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Zvi YS, Follett LY, Reddy H, Seref-Ferlengez Z, Weiser MC, Kamara E. Non-inferiority and Safety of Increased Povidone-Iodine (Betadine) Concentration for Irrigation Following Primary Total Joint Arthroplasty (TJA). Cureus 2024; 16:e53453. [PMID: 38435161 PMCID: PMC10909383 DOI: 10.7759/cureus.53453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2024] [Indexed: 03/05/2024] Open
Abstract
Introduction Diluted Betadine (Purdue Pharma, Stamford, Conn) irrigation following primary total joint arthroplasty (pTJA) may reduce the risk of periprosthetic joint infection (PJI). A recent in vitro study found a minimal inhibitory concentration (MIC) of 0.63% Povidone-iodine (Betadine) for several bacterial isolates. This study reports outcomes of patients undergoing TJA using 0.54% Betadine irrigation compared to a historical cohort using 0.3% Betadine irrigation. Methods A retrospective chart review of patients who underwent pTJA from September 2017 to December 2020. 0.3% Betadine was used in a historical cohort and 0.54% Betadine in the experimental group. Patient demographics, intra-operative data, all-cause revision, and infection data were collected for the three-month post-operative period. Outcome frequencies between groups were compared using Fisher-Exact tests. Results Six hundred sixty-one patients underwent pTJA: 308 total knee arthroplasty (TKA), and 353 total hip arthroplasty (THA). 0.3% Betadine group had seven (3.1%) revisions: five (2.2%) underwent a revision for non-infectious reasons, and two (0.9%) for PJI. 0.54% Betadine group had 11 (2.5%) revisions: nine (2.1%) underwent revision for non-infectious reasons, two (0.4%) for PJI. No significant difference was found for rates of all-cause revision or infection between groups. No adverse intra-operative events occurred with the higher Betadine concentration. Conclusion This study demonstrated no difference in rates of all-cause revision or PJI when using 0.3% Betadine versus 0.54% Betadine for irrigation following pTJA. No adverse intraoperative events occurred with 0.54% Betadine irrigation. Given recent in vitro data supporting increased Betadine MIC, our results showed safety and non-inferiority with respect to three-month post-operative complication rates. Further investigation through a large powered randomized controlled study is needed to determine the optimal Betadine irrigation concentration for PJI prevention is required.
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Affiliation(s)
- Yoav S Zvi
- Orthopedic Surgery, Montefiore Medical Center, Bronx, USA
| | - Lisa Y Follett
- Orthopedic Surgery, Montefiore Medical Center, Bronx, USA
| | - Hemant Reddy
- Orthopedic Surgery, Montefiore Medical Center, Bronx, USA
| | | | | | - Eli Kamara
- Orthopedic Surgery, Montefiore Medical Center, Bronx, USA
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Wattam AR, Bowers N, Brettin T, Conrad N, Cucinell C, Davis JJ, Dickerman AW, Dietrich EM, Kenyon RW, Machi D, Mao C, Nguyen M, Olson RD, Overbeek R, Parrello B, Pusch GD, Shukla M, Stevens RL, Vonstein V, Warren AS. Comparative Genomic Analysis of Bacterial Data in BV-BRC: An Example Exploring Antimicrobial Resistance. Methods Mol Biol 2024; 2802:547-571. [PMID: 38819571 DOI: 10.1007/978-1-0716-3838-5_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
As genomic and related data continue to expand, research biologists are often hampered by the computational hurdles required to analyze their data. The National Institute of Allergy and Infectious Diseases (NIAID) established the Bioinformatics Resource Centers (BRC) to assist researchers with their analysis of genome sequence and other omics-related data. Recently, the PAThosystems Resource Integration Center (PATRIC), the Influenza Research Database (IRD), and the Virus Pathogen Database and Analysis Resource (ViPR) BRCs merged to form the Bacterial and Viral Bioinformatics Resource Center (BV-BRC) at https://www.bv-brc.org/ . The combined BV-BRC leverages the functionality of the original resources for bacterial and viral research communities with a unified data model, enhanced web-based visualization and analysis tools, and bioinformatics services. Here we demonstrate how antimicrobial resistance data can be analyzed in the new resource.
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Affiliation(s)
- Alice R Wattam
- Biocomplexity Institute, University of Virginia, Charlottesville, VA, USA.
| | - Nicole Bowers
- Consortium for Advanced Science and Engineering, University of Chicago, Chicago, IL, USA
- Division of Data Science and Learning, Argonne National Laboratory, Argonne, IL, USA
| | - Thomas Brettin
- Consortium for Advanced Science and Engineering, University of Chicago, Chicago, IL, USA
- Computing, Environment and Life Sciences, Argonne National Laboratory, Argonne, IL, USA
| | - Neal Conrad
- Consortium for Advanced Science and Engineering, University of Chicago, Chicago, IL, USA
- Division of Data Science and Learning, Argonne National Laboratory, Argonne, IL, USA
| | - Clark Cucinell
- Biocomplexity Institute, University of Virginia, Charlottesville, VA, USA
| | - James J Davis
- Consortium for Advanced Science and Engineering, University of Chicago, Chicago, IL, USA
- Division of Data Science and Learning, Argonne National Laboratory, Argonne, IL, USA
| | - Allan W Dickerman
- Biocomplexity Institute, University of Virginia, Charlottesville, VA, USA
| | - Emily M Dietrich
- Consortium for Advanced Science and Engineering, University of Chicago, Chicago, IL, USA
- Division of Data Science and Learning, Argonne National Laboratory, Argonne, IL, USA
| | - Ronald W Kenyon
- Biocomplexity Institute, University of Virginia, Charlottesville, VA, USA
| | - Dustin Machi
- Biocomplexity Institute, University of Virginia, Charlottesville, VA, USA
| | - Chunhong Mao
- Biocomplexity Institute, University of Virginia, Charlottesville, VA, USA
| | - Marcus Nguyen
- Consortium for Advanced Science and Engineering, University of Chicago, Chicago, IL, USA
- Division of Data Science and Learning, Argonne National Laboratory, Argonne, IL, USA
| | - Robert D Olson
- Consortium for Advanced Science and Engineering, University of Chicago, Chicago, IL, USA
- Division of Data Science and Learning, Argonne National Laboratory, Argonne, IL, USA
| | - Ross Overbeek
- Consortium for Advanced Science and Engineering, University of Chicago, Chicago, IL, USA
- Fellowship for Interpretation of Genomes, Burr Ridge, IL, USA
| | - Bruce Parrello
- Consortium for Advanced Science and Engineering, University of Chicago, Chicago, IL, USA
- Fellowship for Interpretation of Genomes, Burr Ridge, IL, USA
| | - Gordon D Pusch
- Fellowship for Interpretation of Genomes, Burr Ridge, IL, USA
| | - Maulik Shukla
- Consortium for Advanced Science and Engineering, University of Chicago, Chicago, IL, USA
- Division of Data Science and Learning, Argonne National Laboratory, Argonne, IL, USA
| | - Rick L Stevens
- Department of Computer Science, University of Chicago, Chicago, IL, USA
| | | | - Andrew S Warren
- Biocomplexity Institute, University of Virginia, Charlottesville, VA, USA
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Ebrahimzadeh MH, Safdari MR, Moradi A, Rastaghi S, Daliri M. How effective is diluted povidone-iodine in preventing periprosthetic joint infection in total joint arthroplasty (TJA)? An updated systematic review and meta-analysis. BMC Musculoskelet Disord 2023; 24:416. [PMID: 37231378 DOI: 10.1186/s12891-023-06548-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 05/18/2023] [Indexed: 05/27/2023] Open
Abstract
PURPOSE Periprosthetic joint infection (PJI) is a serious complication with total joint arthroplasty (TJA), that necessitates reoperation. Pre-closure irrigation with dilute povidone-iodine (PI) is among the preventive measures, but its efficiency is still controversial. As a result, the focus of this systematic review and meta-analysis is on the effect of dilute PI wound irrigation in the prevention of PJI following TJA. METHODS We systematically reviewed and analyzed articles that compared PI with other agents in terms of PJI rate after TJA, searching Medline, Scopus, Web of science, and Cochrane databases. A number of 13 papers including 63,950 patients in total, were finally considered in qualitative and quantitative assessments. We have also further assessed review articles. RESULTS In comparison with normal saline (NS), PI reduced post-operative infection rate (OR: 0.44; CI 95%: 0.34-0.56). However, there was no difference between PI and chlorhexidine (CHG) (OR: 1.61; CI 95%: 0.83-3.09)) or undetermined comparators (OR: 1.08; CI 95%: 0.67-1.76). CONCLUSION PI irrigation seems an efficient preventive measure for post-operative PJI and would seem to be the most feasible for TJA protocol.
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Affiliation(s)
- Mohammad-H Ebrahimzadeh
- Orthopedics Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad-R Safdari
- Orthopedics Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Surgery, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Ali Moradi
- Orthopedics Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sedighe Rastaghi
- Department of Biostatistics, School of Public Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahla Daliri
- Orthopedics Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.
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Parker DM, Koch JA, Gish CG, Brothers KM, Li W, Gilbertie J, Rowe SE, Conlon BP, Byrapogu VKC, Urish KL. Hydrogen Peroxide, Povidone-Iodine and Chlorhexidine Fail to Eradicate Staphylococcus aureus Biofilm from Infected Implant Materials. Life (Basel) 2023; 13:1230. [PMID: 37374013 DOI: 10.3390/life13061230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/18/2023] [Accepted: 05/18/2023] [Indexed: 06/29/2023] Open
Abstract
Hydrogen peroxide, povidone-iodine, and chlorhexidine are antiseptics that are commonly added to irrigants to either prevent or treat infection. There are little clinical data available that demonstrate efficacy of adding antiseptics to irrigants in the treatment of periprosthetic joint infection after biofilm establishment. The objective of the study was to assess the bactericidal activity of the antiseptics on S. aureus planktonic and biofilm. For planktonic irrigation, S. aureus was exposed to different concentrations of antiseptics. S. aureus biofilm was developed by submerging a Kirschner wire into normalized bacteria and allowing it to grow for forty-eight hours. The Kirschner wire was then treated with irrigation solutions and plated for CFU analysis. Hydrogen peroxide, povidone-iodine, and chlorhexidine were bactericidal against planktonic bacteria with over a 3 log reduction (p < 0.0001). Unlike cefazolin, the antiseptics were not bactericidal (less than 3 log reduction) against biofilm bacteria but did have a statistical reduction in biofilm as compared to the initial time point (p < 0.0001). As compared to cefazolin treatment alone, the addition of hydrogen peroxide or povidone-iodine to cefazolin treatment only additionally reduced the biofilm burden by less than 1 log. The antiseptics demonstrated bactericidal properties with planktonic S. aureus; however, when used to irrigate S. aureus biofilms, these antiseptics were unable to decrease biofilm mass below a 3 log reduction, suggesting that S. aureus biofilm has a tolerance to antiseptics. This information should be considered when considering antibiotic tolerance in established S. aureus biofilm treatment.
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Affiliation(s)
- Dana M Parker
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - John A Koch
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Charles G Gish
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Kimberly M Brothers
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - William Li
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Jessica Gilbertie
- Center for One Health Research, Edward Via College of Osteopathic Medicine, Blacksburg, VA 24060, USA
| | - Sarah E Rowe
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Brian P Conlon
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Marsico Lung Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Venkata K C Byrapogu
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15261, USA
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Prevention Techniques Have Had Minimal Impact on the Population Rate of Prosthetic Joint Infection for Primary Total Hip and Knee Arthroplasty: A National Database Study. J Arthroplasty 2023; 38:1131-1140. [PMID: 36858132 DOI: 10.1016/j.arth.2023.02.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Several studies over the years have offered modalities that may greatly decrease the rate of periprosthetic joint infection when implemented. As a result, one would expect a drastic decrease in infection rate among the implementing population with its widespread use. The purpose of this study was to assess whether there exists a decrease in infection rate over time, after accounting for available confounding variables, within a large national database. METHODS A large national database from 2005 to 2019 was queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). In total, 221,416 THAs and 354,049 TKAs were performed over the study period. Differences in 30-day infection rate were assessed with time and available preoperative risk factors using multinominal logistic regressions. RESULTS Rate of infection overall trended downward for both THA and TKA. After accounting for confounding variables, odds of THA infection marginally decreased over time (odds ratio 0.968 [0.952-0.985], P < .0001), while the odds of a TKA infection marginally increased with time (odds ratio 1.037 [1.020-1.054], P < .0001). CONCLUSION Individual peer-reviewed publications have presented infection control modalities demonstrating dramatic decreases in infection rate while analysis at a population level shows almost no changes in infection rate over a 15-year time period. This study supports continued investigation for influential modalities in preventing periprosthetic joint infection and care in patient selection for primary hip and knee arthroplasty.
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Tran P, Kopel J, Luth K, Dong H, Dev A, Mehta D, Mitchell K, Moeller KW, Moeller CD, Reid T. The in vitro efficacy of betadine antiseptic solution and colloidal silver gel combination in inhibiting the growth of bacterial biofilms. Am J Infect Control 2023; 51:23-28. [PMID: 35439543 DOI: 10.1016/j.ajic.2022.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Betadine (Povidone-Iodine) solution is a topically applied antiseptic, which has been used routinely used in wound care and general surgery to prevent skin and wound infections. However, several studies have documented the ineffectiveness of betadine. Other topical antimicrobial dressings, including those that contain silver, have been used in the management of infected wounds. The present study was undertaken to determine if the combination of 5% betadine solution and silver colloidal gel (Ag-gel) is more effective than either substance alone in inhibiting the growth gram-negative and gram-positive bacteria. METHODS The effectiveness of 5% betadine solution and Ag-gel as anti-microbial agents were assessed using both colony forming unit (CFU) assay and confocal laser scanning microscopy (CLSM). RESULTS Ag-gel showed complete inhibition on all the bacteria species examined except the Klebsiella pneumoniae clinical isolate (CL) strain while 5% betadine concentrations did not completely kill any of the tested bacteria. In contrast, K. pneumoniae was completely eliminated in the presence of both 5% betadine solution and Ag-gel together. The CLSM showed similar findings to the CFU results examining the 5% betadine solution and Ag-gel combination. CONCLUSIONS This study demonstrated that while the individual treatments using either 5% betadine solution and Ag-gel alone were infective antimicrobial agents, the combination of 5% betadine solution and Ag-gel was superior at eliminating all tested bacteria, including K. pneumoniae CL.
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Affiliation(s)
- Phat Tran
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Jonathan Kopel
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Keaton Luth
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Huy Dong
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Ameesh Dev
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | | | - Kelly Mitchell
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | | | | | - Ted Reid
- Texas Tech University Health Sciences Center, Lubbock, TX, USA.
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Hammond EN, Kates AE, Putman-Buehler N, Watson L, Godfrey JJ, Brys N, Deblois C, Steinberger AJ, Cox MS, Skarlupka JH, Haleem A, Bentz ML, Suen G, Safdar N. A quality improvement study on the relationship between intranasal povidone-iodine and anesthesia and the nasal microbiota of surgery patients. PLoS One 2022; 17:e0278699. [PMID: 36490265 PMCID: PMC9733847 DOI: 10.1371/journal.pone.0278699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION The composition of the nasal microbiota in surgical patients in the context of general anesthesia and nasal povidone-iodine decolonization is unknown. The purpose of this quality improvement study was to determine: (i) if general anesthesia is associated with changes in the nasal microbiota of surgery patients and (ii) if preoperative intranasal povidone-iodine decolonization is associated with changes in the nasal microbiota of surgery patients. MATERIALS AND METHODS One hundred and fifty-one ambulatory patients presenting for surgery were enrolled in a quality improvement study by convenience sampling. Pre- and post-surgery nasal samples were collected from patients in the no intranasal decolonization group (control group, n = 54). Pre-decolonization nasal samples were collected from the preoperative intranasal povidone-iodine decolonization group (povidone-iodine group, n = 97). Intranasal povidone-iodine was administered immediately prior to surgery and continued for 20 minutes before patients proceeded for surgery. Post-nasal samples were then collected. General anesthesia was administered to both groups. DNA from the samples was extracted for 16S rRNA sequencing on an Illumina MiSeq. RESULTS In the control group, there was no evidence of change in bacterial diversity between pre- and post-surgery samples. In the povidone-iodine group, nasal bacterial diversity was greater in post-surgery, relative to pre-surgery (Shannon's Diversity Index (P = 0.038), Chao's richness estimate (P = 0.02) and Inverse Simpson index (P = 0.027). Among all the genera, only the relative abundance of the genus Staphylococcus trended towards a decrease in patients after application (FDR adjusted P = 0.06). Abundant genera common to both povidone-iodine and control groups included Staphylococcus, Bradyrhizobium, Corynebacterium, Dolosigranulum, Lactobacillus, and Moraxella. CONCLUSIONS We found general anesthesia was not associated with changes in the nasal microbiota. Povidone-iodine treatment was associated with nasal microbial diversity and decreased abundance of Staphylococcus. Future studies should examine the nasal microbiota structure and function longitudinally in surgical patients receiving intranasal povidone-iodine.
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Affiliation(s)
- Eric N. Hammond
- Institute for Clinical and Translational Research, University of Wisconsin-Madison, Madison, WI, United States of America
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
| | - Ashley E. Kates
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
- William S. Middleton Memorial Veterans Hospital, Madison, WI, United States of America
| | - Nathan Putman-Buehler
- Department of Biochemistry, College of Agricultural and Life Sciences, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Lauren Watson
- SSM Health, St. Mary’s Hospital, Madison, WI, United States of America
| | - Jared J. Godfrey
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
- William S. Middleton Memorial Veterans Hospital, Madison, WI, United States of America
| | - Nicole Brys
- Waisman Center, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Courtney Deblois
- Department of Bacteriology, University of Wisconsin-Madison, Madison, WI, United States of America
- Microbiology Doctoral Training Program, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Andrew J. Steinberger
- Department of Bacteriology, University of Wisconsin-Madison, Madison, WI, United States of America
- Microbiology Doctoral Training Program, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Madison S. Cox
- Department of Bacteriology, University of Wisconsin-Madison, Madison, WI, United States of America
- Microbiology Doctoral Training Program, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Joseph H. Skarlupka
- Department of Bacteriology, University of Wisconsin-Madison, Madison, WI, United States of America
- Microbiology Doctoral Training Program, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Ambar Haleem
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
| | - Michael L. Bentz
- Division of Plastic and Reconstructive Surgery and Urology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
| | - Garret Suen
- Department of Bacteriology, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Nasia Safdar
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
- William S. Middleton Memorial Veterans Hospital, Madison, WI, United States of America
- * E-mail:
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"Recommendations for periprosthetic joint infections (PJI) prevention: the European Knee Associates (EKA)-International Committee American Association of Hip and Knee Surgeons (AAHKS)-Arthroplasty Society in Asia (ASIA) survey of members". Knee Surg Sports Traumatol Arthrosc 2022; 30:3932-3943. [PMID: 34518895 DOI: 10.1007/s00167-021-06742-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/02/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE Periprosthetic joint infections (PJIs) represent a devastating consequence of total joint arthroplasty. The European Knee Associates (EKA), the American Association of Hip and Knee Surgeons (AAHKS) International Committee, and the Arthroplasty Society in Asia (ASIA) board members were interested in quantifying differences in arthroplasty surgeons' use of various PJI prevention measures to provide clinical recommendations to reduce PJI incidence. METHODS A prospective Microsoft Forms online survey was distributed among EKA, AAHKS International Committee, and ASIA members and their affiliated arthroplasty surgeons. The survey consisted of 20 single and multiple response questions focused on PJI prevention strategies at three perioperative periods: preoperatively, intraoperatively, and postoperatively. RESULTS Three hundred and ninety-four arthroplasty surgeons from 6 different continents completed the survey. Preoperative: (A) PJI Risk Stratification: 40.6% routinely set thresholds (e.g., BMI, HgbA1C) to be met to qualify for surgery, 36.5% only review past medical history; 9.1% use machine learning to personalize PJI risk; (B) BMI limit: 36% no limit; 15.4% BMI < 35; 30.9% BMI < 40; 17.2% BMI < 45; (C) Nutritional status: 55.3% do not screen; among those who screen their patients (44.7%), albumin is the single most used marker (86.3%); (D) Hyperglycemia/Diabetes: 83.3% check this comorbidity; 88.1% use HgbA1C as single best screening test; (E) MRSA nasal colonization: 63.7% do not test; 28.9% test all patients; 7.4% test selectively. Intraoperative: (A) Antibiotic prophylaxis in high-risk patients: 43.4% use single antibiotic for 24 h; 21.3% use double antibiotic for 24 h; 14.2% use single/double antibiotic for 7 days postoperatively; (B) Skin-cleansing: 68.7% at home (45.6% chlorhexidine sponge; 11.9% clippers); (C) Intraoperative skin disinfection: 46.9% single chlorhexidine; 25% double chlorhexidine-povidone-iodine;15.4% single povidone-iodine; (D) Tranexamic acid (TXA) to reduce bleeding/SSI: 96% yes (51% double IV dose, 35.2% single IV dose, 23.6% intra-articular injection); (E) Surgical suction drain: 52% do not use drains; 19.7% use a drain < 24 h; (F) Intra-articular lavage: 64.9% use only saline; 28.1% use dilute povidone-iodine; (G) Antibiotic local delivery to prevent PJI: 82.4% use antibiotic-added cement. Postoperative: (A) Routine monitoring of PJI serologic markers: 42% only in symptomatic patients; 34.2% do not; 20.8% in all patients; (B) Serologic markers to rule in/out PJI: 95.9% CRP; 71% SEDRATE; 60.6% WBC; (C) Synovial fluid test to rule in/out PJI: 79.6% culture/sensitivity; 69.5% WBC count; 31.4% CRP. CONCLUSIONS This survey demonstrated that notable differences still exist in the application of PJI preventive measures across different geographic areas: Optimizing the patient preoperatively and applying multimodal intraoperative strategies represent newer, clinically relevant steps in the effort to reduce the burden of PJI. More uniform guidelines still need to be produced from international scientific societies in order facilitate a more comprehensive approach to this devastating complication. LEVEL OF EVIDENCE IV.
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Tillet F, Bochatey E, Pérez Alamino L, Lopreite FA. Lavado con povidona yodada diluida en el reemplazo articular de cadera y rodilla para prevenir infecciones: estudio retrospectivo comparativo. REVISTA DE LA ASOCIACIÓN ARGENTINA DE ORTOPEDIA Y TRAUMATOLOGÍA 2022. [DOI: 10.15417/issn.1852-7434.2022.87.5.1530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Introducción: Una de las medidas profilácticas para disminuir la incidencia de infecciones periprotésicas es el lavado con povidona yodada diluida, un agente con acción bactericida contra distintos microorganismos. El propósito de este estudio fue evaluar la incidencia de infecciones periprotésicas dentro de los primeros 90 días, en pacientes a quienes se les realizó un lavado con povidona yodada luego de implantar los componentes protésicos y antes del cierre de la herida.
Materiales y Métodos: Se llevó a cabo un análisis retrospectivo comparativo de pacientes sometidos a artroplastias primarias de cadera y rodilla por artrosis y se comparó la incidencia de infecciones periprotésicas dentro de los primeros 90 días posoperatorios, entre pacientes que fueron operados antes de la introducción del lavado con povidona yodada y luego con su uso rutinario.
Resultados: Se realizaron 643 (47,60%) reemplazos de rodilla y 708 (52,40%) reemplazos de cadera. Al comparar la incidencia de infecciones periprotésicas entre ambos grupos, no se observaron diferencias estadísticamente significativas (0,92% vs. 0,21%; p = 0,11). Sin embargo, se incrementó el riesgo de infección en los primeros 90 días posteriores a la cirugía (OR = 4,5; IC95% 0,56-36,19) cuando no se utilizóla solución.
Conclusiones: El riesgo de desarrollar infecciones periprotésicas se incrementó 4,5 veces al realizar una artroplastia sin irrigación con povidona yodada diluida. Sin embargo, no se pudo demostrar que esto fuese estadísticamente significativo.
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Garbrecht E, Packard B, Nguyen PAH, Elghazali NA, Salas C, Hill DA, Canavan HE, Decker M. Ex Vivo Toxicity of Commonly Used Topical Antiseptics and Antibiotics on Human Chondrocytes. Orthopedics 2022; 45:e263-e268. [PMID: 35485887 DOI: 10.3928/01477447-20220425-06] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Topical povidone-iodine, chlorhexidine, bacitracin, and vancomycin are commonly used antiseptic and antimicrobial agents to reduce risk and treat surgical site infections in numerous orthopedic procedures. Chondrocytes potentially may be exposed to these agents during operative procedures. The impact of these topical agents on chondrocyte viability is unclear. The goal of this study is to determine human chondrocyte viability ex vivo after exposure to commonly used concentrations of these topical antiseptic and antimicrobial agents. Human osteochondral plugs were harvested from the knee joint of a human decedent within 36 hours of death. Individual human osteochondral plugs were exposed to normal saline as a control; a range of concentrations of povidone-iodine (0.25%, 0.5%, and 1%), chlorhexidine (0.01% and 0.5%), and bacitracin (10,000 units/L, 50,000 units/L, and 100,000 units/L) for 1-minute lavage; or a 48-hour soak in vancomycin (0.16 mg/mL, 0.4 mg/mL, and 1.0 mg/mL) with nutrient media. Chondrocyte viability was evaluated with a live/dead viability assay at 0, 2, 4, and 6 days after exposure to bacitracin at 0, 3, and 6 days). Control subjects showed greater than 70% viability at all time points. Povidone-iodine, 0.5% chlorhexidine, and vancomycin showed significant cytotoxicity, with viability dropping to less than 40% by day 6. Chondrocytes exposed to 0.01% chlorhexidine maintained viability. Chondrocytes exposed to bacitracin showed viability until day 3, when there was a large drop in viability. Commonly used topical concentrations of povidone-iodine, vancomycin, and bacitracin are toxic to human chondrocytes ex vivo. A low concentration of chlorhexidine appears safe. Caution should be used when articular cartilage may be exposed to these agents during surgery. [Orthopedics. 2022;45(5):e263-e268.].
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Caid M, Valk J, Danoff J. Irrigation Solutions in Total Joint Arthroplasty. Spartan Med Res J 2022; 7:37502. [PMID: 36128028 PMCID: PMC9448655 DOI: 10.51894/001c.37502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Despite advancements in the field of adult reconstruction, prosthetic joint infection (PJI) remains a common and devastating complication of total joint arthroplasty. Eradication of these infections can often prove difficult, and they remain a source of considerable morbidity and mortality. This clinical review paper will focus on some of the more commonly used irrigation solutions; povidone-iodine (PI), chlorhexidine (CHG), acetic acid (AA), hydrogen peroxide (HP), antibiotic irrigations, taurolidine, and polyhexanide-betaine (PB). SUMMARY OF THE EVIDENCE Significant research has been performed on the prevention of PJI, including use of intraoperative joint irrigation solutions. Several solutions have been theorized to aid in infection prevention, but no evidence-based practice guidelines in this area of orthopaedics have been established. There is a paucity of prospective randomized control trials to compare the efficacy of these joint irrigation solutions. CONCLUSIONS The authors present a review regarding seven major categories of commonly used intraoperative joint irrigation solutions. The current literature fails to demonstrate a clear consensus for a preferred solution and concentration for povidone-iodine, chlorhexidine, hydrogen peroxide, acetic acid, antibiotic irrigations, taurolidine, and polyhexanide-betaine. Prospective, randomized control trials directly comparing these different irrigation solutions are needed.
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Hill DL, Pinger C, Noland EL, Morton K, Hunt AMA, Pensler E, Cantu S, Attar PS, Siddiqi A. A novel activated-zinc antiseptic solution effective against MRSA and Pseudomonas aeruginosa: a pig model. J Wound Care 2022; 31:S41-S50. [PMID: 35797249 DOI: 10.12968/jowc.2022.31.sup7.s41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the antimicrobial efficacy of a novel activated zinc solution against meticillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa after one hour, and to evaluate any untoward effect of the solution on local wound tissue at 24 hours after solution exposure in a pig wound model. METHOD A pathogen-free, commercially raised, Yorkshire-cross female pig was acquired 12 days prior to the procedure. Within one week prior to the procedure, a small loopful of test bacteria, Pseudomonas aeruginosa (pig-isolate) and MRSA (ATCC-6538), were streaked and cultured on a non-selective agar. Full-thickness wounds (n=24) were created and evenly divided into three groups: control wounds (exposed to bacteria but untreated, n=8); wounds treated with Compound 1 (n=8), and wounds treated with Compound 2 (n=8). All wounds were dressed and monitored for one hour and 24 hours. RESULTS After one hour, the wounds treated with Compound 1 and Compound 2 had a mean recoverable total bacteria of 2.8 log colony forming units (CFUs) and 3.5 logCFUs, respectively. After one hour, the wounds treated with Compound 1 and Compound 2 had a mean recoverable MRSA of 2.3 logCFUs and 1.6 logCFUs, respectively (p=0.009). After one hour, the wounds treated with Compound 1 and Compound 2 had a mean recoverable Pseudomonas aeruginosa of 0.3 logCFUs and 0.0 logCFUs, respectively (p=0.000). After 24 hours of exposure to Compound 1 and Compound 2, there was no statistically significant increased necrosis (p=0.12, p=0.31, respectively) or neutrophilic infiltrate (Compound 2, p=0.12) when compared with control wounds. CONCLUSION The novel activated-zinc compound used in this study demonstrated a 99.5-99.9% reduction in total bacteria, a 99.9-99.98% reduction in MRSA, and 100% eradication of Pseudomonas aeruginosa one hour after exposure. This novel solution may provide another significant tool to treat and/or prevent wound infections.
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Affiliation(s)
- Derek L Hill
- Michigan State University College of Osteopathic Medicine Hill Orthopedics, US
| | - Cody Pinger
- Institute for Quantitative Health Science and Engineering Michigan State University, US
| | - Erica L Noland
- Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine, Michigan State University, US
| | - Kevin Morton
- Ascension Macomb-Oakland, Michigan State University College of Osteopathic Medicine, US
| | | | | | | | | | - Ahmed Siddiqi
- Cleveland Clinic Foundation, Orthopaedic and Rheumatologic Institute, Cleveland, OH, US
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Lin HH, Chou PH, Ma HH, Chang YW, Wang ST, Chang MC. Efficacy of Povidone Iodine Solution in the Prevention of Surgical Site Infections in Minimally Invasive Instrumented Spinal Fusion Surgery. Global Spine J 2022; 12:1058-1065. [PMID: 33272055 PMCID: PMC9210233 DOI: 10.1177/2192568220975385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
STUDY DESIGN A retrospective case-controlled study. OBJECTIVES To evaluate overall infection rate and adverse event after harvesting bone graft soaking and surgical wound irrigation by povidone iodine solution (PVI) in the minimally invasive instrumented spinal fusion surgery. In order to reduce the rate of surgical site infection in spinal surgery, surgical wound irrigation by povidone iodine solution has been well-established. However, the efficacy of autologous bone graft soaking by PVI has not been evaluated before. METHODS This is a retrospective cohort study. 120 patients were enrolled in the PVI group and compared with 124 patients in the historical cohort. In the PVI group, the harvesting autologous bone graft was soaking and the surgical wound was also irrigated by diluted PVI solution. The outcome measures were overall infection rate, superficial wound infection and deep infection. In addition, the delayed union of the fusion mass was also evaluated through the radiograph evaluation. RESULTS Both groups shared similar patient demographics instead of body mass index. The use of PVI solution had decreased the overall infection rate (0% versus 4.03%, p = 0.026) and deep infection rate (0% versus 3.23%, p = 0.047). In addition, there was no delayed bone healing in the PVI group after autologous bone graft soaking. CONCLUSIONS In this study, we conclude that harvested autologous bone graft after PVI soaking in spinal fusion surgery can decrease the incidence of deep infection.
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Affiliation(s)
- Hsi-Hsien Lin
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei,National Yang-Ming University, School of Medicine, Taipei
| | - Po-Hsin Chou
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei,National Yang-Ming University, School of Medicine, Taipei
| | - Hsuan-Hsiao Ma
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei,National Yang-Ming University, School of Medicine, Taipei
| | - Yu-Wei Chang
- National Yang-Ming University, School of Medicine, Taipei
| | - Shih-Tien Wang
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei,National Yang-Ming University, School of Medicine, Taipei
| | - Ming-Chau Chang
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei,National Yang-Ming University, School of Medicine, Taipei,Ming-Chau Chang, Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, No. 201, Section. 2, Shi-pai Road, Taipei.
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Bashyal RK, Mathew M, Bowen E, James GA, Stulberg SD. A Novel Irrigant to Eliminate Planktonic Bacteria and Eradicate Biofilm Superstructure With Persistent Effect During Total Hip Arthroplasty. J Arthroplasty 2022; 37:S647-S652. [PMID: 35210150 DOI: 10.1016/j.arth.2022.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/03/2022] [Accepted: 01/20/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Numerous studies have examined the use of topical and irrigation-related adjuvants to decrease the risk of periprosthetic joint infection (PJI) after total hip arthroplasty. Many issues related to their use remain to be investigated. These include cost, antibiotic stewardship, bactericidal effect on planktonic bacteria, host cytotoxicity, necessity to irrigate/dilute potentially cytotoxic agents after their application, and impact on biofilm. METHODS Bacterial strains of microorganisms were grown in optimal medium. After the growth phase, the organisms were exposed to the novel irrigation solution (XPerience) or phosphate buffer solution (PBS) for 5 minutes before a neutralizing broth was added. The colony-forming units per milliliter and the log reduction in colony-forming units in the treated sample vs the control were then determined. Subsequently, biofilms of microorganisms were grown on hydroxyapatite-coated glass slides. Each slide was then exposed to irrigation solutions for various contact times. Biofilm quantification was performed and the log10 density of each organism was obtained. RESULTS In vitro testing of the irrigant demonstrated 6-log reductions in planktonic bacteria in 5 minutes, and 4-log to 8-log reductions in biofilms. Laboratory tissue testing has demonstrated minimal cytotoxic effects to host tissue allowing for solution to remain in contact with the host without need for subsequent irrigation, creating a barrier to biofilm for up to 5 hours after its application. CONCLUSION This novel irrigant demonstrates high efficacy against both planktonic bacteria and bacterial biofilms in laboratory testing. Large series in vivo data are necessary to further establish its efficacy in reducing primary and recurrent surgical site infections.
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Affiliation(s)
- Ravi K Bashyal
- NorthShore University Health System, NorthShore Orthopaedic & Spine Institute, Skokie, IL
| | - Matt Mathew
- NorthShore University Health System, NorthShore Orthopaedic & Spine Institute, Skokie, IL
| | | | - Garth A James
- Center for Biofilm Engineering, Montana State University, Bozeman, MT
| | - S David Stulberg
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL
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Christopher ZK, Deckey DG, Pollock JR, Spangehl MJ. Antiseptic Irrigation Solutions Used in Total Joint Arthroplasty: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202203000-00005. [PMID: 35231016 DOI: 10.2106/jbjs.rvw.21.00225] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» There are limited data that directly compare the efficacy of antiseptic irrigation solutions used for the prevention and treatment of periprosthetic joint infections in orthopaedic procedures; there is a notable lack of prospective data. » For prevention of periprosthetic joint infections, the strongest evidence supports the use of low-pressure povidone-iodine. » For the treatment of periprosthetic joint infections, delivering multiple solutions sequentially may be beneficial.
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What Is the Duration of Irrigation? An In Vitro Study of the Minimum Exposure Time to Eradicate Bacteria With Irrigation Solutions. J Arthroplasty 2022; 37:385-389.e2. [PMID: 34740788 DOI: 10.1016/j.arth.2021.10.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/14/2021] [Accepted: 10/20/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Antiseptic irrigation solutions are commonly used by arthroplasty surgeons to reduce intraoperative bacterial colonization with the goal of reducing postoperative infections in the setting of primary total joint arthroplasty. Currently, the minimum irrigation time to eliminate common microbes implicated in periprosthetic joint infection is unknown. We sought to determine the minimum effective exposure time required to prevent growth of Staphylococcus aureus, Staphylococcus epidermidis, and Cutibacterium acnes with common antiseptic solutions. METHODS S aureus, S epidermidis, and C acnes cultures were treated with povidone-iodine (0.35%), chlorhexidine (0.05%), sodium hypochlorite (0.5%), polyhexamethylene biguanide, and an acetic acid-based solution for 15, 30, 60, 90, and 120 seconds in triplicate. Bacterial growth was quantified using the drop plate method. Failure to eliminate all bacteria was considered "not effective" at that time point. RESULTS Povidone-iodine 0.35% (Betadine), sodium hypochlorite 0.5% (HySept), and acetic acid (Bactisure) eradicated all bacterial growth after 90 seconds of treatment, and as low as 15 seconds in S aureus and C acnes (Betadine) or S epidermidis (Bactisure). Polyhexamethylene biguanide (Prontosan) required 90 seconds for elimination of S aureus and S epidermidis, and 120 seconds for C acnes. Chlorhexidine 0.05% (Irrisept) did eliminate S epidermidis at 120 seconds but did not effectively eradicate S aureus or C acnes. CONCLUSION All tested antiseptic solutions demonstrated successful eradication of all bacterial growth in under 2 minutes of treatment time except chlorhexidine. Povidone-iodine may require the shortest duration of treatment time to successfully eradicate common bacteria.
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Siddiqi A, Abdo ZE, Rossman SR, Kelly MA, Piuzzi NS, Higuera CA, Schwarzkopf R, Springer BD, Chen AF, Parvizi J. What Is the Optimal Irrigation Solution in the Management of Periprosthetic Hip and Knee Joint Infections? J Arthroplasty 2021; 36:3570-3583. [PMID: 34127346 DOI: 10.1016/j.arth.2021.05.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/16/2021] [Accepted: 05/19/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Thorough irrigation and debridement using an irrigation solution is a well-established treatment for both acute and chronic periprosthetic joint infections (PJIs). In the absence of concrete data, identifying the optimal irrigation agent and protocol remains challenging. METHODS A thorough review of the current literature on the various forms of irrigations and their additives was performed to evaluate the efficacy and limitations of each solution as pertaining to pathogen eradication in the treatment of PJI. As there is an overall paucity of high-quality literature comparing irrigation additives to each other and to any control, no meta-analyses could be performed. The literature was therefore summarized in this review article to give readers concise information on current irrigation options and their known risks and benefits. RESULTS Antiseptic solutions include povidone-iodine, chlorhexidine gluconate, acetic acid, hydrogen peroxide, sodium hypochlorite, hypochlorous acid, and preformulated commercially available combination solutions. The current literature suggests that intraoperative use of antiseptic irrigants may play a role in treating PJI, but definitive clinical studies comparing antiseptic to no antiseptic irrigation are lacking. Furthermore, no clinical head-to-head comparisons of different antiseptic irrigants have identified an optimal irrigation solution. CONCLUSION Further high-quality studies on the optimal irrigation additive and protocol for the management of PJI are warranted to guide future evidence-based decisions.
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Affiliation(s)
- Ahmed Siddiqi
- A Division of Ortho Alliance NJ, Orthopaedic Institute of Central Jersey, Manasquan, NJ; Department of Orthopedic Surgery, Hackensack Meridian Health, Hackensack Meridian School of Medicine, Hackensack, NJ; Department of Orthopedic Surgery, Jersey Shore University Medical Center, Neptune, NJ
| | - Zuhdi E Abdo
- Department of Orthopedics, Rutgers New Jersey Medical School, Newark, NJ
| | - Stephen R Rossman
- Department of Orthopedic Surgery, Hackensack Meridian Health, Hackensack Meridian School of Medicine, Hackensack, NJ
| | - Michael A Kelly
- Department of Orthopedic Surgery, Hackensack Meridian Health, Hackensack Meridian School of Medicine, Hackensack, NJ
| | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Carlos A Higuera
- Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Ran Schwarzkopf
- Department of Orthopedics, New York University Langone Medical Center, New York, NY
| | - Bryan D Springer
- Department of Orthopedics, Atrium Musculoskeletal Institute, OrthoCarolina Hip and Knee Center, Charlotte, NC
| | - Antonia F Chen
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Javad Parvizi
- Department of Orthopedics, Rothman Orthopedics, Philadelphia, PA
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18
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Kobayashi N, Kamono E, Maeda K, Misumi T, Yukizawa Y, Inaba Y. Effectiveness of diluted povidone-iodine lavage for preventing periprosthetic joint infection: an updated systematic review and meta-analysis. J Orthop Surg Res 2021; 16:569. [PMID: 34551791 PMCID: PMC8456523 DOI: 10.1186/s13018-021-02703-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/30/2021] [Indexed: 02/01/2023] Open
Abstract
Background Of the several methods used to prevent surgical site infection (SSI), diluted povidone-iodine (PI) lavage is used widely. However, the clinical utility of PI for preventing periprosthetic joint infection (PJI) remains controversial. The aim of this study was to perform a systematic review and meta-analysis of the utility of dilute PI lavage for preventing PJI in primary and revision surgery. Methods This study was conducted in accordance with the PRISMA checklist for systematic reviews and meta-analyses. A comprehensive literature search of PubMed, CINAHL, ClinicalTrials.gov, and Cochrane Library databases was performed. The results are summarized qualitatively and as a meta-analysis of pooled odds ratios with 95% confidence intervals (95% CIs). Heterogeneity of treatment effects among studies was classified as low, moderate, or high, corresponding to I2 values of < 25%, 25–50%, and > 50%. A random effects model was applied in cases of high heterogeneity; otherwise, the fixed effects model was applied. Subgroup analyses were conducted to identify potential sources of heterogeneity. Results After the screening and eligibility assessment process, eight studies were finally extracted for analysis. Overall, the results showed that PI had no significant effect on PJI with ununified control group. However, subgroup analysis of studies with a saline control group revealed an odds ratio of 0.33 (95% CI, 0.16–0.71) for the PI group, suggesting a significant effect for preventing PJI. Conclusion The systematic review and meta-analysis of the current literature demonstrates that diluted PI lavage is significantly better than saline solution lavage for preventing PJI. Level of evidence Level I, Systematic review and meta-analysis.
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Affiliation(s)
- Naomi Kobayashi
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan.
| | - Emi Kamono
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan
| | - Kento Maeda
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan.,Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Toshihiro Misumi
- Department of Biostatistics, Yokohama City University, Yokohama, Japan
| | - Yohei Yukizawa
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan
| | - Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
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Siddiqi A, Abdo ZE, Springer BD, Chen AF. Pursuit of the ideal antiseptic irrigation solution in the management of periprosthetic joint infections. J Bone Jt Infect 2021; 6:189-198. [PMID: 34109103 PMCID: PMC8182666 DOI: 10.5194/jbji-6-189-2021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/07/2021] [Indexed: 12/23/2022] Open
Abstract
Irrigation and debridement in the treatment of periprosthetic joint infection
(PJI) serve an integral role in the eradication of bacterial burden and
subsequent re-infection rates. Identifying the optimal irrigation agent,
however, remains challenging, as there is limited data on superiority.
Direct comparison of different irrigation solutions remains difficult
because of variability in treatment protocols. While basic science studies
assist in the selection of irrigation fluids, in vitro results do not directly
translate into clinical significance once implemented in vivo. Dilute
povidone iodine, hydrogen peroxide, chlorhexidine gluconate, acetic acid,
sodium hypochlorite, hypochlorous acid, and preformed combination solutions
all have potential against a broad spectrum of PJI pathogens with their own
unique advantages and disadvantages. Future clinical studies are needed to
identify ideal irrigation solutions with optimal bactericidal properties and
low cytotoxicity for PJI treatment.
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Affiliation(s)
- Ahmed Siddiqi
- Orthopaedic Institute of Central Jersey, a division of Ortho Alliance NJ, 2315 Route 34 South Manasquan, NJ 08736, USA.,Hackensack Meridian School of Medicine, Department of Orthopedic Surgery, Hackensack, NJ, USA.,Jersey Shore University Medical Center, Department of Orthopedic Surgery, Neptune, NJ, USA
| | - Zuhdi E Abdo
- Rutgers New Jersey Medical School, Department of Orthopedics, Newark, NJ, 07103, USA
| | - Bryan D Springer
- OrthoCarolina Hip and Knee Center, Department of Orthopedics Atrium Musculoskeletal Institute, Charlotte, NC, 28207, USA
| | - Antonia F Chen
- Brigham & Women's Hospital, Department of Orthopedics, Boston, MA, 02115, USA
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Prevention of Periprosthetic Joint Infection (PJI): A Clinical Practice Protocol in High-Risk Patients. Trop Med Infect Dis 2020; 5:tropicalmed5040186. [PMID: 33322463 PMCID: PMC7768381 DOI: 10.3390/tropicalmed5040186] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 12/04/2020] [Accepted: 12/05/2020] [Indexed: 02/07/2023] Open
Abstract
Background: Periprosthetic joint infection (PJI) represents 25% of failed total knee arthroplasties (TKA). The European Knee Associates (EKA) formed a transatlantic panel of experts to perform a literature review examining patient-related risk factors with the objective of producing perioperative recommendations in PJI high-risk patients. Methods: Multiple databases (Pubmed/MEDLINE, EMBASE, Scopus, Cochrane Library) and recommendations on TKA PJI prevention measures from the International Consensus Meetings on PJI from the AAOS and AAHKS were reviewed. This represents a Level IV study. Results: Strong evidence was found on poor glycemic control, obesity, malnutrition, and smoking being all associated with increased rates of PJI. In the preoperative period, patient optimization is key: BMI < 35, diet optimization, Hemoglobin A1c < 7.5, Fructosamine < 292 mmol/L, smoking cessation, and MRSA nasal screening all showed strong evidence on reducing PJI risk. Intraoperatively, a weight-based antibiotic prophylaxis, accurate fluid resuscitation, betadine and chlorhexidine dual skin preparation, diluted povidone iodine solution irrigation, tranexamic acid administration, and monofilament barbed triclosan-coated sutures for soft tissues closure all represented effective prevention measures. In the postoperative period, failure to reach normalization of ESR, CRP, D-dimer, and IL-6 six weeks postoperatively suggested early PJI. Conclusion: The current recommendations from this group of experts, based on published evidence, support risk stratification to identify high-risk patients requiring implementation of perioperative measures to reduce postoperative PJI.
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Povidone Iodine: Properties, Mechanisms of Action, and Role in Infection Control and Staphylococcus aureus Decolonization. Antimicrob Agents Chemother 2020; 64:AAC.00682-20. [PMID: 32571829 PMCID: PMC7449185 DOI: 10.1128/aac.00682-20] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Nasal decolonization is an integral part of the strategies used to control and prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA) infections. The two most commonly used agents for decolonization are intranasal mupirocin 2% ointment and chlorhexidine wash, but the increasing emergence of resistance and treatment failure has underscored the need for alternative therapies. This article discusses povidone iodine (PVP-I) as an alternative decolonization agent and is based on literature reviewed during an expert’s workshop on resistance and MRSA decolonization. Nasal decolonization is an integral part of the strategies used to control and prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA) infections. The two most commonly used agents for decolonization are intranasal mupirocin 2% ointment and chlorhexidine wash, but the increasing emergence of resistance and treatment failure has underscored the need for alternative therapies. This article discusses povidone iodine (PVP-I) as an alternative decolonization agent and is based on literature reviewed during an expert’s workshop on resistance and MRSA decolonization. Compared to chlorhexidine and mupirocin, respectively, PVP-I 10 and 7.5% solutions demonstrated rapid and superior bactericidal activity against MRSA in in vitro and ex vivo studies. Notably, PVP-I 10 and 5% solutions were also active against both chlorhexidine-resistant and mupirocin-resistant strains, respectively. Unlike chlorhexidine and mupirocin, available reports have not observed a link between PVP-I and the induction of bacterial resistance or cross-resistance to antiseptics and antibiotics. These preclinical findings also translate into clinical decolonization, where intranasal PVP-I significantly improved the efficacy of chlorhexidine wash and was as effective as mupirocin in reducing surgical site infection in orthopedic surgery. Overall, these qualities of PVP-I make it a useful alternative decolonizing agent for the prevention of S. aureus infections, but additional experimental and clinical data are required to further evaluate the use of PVP-I in this setting.
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22
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Matsen FA, Whitson AJ, Pottinger PS, Neradilek MB, Hsu JE. Cutaneous microbiology of patients having primary shoulder arthroplasty. J Shoulder Elbow Surg 2020; 29:1671-1680. [PMID: 32247723 DOI: 10.1016/j.jse.2019.12.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/16/2019] [Accepted: 12/21/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Shoulder periprosthetic infections are predominantly caused by bacteria residing in the skin of healthy individuals. Knowledge of the factors associated with the loads of the different cutaneous bacteria in individuals having shoulder arthroplasty may help identify patients at higher risk of periprosthetic infection and help guide preventive measures. For this reason, we tested the hypothesis that easy-to-obtain preoperative characteristics were significantly associated with the cutaneous microbiology and the loads of specific bacteria in shoulders having joint replacement. METHODS This study identified the microbiology of the unprepared epidermal skin surface and of the dermal edge freshly incised at surgery in 332 patients having primary shoulder arthroplasty. The load of bacteria in each sample was characterized as a value based on the laboratory report: 0 for "no growth"; 0.1 for "one colony only" or for "broth only"; and 1, 2, 3, and 4 for 1+, 2+, 3+, and 4+ growth, respectively. The relationships between preoperative patient characteristics and these semiquantitative results of the cutaneous cultures were analyzed. RESULTS Cultures of the unprepared epidermal skin surface showed positive results for a wide variety of organisms, including Cutibacterium in 72%, coagulase-negative Staphylococcus in 61%, and a spectrum of other organisms in 32%. By contrast, cultures of the freshly incised dermal edge showed a great preponderance of Cutibacterium (34%) in comparison to low levels of coagulase-negative Staphylococcus (8%) and other organisms (2%). An increased dermal load of Cutibacterium was significantly associated with male sex, younger patient age, American Society of Anesthesiologists class 1, use of testosterone supplements, prior shoulder surgery, and higher Cutibacterium loads on the unprepared skin surface. CONCLUSIONS Although the microbiology of the unprepared skin surface is diverse, the same is not true for the freshly incised dermis, where Cutibacterium is the predominant organism. Readily available preoperative patient characteristics are significantly associated with the load of Cutibacterium in the incised dermis. Preoperative cultures of the unprepared skin surface appear to be a new method for predicting the type and load of bacteria found in the freshly incised dermis at the time of surgery. Additional studies are needed to determine whether preoperative cultures of the unprepared epidermal skin surface can provide a method for identifying patients at increased risk of shoulder periprosthetic infections.
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Affiliation(s)
- Frederick A Matsen
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA, USA.
| | - Anastasia J Whitson
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Paul S Pottinger
- Department of Medicine, Division of Allergy & Infectious Diseases, University of Washington Medical Center, Seattle, WA, USA
| | | | - Jason E Hsu
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA, USA
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The Effect of Povidone-Iodine Lavage in Preventing Infection After Total Hip and Knee Arthroplasties: Systematic Review and Meta-Analysis. J Arthroplasty 2020; 35:2267-2273. [PMID: 32229147 DOI: 10.1016/j.arth.2020.03.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/27/2020] [Accepted: 03/02/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Dilute povidone-iodine (PI) lavage, a simple disinfection method, could reduce postoperative infection risk. However, there is no clinical consensus regarding its efficacy in total joint arthroplasties (TJAs). This systematic review and meta-analysis evaluated PI lavage's efficacy in preventing infection after TJA. METHODS MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published before November 22, 2019, that compared postoperative infection rates in patients who underwent TJA with or without PI lavage before wound closure. Subgroup analyses were designed to identify the differences in infection site (overall or deep), type of surgery (total hip arthroplasty or total knee arthroplasty), time until diagnosis of infection (3 or 12 months postoperatively), and primary/aseptic revision arthroplasties. RESULTS We included 7 studies with 31,213 TJA cases, comprising 8861 patients who received PI lavage and 22,352 who did not. Pooled odds ratio for overall infection rate for the PI and non-PI lavage groups was 0.67 (95% confidence interval, 0.38-1.19, P = .17) and for the deep infection rate was 0.90 (95% confidence interval, 0.27-2.98, P = .86). Subgroup analyses revealed no differences in postoperative infection rates between the PI and non-PI lavage groups in terms of total hip arthroplasty and total knee arthroplasty, diagnosis of infection at 3 and 12 months postoperatively, or primary and aseptic revision arthroplasties. CONCLUSION We detected no differences in the overall postoperative infection rates between the PI and non-PI lavage groups before wound closure in TJA including all studies in the subgroup analyses.
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CORR Insights®: Patients with a History of Treated Septic Arthritis are at High Risk of Periprosthetic Joint Infection after Total Joint Arthroplasty. Clin Orthop Relat Res 2019; 477:1613-1614. [PMID: 31107320 PMCID: PMC6999985 DOI: 10.1097/corr.0000000000000734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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25
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Goswami K, Austin MS. Intraoperative povidone-iodine irrigation for infection prevention. Arthroplast Today 2019; 5:306-308. [PMID: 31516971 PMCID: PMC6728529 DOI: 10.1016/j.artd.2019.04.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 03/27/2019] [Accepted: 04/02/2019] [Indexed: 11/16/2022] Open
Abstract
Although prevention of infection following arthroplasty requires a multifaceted approach, the use of intraoperative irrigation is an important component of any protocol. Recent clinical practice guidelines from the Centers for Disease Control, World Health Organization, and International Consensus Meeting on Musculoskeletal Infection advocate the use of a dilute povidone-iodine solution prior to wound closure. Our experience suggests that this practice is safe, inexpensive, and easily implemented. The present article describes our institutional irrigation protocol and reviews the current literature regarding povidone-iodine solutions.
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Affiliation(s)
- Karan Goswami
- Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, PA, USA
| | - Matthew S Austin
- Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, PA, USA
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