Nephrotoxicity After the Treatment of Periprosthetic Joint Infection With Antibiotic-Loaded Cement Spacers

High Incidence of Acute Kidney Injury Following Antibiotic-Loaded Spacer Insertion for Periprosthetic Joint Infection: An Updated Review of the Literature

BACKGROUND

The use of antibiotic-impregnated cement during 2-stage revision arthroplasty for periprosthetic joint infection poses a risk of renal complications following spacer insertion. This systematic review aimed to investigate the rate of acute kidney injury (AKI) following antibiotic-loaded spacer insertion and to identify risk factors associated with this complication.

METHODS

A systematic review was performed using PubMed, Cochrane Central, and Scopus databases. All clinical studies that documented renal complications following antibiotic-loaded spacer insertion for periprosthetic knee (total knee arthroplasty [TKA]) or hip (total hip arthroplasty [THA]) infection were included. Articles that combined THA and TKA outcomes were also included and labeled "THA + TKA." Descriptive statistics were analyzed when data were available.

RESULTS

There were 24 studies (9 THA, 7 TKA, 8 THA + TKA) included. The mean incidences of spacer-related AKI across THA, TKA, and THA + TKA cohorts were 4.2 (range, 0 to 10%), 14 (range, 0 to 19%), and 27% (range, 0 to 35%), respectively. The most common patient-related risk factors for AKI were underlying chronic kidney disease or high baseline creatinine, low preoperative hemoglobin, and blood transfusion requirement. Spacer-related risk factors included high antibiotic dosage (>3.6 g/cement batch) and antibiotic type. While most recovered without complication, select patients required hemodialysis for acute management (2 THA, 18 THA + TKA) and/or developed chronic kidney disease (8 TKA, 8 THA).

CONCLUSION

The rate of AKI following spacer insertion was high and likely under-reported in the literature. Surgeons should be cognizant of this devastating complication and should closely monitor at-risk patients for AKI following antibiotic-loaded spacer insertion.

Utilization of Antibiotic Bone Cement in Spine Surgery: Pearls, Techniques, and Case Review

Vertebral osteomyelitis (VO) encompasses a spectrum of spinal infections ranging from isolated mild vertebral osteomyelitis to severe diffuse infection with associated epidural abscess and fracture. Although patients can often be treated with an initial course of intravenous antibiotics, surgery is sometimes required in patients with sepsis, spinal instability, neurological compromise, or failed medical treatment. Antibiotic bone cement (ABC) has been widely used in orthopedic extremity surgery for more than 150 years, both for prophylaxis and treatment of bacterial infection. However, relatively little literature exists regarding its utilization in spine surgery. This article describes ABC utilization in orthopedic surgery and explains the technique of ABC utilization in spine surgery. Surgeons can choose from multiple premixed ABCs with variable viscosities, setting times, and antibiotics or can mix in antibiotics to bone cements themselves. ABC can be used to fill large defects in the vertebral body or disc space or in some cases to coat instrumentation. Surgeons should be wary of complications such as ABC extravasation as well as an increased difficulty with revision. With a thorough understanding of the properties of the cement and the methods of delivery, ABC is a powerful adjunct in the treatment of spinal infections.

Association of Acute Kidney Injury With Antibiotic Loaded Cement Used for Treatment of Periprosthetic Joint Infection

BACKGROUND

Antibiotic-loaded bone cement (ALBC) is commonly used in the treatment of periprosthetic joint infections (PJIs) to increase the local concentration of antibiotic at the site of infection. Use of ALBC has been associated with rare instances of acute kidney injury (AKI) despite low systemic absorption of the nephrotoxic antibiotics; however, the incidence of AKI is unknown. The purpose of this study was to determine the incidence of and risk factors for AKI associated with ALBC.

METHODS

This single-site, retrospective cohort study compared 162 PJI patients who underwent Stage 1 revision to a spacer with ALBC to 115 PJI patients who underwent debridement, antibiotics, and implant retention (DAIR) without the use of ALBC. Both groups received similar systemic antibiotics postoperatively. Descriptive statistics and multivariable logistic regressions were used to analyze risk factors for AKI.

RESULTS

There was no statistically significant difference in the rate of AKI: 29 patients (17.9%) in the ALBC group and 17 (14.7%) in DAIR group developed AKI (odds ratio 1.43; 95% CI 0.70 to 2.93). There was a trend toward increased severity of AKI in the ALBC group. Chronic kidney disease, systemic vancomycin, and diuretic use were independent factors associated with the risk of AKI.

CONCLUSION

An AKI occurred in 17% of PJI patients receiving either a spacer with ALBC or a DAIR. The use of ALBC was not associated with a significant increased risk of AKI. However, the use of systemic vancomycin and diuretic use were independent predictors of AKI in this patient population.

Incidence, associated factors, and outcomes of acute kidney injury following placement of antibiotic bone cement spacers in two-stage exchange for periprosthetic joint infection: a comprehensive study

Background

Two-stage exchange with placement of antibiotic cement spacer (ACS) is the gold standard for the treatment of chronic periprosthetic joint infection (PJI), but it could cause a high prevalence of acute kidney injury (AKI). However, the results of the current evidence on this topic are too mixed to effectively guide clinical practice.

Methods

We retrospectively identified 340 chronic PJI patients who underwent the first-stage exchange with placement of ACS. The Kidney Disease Improving Global Outcomes guideline was used to define postoperative AKI. Multivariate logistic analysis was performed to determine the potential factors associated with AKI. Furthermore, a systematic review and meta-analysis on this topic were conducted to summarize the knowledge in the current literature further.

Results

In our cohort, the incidence of AKI following first-stage exchange was 12.1%. Older age (per 10 years, OR= 1.509) and preoperative hypoalbuminemia (OR= 3.593) were independent predictors for postoperative AKI. Eight AKI patients progressed to chronic kidney disease after 90 days. A meta-analysis including a total of 2525 PJI patients showed the incidence of AKI was 16.6%, and AKI requiring acute dialysis was 1.4%. Besides, host characteristics, poor baseline liver function, factors contributing to acute renal blood flow injury, and the use of nephrotoxic drugs may be associated with the development of AKI. However, only a few studies supported an association between antibiotic dose and AKI.

Conclusion

AKI occurs in approximately one out of every six PJI patients undergoing first-stage exchange. The pathogenesis of AKI is multifactorial, with hypoalbuminemia could be an overlooked associated factor. Although the need for acute dialysis is uncommon, the fact that some AKI patients will develop CKD still needs to be taken into consideration.

Selecting a high-dose antibiotic-laden cement knee spacer

Prosthetic joint infection [PJI] after total knee arthroplasty (TKA) remains a common and challenging problem for joint replacement surgeons and patients. Once the diagnosis of PJI has been made, patient goals and characteristics as well as the infection timeline dictate treatment. Most commonly, this involves a two-stage procedure with the removal of all implants, debridement, and placement of a static or dynamic antibiotic spacer. Static spacers are commonly indicated for older, less healthy patients that would benefit from soft tissue rest after initial debridement. Mobile spacers are typically used in younger, healthier patients to improve quality of life and reduce soft-tissue contractures during antibiotic spacer treatment. Spacers are highly customizable with regard to antibiotic choice, cement variety, and spacer design, each with reported advantages, drawbacks, and indications that will be covered in this article. While no spacer is superior to any other, the modern arthroplasty surgeon must be familiar with the available modalities to optimize treatment for each patient. Here we propose a treatment algorithm to assist surgeons in deciding on treatment for PJI after TKA.

Acute kidney injury in the context of staged revision arthroplasty and the use of antibiotic-laden cement spacers: a systematic review

BACKGROUND

The most common cause of revision arthroplasty is prosthetic joint infection (PJI). Chronic PJI is commonly treated with two-stage exchange arthroplasty involving the placement of antibiotic-laden cement spacers (ACS) in the first stage, often containing nephrotoxic antibiotics. These patients often have significant comorbidity burdens and have higher rates of acute kidney injury (AKI). This systematic review aims to assess the current literature to identify (1) AKI incidence, (2) associated risk factors, and (3) antibiotic concentration thresholds in ACS that increase AKI risk following first-stage revision arthroplasty.

METHODS

An electronic search was performed of the PubMed database of all studies involving patients undergoing ACS placement for chronic PJI. Studies assessing AKI rates and risk factors were screened by two authors independently. Data synthesis was performed when possible. Significant heterogeneity prevented meta-analysis.

RESULTS

Eight observational studies consisting of 540 knee PJIs and 943 hip PJIs met inclusion criteria. There were 309 (21%) cases involving AKI. The most commonly reported risk factors included perfusion-related factors (lower preoperative hemoglobin, transfusion requirement, or hypovolemia), older age, increased comorbidity burden, and nonsteroidal anti-inflammatory drug consumption. Only two studies found increased risk with greater ACS antibiotic concentration (> 4 g vancomycin and > 4.8 g tobramycin per spacer in one study, > 3.6 g of vancomycin per batch or > 3.6 g of aminoglycosides per batch in the other); however, these were reported from univariate analyses not accounting for other potential risk factors.

DISCUSSION

Patients undergoing ACS placement for chronic PJI are at an increased risk for AKI. Understanding the risk factors may lead to better multidisciplinary care and safer outcomes for chronic PJI patients.

LEVEL OF EVIDENCE III

Evidence for Local Antibiotics in the Prevention of Infection in Orthopaedic Trauma

Prevention of fracture-related infection (FRI) remains a substantial challenge in orthopaedic trauma care. There is evolving evidence to support the use of local antibiotics for both the prevention and treatment of musculoskeletal infection. Local antibiotics can achieve higher local tissue concentrations with a lower risk of systemic complications compared to intravenously administered antibiotics. These antibiotics may be administered in powder or liquid form without carrier, or if sustained release is desired, using a carrier. Polymethylmethacrylate (PMMA), ceramics, and hydrogels are examples of antibiotic carriers. Unlike PMMA, ceramics and hydrogels have the advantage of not requiring a second surgery for removal. The VANCO trial supported the use of powdered vancomycin in high-risk fracture cases for the reduction of Gram-positive infections; although, data is limited. Future studies will evaluate the use of aminoglycoside antibiotics to address Gram-negative infection prevention. While theoretical concerns exist with the use of local antibiotics, available studies suggest local antibiotics are safe with a low-risk of adverse effects.

High-Dose Antibiotic Cement Spacers Independently Increase the Risk of Acute Kidney Injury in Revision for Periprosthetic Joint Infection: A Prospective Randomized Controlled Clinical Trial

BACKGROUND

Standard treatment for periprosthetic joint infection (PJI) involves 2-stage exchange with placement of an antibiotic-impregnated cement spacer (ACS). Conflicting evidence exists on the role of ACS in development of acute kidney injury (AKI) after first-stage surgery. In this randomized clinical trial, we aimed to compare the incidence of AKI between the first-stage of a planned 2-stage exchange vs 1-stage exchange. This study design isolates the effect of the ACS in otherwise identical treatment groups.

METHODS

The primary outcome variable was AKI, defined as a creatinine ≥1.5 times baseline or an increase of ≥0.3 mg/dL. Risk factors for AKI were evaluated using bivariate statistical tests and multivariable logistic regression.

RESULTS

Patients who underwent the first stage of a planned 2-stage exchange were significantly more likely to develop AKI compared with the 1-stage exchange group (15 [22.7%] vs 4 [6.6%], P = .011). On multivariable regression analysis, ACS placement (odds ratio 7.48, 95% confidence limit 1.77-31.56) and chronic kidney disease (odds ratio 3.84, 95% confidence limit 1.22-12.08) were independent risk factors for AKI.

CONCLUSION

Our study provides evidence that high-dose antibiotic cement spacers for treatment of PJI are an independent risk factor for AKI. Therefore, efforts to minimize nephrotoxicity should be employed in revision for PJI when possible.

Does Time to Reimplantation After Explant for Prosthetic Joint Infection Influence the Likelihood of Successful Outcomes at 2 Years?

BACKGROUND

Consensus recommendations are lacking regarding appropriate timing of reimplantation following 2-stage resection arthroplasty for prosthetic joint infections (PJIs). We investigated whether the time from resection arthroplasty to reimplantation was associated with treatment outcome at 2 years.

METHODS

Retrospective cohort review was conducted for 101 patients undergoing resection arthroplasty with an antibiotic spacer for PJI at a single tertiary academic referral institution. Time from explantation and spacer placement to reimplantation was categorized into 3 groups: <12, 12-18, and >18 weeks. Baseline patient and treatment course characteristics across these groups were obtained. Multivariate binary logistic regression was used to characterize association between treatment failure and time to reimplantation, controlling for American Society of Anesthesiologists (ASA) score and prior revision surgery.

RESULTS

Time to reimplantation (TTR) >18 weeks demonstrated statistically significant increased odds of treatment failure, after controlling for ASA score and prior revision surgery (odds ratio 7.00, confidence interval 2.14-25.42, P = .002). After excluding patients requiring second spacer or Girdlestone prior to replant, this increased odds of failure remained (odds ratio 4.12, confidence interval 1.18-15.37, P = .029). TTR groups were similar with respect to demographics, except for ASA (2.96 for time to reimplantation >18 weeks vs 2.55 for time to reimplantation <12 weeks; P = .011). Patients with TTR >18 weeks were more likely to have an unplanned readmission during the spacer period (48%, 19%, and 6% for time to reimplantation >18, 12-18, and 0-12 weeks, respectively; P < .002).

CONCLUSION

Although decision regarding TTR is largely patient specific, surgeons should be aware that TTR >18 weeks may be associated with higher rates of treatment failure at 2 years.

Perioperative acute kidney injury and urine output in lower limb arthroplasties

BACKGROUND

This study aimed to evaluate the occurrence and perioperative risk factors of acute kidney injury (AKI) in primary elective hip and knee and emergency hip arthroplasty patients. We also aimed to assess the effect of urine output (UOP) as a diagnostic criterion in addition to serum creatinine (sCr) levels. We hypothesized that emergency arthroplasties are prone to AKI and that UOP is an underrated marker of AKI.

METHODS

This retrospective, register-based study assessed 731 patients who underwent primary elective knee or hip arthroplasty and 170 patients who underwent emergency hip arthroplasty at Oulu University Hospital, Finland, between January 2016 and February 2017.

RESULTS

Of the elective patients, 18 (2.5%) developed AKI. The 1-year mortality rate was 1.5% in elective patients without AKI and 11.1% in those with AKI (P = .038). Of the emergency patients, 24 (14.1%) developed AKI. The mortality rate was 16.4% and 37.5% in emergency patients without and with AKI, respectively (P = .024). In an AKI subgroup analysis of the combined elective and emergency patients, the mortality rate was 31.3% (n = 5) in the sCr group (n = 16), 23.5% (n = 4) in the UOP group (n = 17), and 22.2% (n = 2) in AKI patients who met both the sCr and UOP criteria (n = 9).

CONCLUSION

Emergency hip arthroplasty is associated with an increased risk of AKI. Since AKI increases mortality in both elective and emergency arthroplasty, perioperative oliguria should also be considered as a diagnostic criterion for AKI. Focusing solely on sCr may overlook many cases of AKI.

Renal Toxicity Associated With Resection and Spacer Insertion for Chronic Hip PJI

BACKGROUND

Two-stage exchange arthroplasty with high-dose antibiotic-loaded bone cement spacer and intravenous (IV) antibiotics is the most common method of managing infected total hip arthroplasties. However, the contemporary incidence, risk factors, and outcomes of acute kidney injuries (AKIs) in this cohort are unknown.

METHODS

We identified 227 patients treated with 256 antibiotic-loaded bone cement spacers after resection of an infected primary total hip arthroplasty between 2000 and 2017. Mean age was 65 years, mean body mass index was 30 mg/kg², 55% were men, and 16% had pre-existing chronic kidney disease (CKD). Spacers were in situ for a mean of 15 weeks, concomitantly associated with IV or oral antibiotics for a mean of 6 weeks. AKI was defined as a creatinine ≥1.5X baseline or ≥0.3 mg/dL. Mean follow-up was 8 years.

RESULTS

AKI occurred in 13 patients without pre-existing CKD (7%) vs 10 patients with CKD (28%; OR 5; P = .0001). None required acute dialysis. Postoperative fluid depletion (β = 0.31; P = .0001), ICU requirement (β = 0.40; P = .0001), and acute atrial fibrillation (β = 0.43; P = .0001) were independent predictors for AKI in patients without pre-existing CKD. Duration of in situ spacer, mean antibiotic dose in cement, use of amphotericin B, and type of IV antibiotics were not significant risk factors. At last follow-up, 8 AKIs progressed to CKD, with one receiving dialysis 7 years later.

CONCLUSION

AKIs occurred in 7% of patients with normal renal function, with 5-fold greater risk in those with CKD, and 4% did develop CKD. Importantly, causes of acute renal blood flow impairment were independent predictors for AKI.

LEVEL OF EVIDENCE

Level III, comparative study.

Total Femur Antibiotic Spacers: Effective Salvage for Complex Periprosthetic Joint Infections

BACKGROUND

A simultaneous periprosthetic joint infection (PJI) of an ipsilateral hip and knee arthroplasty is a challenging complication of lower extremity reconstructive surgery. We evaluated the use of total femur antibiotic-impregnated polymethylmethacrylate (PMMA) bone cement spacers in the staged treatment of such limb-threatening PJIs.

METHODS

Thirteen patients were treated with a total femur antibiotic spacer. The mean age at the time of spacer placement was 65 years. Nine patients had polymicrobial PJIs. All spacers incorporated vancomycin (3.0 g/40 g PMMA) and gentamicin (3.6 g/40 g PMMA), while 8 also included amphotericin (150 mg/40 g PMMA). Eleven spacers were biarticular. Twelve spacers were implanted through one longitudinal incision, while 8 of 12 reimplantations occurred through 2 smaller, separate hip and knee incisions. Mean follow-up after reimplantation was 3 years.

RESULTS

Twelve (92%) patients underwent reimplantation of a total femur prosthesis at a mean of 26 weeks. One patient died of medical complications 41 days after spacer placement. At latest follow-up, 3 patients had experienced PJI recurrence managed with irrigation and debridement. One required acetabular component revision for instability. All 12 reimplanted patients retained the total femur prosthesis with no amputations. Eleven (91%) were ambulatory, and 7 (58%) remained on suppressive antibiotics.

CONCLUSION

Total femur antibiotic spacers are a viable, but technically demanding, limb-salvage option for complex PJIs involving the ipsilateral hip and knee. In the largest series to date, there were no amputations and 75% of reimplanted patients remained infection-free. Radical debridement, antimicrobial diversity, prolonged spacer retention, and limiting recurrent soft tissue violation are potential tenets of success.

LEVEL OF EVIDENCE

IV.

Acute Kidney Injury When Treating Periprosthetic Joint Infections After Total Knee Arthroplasties with Antibiotic-Loaded Spacers: Incidence, Risks, and Outcomes

BACKGROUND

Two-stage exchange arthroplasty with a high-dose antibiotic-loaded bone cement (ALBC) spacer and intravenous or oral antibiotics is the most common method of managing a periprosthetic joint infection (PJI) after a total knee arthroplasty (TKA). However, little is known about the contemporary incidence, the risk factors, and the outcomes of acute kidney injuries (AKIs) in this cohort.

METHODS

We identified 424 patients who had been treated with 455 ALBC spacers after resection of a PJI following a primary TKA from 2000 to 2017. The mean age at resection was 67 years, the mean body mass index (BMI) was 33 kg/m2, 47% of the patients were women, and 15% had preexisting chronic kidney disease (CKD). The spacers (87% nonarticulating) contained a mean of 8 g of vancomycin and 9 g of an aminoglycoside per construct (in situ for a mean of 11 weeks). Eighty-six spacers also had amphotericin B (mean, 412 mg). All of the patients were concomitantly treated with systemic antibiotics for a mean of 6 weeks. An AKI was defined as a creatinine level of ≥1.5 times the baseline or an increase of ≥0.3 mg/dL within any 48-hour period. The mean follow-up was 6 years (range, 2 to 17 years).

RESULTS

Fifty-four AKIs occurred in 52 (14%) of the 359 patients without preexisting CKD versus 32 AKIs in 29 (45%) of the 65 patients with CKD (odds ratio [OR], 5; p = 0.0001); none required acute dialysis. Overall, when the vancomycin concentration or aminoglycoside concentration was >3.6 g/batch of cement, the risk of AKI increased (OR, 1.9 and 1.8, respectively; p = 0.02 for both). Hypertension (β = 0.17; p = 0.002), perioperative hypovolemia (β = 0.28; p = 0.0001), and acute atrial fibrillation (β = 0.13; p = 0.009) were independent predictors for AKI in patients without preexisting CKD. At the last follow-up, 8 patients who had sustained an AKI had progressed to CKD, 4 of whom received dialysis.

CONCLUSIONS

In our study, the largest series to date that we are aware of regarding this issue, AKI occurred in 14% of patients with normal renal function at baseline, and 2% developed CKD after undergoing a 2-stage exchange arthroplasty for a PJI after TKA. However, the risk of AKI was fivefold greater in those with preexisting CKD. The causes of acute renal blood flow impairment were independent predictors for AKI.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Intraosseous Regional Administration of Vancomycin in Primary Total Knee Arthroplasty Does Not Increase the Risk of Vancomycin-Associated Complications

BACKGROUND

Periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is a rare but major complication. Owing to an increasing antibiotic resistance in bacteria causing PJI, vancomycin has been investigated as a prophylactic agent. Intraosseous regional administration (IORA) of vancomycin achieves significantly higher local tissue concentrations than systemic administration. There are limited data on IORA of vancomycin with respect to vancomycin-associated complications.

METHODS

Single-surgeon retrospective review of primary TKA was performed between January 2015 and May 2019. All patients received 500 mg of IORA of vancomycin after tourniquet inflation and 3 × 1 g intravenous cefazolin in 24 hrs. Preoperative data collected included age, gender, body mass index, American Society of Anesthesiologists (ASA) score, diabetes, and chronic kidney disease (CKD). We documented in-hospital complications and complications requiring readmission within 12 months. Primary outcome measures were the incidence of acute kidney injury (AKI), 'red man syndrome' (RMS), and neutropenia. The secondary outcome measure was PJI incidence.

RESULTS

We identified 631 primary TKAs in 556 patients, of which 331 received IORA. The mean age was 67.7 ± 8.7 years, and 57.8% were women. CKD was prevalent in 17.2% of the cohort. AKI occurred in 25 (3.9%) cases. After controlling for covariates, CKD was the only significant predictor of AKI (odds ratio = 3.035, P = .023). RMS and neutropenia were not observed in this cohort. The 90-day PJI rate was 0%, and the 1-year PJI rate was 0.2%.

CONCLUSIONS

Low-dose IORA of vancomycin in addition to standard intravenous systemic cefazolin prophylaxis in TKA is safe without significant adverse effects of vancomycin such as AKI, RMS, or neutropenia.

Evaluation of Intra-Operative Topical Vancomycin and the Incidence of Acute Kidney Injury

Background: Intra-operative topical vancomycin (VAN) is a strategy used to prevent surgical site infections (SSI). Although evidence supporting efficacy in SSI prevention is evolving, data describing safety, specifically acute kidney injury (AKI), are limited. The purpose of this study was to determine AKI incidence in patients who received intra-operative topical VAN. Patients and Methods: This is a retrospective study of adult inpatient encounters in which topical VAN was administered intra-operatively as powder/paste, beads, rods/cement/spacers, or unspecified topical route from February to July 2018. Patients were excluded for AKI or renal replacement therapy (RRT) at baseline or ≤2 serum creatinine (SCr) values post-surgery. The primary outcome was AKI incidence after intra-operative topical VAN, defined as increase in SCr ≥50% or 0.5 mg/dL from baseline or RRT initiation. Secondary outcomes included analysis of AKI risk factors and SSI incidence. Acute kidney injury risk factors were analyzed using multivariable logistic regression. Results: Five hundred thirty-four patient encounters met study criteria. Powder/paste were the most common topical VAN formulations (44.8%) with median doses of 2,000 (range, 1,000-26,000) mg. Acute kidney injury incidence was 8.8%. Independent risk factors for AKI were higher Charlson comorbidity index (adjusted odds ratio [aOR], 1.20 [range, 1.06-1.36]), concomitant systemic VAN (aOR, 2.44 [range, 1.29-4.58]), and doubling of total topical VAN dose (aOR, 1.51 [range, 1.13-2.03]). Conclusions: The incidence of AKI with intra-operative topical VAN is comparable to reported rates as systemic VAN. Clinicians may consider total topical VAN dose and concomitant systemic VAN to limit AKI incidence with topical VAN use.

Acute Renal Failure After the First Stage of a 2-Stage Exchange for Periprosthetic Joint Infection

BACKGROUND

Two-stage exchange using antibiotic-loaded spacers is a common approach in treating periprosthetic joint infections. Acute kidney injury (AKIN) can be a systemic complication of this procedure. This study investigates the prevalence of AKIN and identifies potential risk factors.

METHODS

This is a single-center retrospective analysis of patients undergoing 2-stage exchange using a spacer in 285 patients treated between 2010 and 2017. Risk factors were evaluated using parametric and nonparametric analyses and a multivariate, binary logistic regression model.

RESULTS

Thirty-three percent of patients (95/285) developed an AKIN postoperatively. Twenty-four percent (23/95) of these patients had an acute on chronic kidney failure with a previously impaired renal function. In multivariate analysis, a higher age (hazard ratio [HR], 1.034; 95% confidence interval [CI], 1-1.068; P = .046) and a higher baseline creatinine level (HR, 1.94; 95% CI, 1.237-3.052; P = .004) were risk factors for AKIN. Treatment with vancomycin in the spacer or systemically was not associated with AKIN while a high vancomycin blood level (HR, 1.91; 95% CI, 0.913-3.992; P = .086) and fungal infections were (HR, 3.482; 95% CI, 0.968-12.521; P = .056). Furthermore, in univariate analysis, a higher median Charlson comorbidity index (4 vs 3, P = .007), a lower preoperative hemoglobin (10.9 vs 11.7 g/dL, P = .008), and a higher number of blood transfusions (1 vs 0, P = .004) were associated with AKIN.

CONCLUSION

AKIN is common in patients undergoing 2-stage exchange. Associated patient factors, particularly in patients with chronic renal dysfunction, should be optimized. The general use of glycopeptide antibiotics was no risk factor for AKIN.

Progress of antibiotic-loaded bone cement in joint arthroplasty

Bone cement, consisting of polymethyl methacrylate, is a bioinert material used for prothesis fixation in joint arthroplasty. To treat orthopedic infections, such as periprosthetic joint infection, antibiotic-loaded bone cement (ALBC) was introduced into clinical practice. Recent studies have revealed the limitations of the antibacterial effect of ALBC. Moreover, with the increase in high infection risk patients and highly resistant microbes, more researches and modification of ALBC are required. This paper reviewed latest findings about ALBC for most popular and destructive pathogens, summarized the influence of antibiotic kind, drug dosage, application method, and environment towards characteristic of ALBC. Subsequently, new cement additives and clinical applications of ALBC in joint arthroplasty were also discussed.

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

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

Antibiotic Cement Spacers for Infected Total Knee Arthroplasties

Periprosthetic infection remains a frequent complication after total knee arthroplasty. The most common treatment is a two-stage procedure involving removal of all implants and cement, thorough débridement, insertion of some type of antibiotic spacer, and a course of antibiotic therapy of varying lengths. After some interval, and presumed eradication of the infection, new arthroplasty components are implanted in the second procedure. These knee spacers may be static or mobile spacers, with the latter presumably providing improved function for the patient and greater ease of surgical reimplantation. Numerous types of antibiotic cement spacers are available, including premolded cement components, surgical molds for intraoperative spacer fabrication, and the use of new metal and polyethylene knee components; all these are implanted with surgeon-prepared high-dose antibiotic cement. As there are advantages and disadvantages of both static and the various mobile spacers, surgeons should be familiar with several techniques. There is inconclusive data on the superiority of any antibiotic spacer. Both mechanical complications and postoperative renal failure may be associated with high-dose antibiotic cement spacers.

The Effects of Amoxicillin, Cefazolin, and Gentamicin Antibiotics on the Antioxidant System in Mouse Heart Tissues

BACKGROUND

Free radicals lead to destruction in various organs of the organism. The improper use of antibiotics increases the formation of free radicals and causes oxidative stress.

OBJECTIVE

In this study, it was aimed to determine the effects of gentamicin, amoxicillin, and cefazolin antibiotics on the mouse heart.

METHODS

20 male mice were divided into 4 groups (1st control, 2nd amoxicillin, 3rd cefazolin, and 4th gentamicin groups). The mice in the experimental groups were administered antibiotics intraperitoneally at a dose of 100 mg / kg for 6 days. The control group received normal saline in the same way. The gene expression levels and enzyme activities of SOD, CAT, GPx, GR, GST, and G6PD antioxidant enzymes were investigated.

RESULTS

GSH levels decreased in both the amoxicillin and cefazolin groups, while GR, CAT, and SOD enzyme activities increased. In the amoxicillin group, Gr, Gst, Cat, and Sod gene expression levels increased.

CONCLUSION

As a result, it was concluded that amoxicillin and cefazolin caused oxidative stress in the heart, however, gentamicin did not cause any effects.

What Determines the Type and Dose of Antibiotic That Is Needed to Be Added to the Cement Spacer in Patients With Infected Total Ankle Arthroplasty (TAA)?

RECOMMENDATION

We recommend tailoring the antibiotic in cement spacers to the infecting organism if it has been identified, as is typically done in total knee and hip arthroplasty. Otherwise, broad-spectrum antibiotics may be utilized. Medical comorbidities should always be considered, especially with regard to renal function and allergy profile. A thermostable antibiotic should be added to cement.

LEVEL OF EVIDENCE

Consensus.

DELEGATE VOTE

Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Comparative Study of Antibiotic Elution Profiles From Alternative Formulations of Polymethylmethacrylate Bone Cement

BACKGROUND

Polymethylmethacrylate (PMMA) bone cement is commonly used in orthopedic surgery for implant fixation and local antibiotic delivery following surgical debridement. The incidence of nephrotoxicity necessitates the balance of antiinfective properties with the potential for toxicity. Thus, understanding antibiotic elution characteristics of different PMMA formulations is essential. We sought to address this by assessing elution of vancomycin, daptomycin, and tobramycin from Palacos LV (Palacos), Stryker Surgical Simplex P (Simplex), BIOMET Cobalt HV (Cobalt), and Zimmer Biomet Bone Cement R (Zimmer) radiopaque bone cements.

METHODS

Antibiotics were mixed with each cement formulation, and molds were used to produce beads of cement. Beads were incubated in phosphate-buffered saline at 37°C, and antibiotic elution was measured daily for 10 days with vancomycin and 5 days with daptomycin and tobramycin. Active antibiotic was quantified by serial dilution and comparison to the minimum inhibitory concentration.

RESULTS

The elution profiles of Simplex were significantly lower than all other cements with all antibiotics (P < .00093). Palacos exhibited a significantly higher vancomycin elution profile than all other cements (P < .00001). The difference in daptomycin elution profiles for Cobalt and Palacos was not significant (P > .43), but both were significantly higher than Zimmer (P < .0006).

CONCLUSION

Overall, Stryker Surgical Simplex P exhibits a significantly lower elution profile than all other cements tested. In general, Palacos LV exhibits an increased elution profile compared with other cements. This elution information may assist the surgeon in choosing different cement formulations for the local delivery of antibiotics.

Antibiotic-Loaded Bone Cement in Primary Total Knee Arthroplasty: Utilization Patterns and Impact on Complications Using a National Database

BACKGROUND

The routine usage of antibiotic-loaded bone cement (ALBC) in primary total knee arthroplasty (TKA) is controversial. Its effectiveness in reducing infection risk remains unclear while high-dose antibiotics can lead to multiple adverse effects. The purpose of this population-based study is to evaluate utilization patterns of ALBC in primary TKA and its impact on clinical outcomes.

METHODS

This retrospective cohort study used data from the nationwide Premier Healthcare claims database (2006-2016). Multivariable models estimated associations between ALBC use and early postoperative infection, kidney injury, allergic reaction, hospital readmission, cost, and length of stay.

RESULTS

ALBC was used in 27.2% of all primary TKAs (N = 1,184,270). Usage increased from 17.3% to 30.2% in 2006-2010, then plateaued. Study covariates differed minimally between groups, suggesting nonselective ALBC use. Utilization was lower in rural (21.4%) and higher in large (>500 beds; 29.4%) hospitals. After adjusting for relevant covariates, ALBC use was associated with significantly decreased odds for early postoperative infection (odds ratio, 0.89; confidence interval, 0.83-0.96) and increased odds for acute kidney injury (odds ratio, 1.06; confidence interval, 1.02-1.11).

CONCLUSION

With utilization rates of around 30%, we found that ALBC reduced odds for early postoperative infection and increased odds for kidney injury. Strong consideration should be given for selective use of ALBC in primary TKA.

New Innovations in the Treatment of PJI and Biofilms-Clinical and Preclinical Topics

PURPOSE OF REVIEW

Periprosthetic joint infection (PJI) is a devastating complication after total joint replacement. A main source for antibiotic tolerance and treatment failure is bacterial production of biofilm-a resilient barrier against antibiotics, immune system, and mechanical debridement. The purpose of this review is to explore some novel approaches to treat PJI and biofilm-related infections.

RECENT FINDINGS

Innovative treatment strategies of bacterial and biofilm infections revolve around (a) augmenting current therapies, such as improving the delivery and efficiency of conventional antibiotics and enhancing the efficacy of antiseptics and (b) administrating completely new therapeutic modalities, such as using immunotherapy, nanoparticles, lytic bacteriophages, photodynamic therapy, novel antibiotics, and antimicrobial peptides. Several promising treatment strategies for PJI are available to be tested further. The next requirement for most of the novel treatments is reproducing their effects in clinically representative animal models of PJI against clinical isolates of relevant bacteria.