained showed high stability in the environment with different pH and temperature values. Modification of the Uni-Graft prosthesis surface with the synthetic AEBSF inhibitor and human α₁-antitrypsin inhibited the adhesion and multiplication of Staphylococcus aureus subs. aureus ATCC^® 25923^TM and Candida albicans from the collection of the Department of Genetics and Microbiology, UMCS. Optical profilometry analysis indicated that, after the immobilization process on the surface of AEBSF-modified Uni-Graft prostheses, there were more structures with a high number of protrusions, while the introduction of modifications with a protein inhibitor led to the smoothing of their surface.

Clinical Experience with Tigecycline in the Treatment of Prosthetic Joint Infections

Abstract. Purpose: The purpose of this study was to examine the use of tigecycline in the treatment of prosthetic joint infection (PJI).Methods: This is a retrospective review performed from 2008 to 2017, examining adult patients with PJI at a tertiary medical referral center who received tigecycline for 75% or greater of the treatment course. Failure was defined as need to return to the operating room for an infectious complication or persistent drainage from the joint.Results: A total of 37 patients met inclusion criteria. The median age was 65 years, and 65% of patients were female. The most common reasons for tigecycline use were culture negative infection, polymicrobial infection, and renal failure, but other reasons included antimicrobial allergies and resistant organisms. The mean duration of tigecycline therapy was 40 days (range 28-52 days). Treatment success was documented in 16 cases (43%).Conclusions: Tigecycline is a glycylcycline approved for treatment of a variety of infections including skin and soft tissue infections, but little is known about its use in the treatment of PJI. We found that tigecycline is well-tolerated for prolonged durations. Our success rate was 43%, but the majority of patients in this study had complicated infectious surgical histories and had received prior prolonged courses of antimicrobial therapy which likely affected treatment outcome. We concluded that tigecycline should be reserved as an alternative when other antimicrobials for PJI have been exhausted. More studies are needed to assess tigecycline's use in the treatment of PJI.

Pharmacotherapy options and drug development in managing periprosthetic joint infections in the elderly

INTRODUCTION

Prosthetic joint infections are an increasingly important problem among patients undergoing arthroplasty procedures, and are associated with significant morbidity, reduced quality of life, substantial healthcare costs, and even mortality. Arthroplasties are performed with increasing frequency in elderly patients, who present specific problems.

AREAS COVERED

Surgical therapy is clearly influenced by the clinical status of the patient, which in some case can contraindicate surgery. Antibiotic selection is also affected by comorbidities and underlying diseases, which in some cases reduce therapeutic options. The authors review this together with the changes in pharmacokinetics and pharmacodynamics in the elderly population and the prospects for future research on prevention and treatment.

EXPERT OPINION

The management of PJI in the elderly makes multidisciplinary teams even more mandatory than in other patients, because the complexity of these patients. A frequent scenario is that in which surgery is contraindicated with long-term suppressive treatment as the only available option. Treating physicians must consider the presence of multiple comorbidities, interactions with other treatments and secondary effects when choosing antibiotic treatment. An in-depth knowledge of the alterations in pharmacokinetics and pharmacodynamics in elderly patients is key for a proper treatment selection.

Is There an Association Between Smoking Status and Prosthetic Joint Infection After Primary Total Joint Arthroplasty?

BACKGROUND

Recent reports highlighted the association between smoking and higher risk of postsurgical infections. The aim was to compare the incidence of prosthetic joint infection after primary total joint arthroplasty (TJA) according to smoking status.

METHODS

A prospective hospital registry-based cohort study was performed including all primary knee and hip TJAs performed between March 1996 and December 2013. Smoking status preoperatively was classified into never, former, and current smoker. Incidence rates and hazard ratios (HRs) for prosthetic joint infection according to smoking status were assessed within the first year and beyond.

RESULTS

We included 8559 primary TJAs (mean age 69.5 years), and median follow-up was 67 months. There were 5722 never, 1315 former, and 1522 current smokers. Incidence rates of infection within the first year for never, former, and current smokers were, respectively, 4.7, 10.1, and 10.9 cases/1000 person-years, comparing ever vs never smokers, crude and adjusted HRs were 2.35 (95% confidence interval [CI] 1.39-3.98) and 1.8 (95% CI 1.04-3.2). Beyond the first year, crude and adjusted HRs were 1.37 (95% CI 0.78-2.39) and 1.12 (95% CI 0.61-2.04).

CONCLUSION

Smoking increased the infection risk about 1.8 times after primary hip or knee TJA in both current and former smokers. Beyond the first year, the infection risk was similar to never smokers.

Antibacterial Prophylaxis for Surgical Site Infection in the Elderly: Practical Application

Surgical site infections are among the most common healthcare-associated infections and are linked with increased length of hospitalization, re-admission, mortality and significant financial burden. Risk factors for the occurrence of surgical site infections include variables related to the surgical procedure as well as host factors. Increasing age is associated with the occurrence of surgical site infections. The aim of this review is to give an update on the antibiotic prophylaxis for surgical site infection in elderly people. We focused on specific issues and practical applications, such as the importance of targeting the antimicrobial agent to the susceptibility pattern of colonizing flora in selected cases and the need for dosage modifications.

Concordance between the old and new diagnostic criteria for periprosthetic joint infection

PURPOSE

There is no uniform definition for periprosthetic joint infection (PJI). New diagnostic criteria were formulated in an international consensus meeting in 2013 and adopted by Centers for Disease Control (CDC) in 2016. The purpose of this study is to compare the new diagnostic criteria with the old CDC criteria from the year 1992.

METHODS

Patients, who had been treated for PJI of hip or knee from 2002 to 2014, in a tertiary care hospital, were identified. Patient records were reviewed by a physician to identify PJI cases fulfilling the old or new CDC criteria and to record data concerning the diagnostic criteria. PJI frequencies were calculated for the two diagnostic criteria sets. Cross tables were formed to compare the concordance between the two sets of criteria in the whole material and in different clinical subgroups.

RESULTS

Overall 405 cases fulfilling either or both sets of criteria for PJI were identified. 73 (18%) of the patients fulfilled only the old criteria, whereas only one (0.2%) fulfilled only the new criteria. Of the patients who did not fulfil the new criteria, in 39 (53%) the diagnosis was based solely on the clinician's opinion.

CONCLUSIONS

The number of PJIs is notably lower when using the new, more objective, diagnostic criteria. A large portion of the cases diagnosed as infection by the treating clinician, did not fulfil the new diagnostic criteria.

Clinical characteristics and outcomes of septic bursitis

PURPOSE

Limited data guide practice in evaluation and treatment of septic bursitis. We aimed to characterize clinical characteristics, microbiology, and outcomes of patients with septic bursitis stratified by bursal involvement, presence of trauma, and management type.

METHODS

We conducted a retrospective cohort study of adult patients admitted to a single center from 1998 to 2015 with culture-proven olecranon and patellar septic bursitis. Baseline characteristics, clinical features, microbial profiles, operative interventions, hospitalization lengths, and 60-day readmission rates were determined. Patients were stratified by bursitis site, presence or absence of trauma, and operative or non-operative management.

RESULTS

Of 44 cases of septic bursitis, patients with olecranon and patellar bursitis were similar with respect to age, male predominance, and frequency of bursal trauma; patients managed operatively were younger (p = 0.05). Clinical features at presentation and comorbidities were similar despite bursitis site, history of trauma, or management. The most common organism isolated from bursal fluid was Staphylococcus aureus. Patients managed operatively were discharged to rehabilitation less frequently (p = 0.04).

CONCLUSIONS

This study of septic bursitis is among the largest reported. We were unable to identify presenting clinical features that differentiated patients treated surgically from those treated conservatively. There was no clear relationship between preceding trauma or bursitis site and clinical course, management, or outcomes. Patients with bursitis treated surgically were younger. Additional study is needed to identify patients who would benefit from early surgical intervention for septic bursitis.

Pyogenic arthritis, pyoderma gangrenosum, and acne (PAPA) syndrome: differential diagnosis of septic arthritis by regular detection of exceedingly high synovial cell counts

Pyogenic arthritis, pyoderma gangrenosum and acne syndrome was diagnosed in a 42-year-old patient, after an unusual persistency of high synovial cell counts had been noticed. Clinical peculiarities and problems with diagnosing septic versus non-septic arthritis are discussed.

Osteogenic and bactericidal surfaces from hydrothermal titania nanowires on titanium substrates

Nanotopographical cues on Ti have been shown to elicit different cell responses such as cell differentiation and selective growth. Bone remodelling is a constant process requiring specific cues for optimal bone growth and implant fixation. Moreover, biofilm formation and the resulting infection on surgical implants is a major issue. Our aim is to identify nanopatterns on Ti surfaces that would be optimal for both bone remodelling and for reducing risk of bacterial infection. Primary human osteoblast/osteoclast co-cultures were seeded onto Ti substrates with TiO₂ nanowires grown under alkaline conditions at 240 °C for different times (2, 2.5 or 3 h). Cell growth and behaviour was assessed by scanning electron microscopy (SEM), immunofluorescence microscopy, histochemistry and quantitative RT-PCR methods. Bacterial colonisation of the nanowire surfaces was also assessed by confocal microscopy and SEM. From the three surfaces tested the 2 h nanowire surface supported osteoblast and to a lesser extent osteoclast growth and differentiation. At the same time bacterial viability was reduced. Hence the 2 h surface provided optimal bone remodeling in vitro conditions while reducing infection risk, making it a favourable candidate for future implant surfaces.

Comparison of livestock-associated and health care-associated MRSA-genes, virulence, and resistance

Livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) may colonize and infect humans with close contact to pigs. We compared phenotypic and genotypic differences in resistance and virulence of LA-MRSA isolates from farms and farmers with hospital-acquired methicillin-resistant S. aureus (HA-MRSA) and assessed carriage rates. Samples from pigs (n=330), occupationally exposed personnel (n=63), the farm environment (n=134), and hospital patients (n=220) were obtained. Approximately 50% (166/330) of pigs were MRSA positive. All LA-MRSA were resistant to tetracycline, compared to only 8% of HA-MRSA (P<0.001). In contrast, HA-MRSA isolates showed significantly higher resistance rates to quinolones (81% versus 7%; P<0.001). All strains isolated from occupationally exposed personnel (61.9%; 39/63) belonged to CC398. HA-MRSA isolates were diversely distributed, with predominance of CC5 (62.7%). Human strains carried significantly more virulence genes than porcine strains, especially exotoxins (P<0.001) and immune-evasion cluster genes (P<0.001). There were significant differences in resistance patterns and recognized genotypic virulence loci between LA-MRSA and HA-MRSA.

Silver Nanocoating Technology in the Prevention of Prosthetic Joint Infection

Prosthetic joint infection (PJI) is a feared complication of total joint arthroplasty associated with increased morbidity and mortality. There is a growing body of evidence that bacterial colonization and biofilm formation are critical pathogenic events in PJI. Thus, the choice of biomaterials for implanted prostheses and their surface modifications may significantly influence the development of PJI. Currently, silver nanoparticle (AgNP) technology is receiving much interest in the field of orthopaedics for its antimicrobial properties and a strong anti-biofilm potential. The great advantage of AgNP surface modification is a minimal release of active substances into the surrounding tissue and a long period of effectiveness. As a result, a controlled release of AgNPs could ensure antibacterial protection throughout the life of the implant. Moreover, the antibacterial effect of AgNPs may be strengthened in combination with conventional antibiotics and other antimicrobial agents. Here, our main attention is devoted to general guidelines for the design of antibacterial biomaterials protected by AgNPs, its benefits, side effects and future perspectives in PJI prevention.