Surveillance of prosthetic joint infections: international overview and new insights for hospital databases

Diagnostic value of magnetic resonance imaging for patients with periprosthetic joint infection: a systematic review

PURPOSE

The purpose of this study was to provide a critical systematic review of the role of magnetic resonance imaging (MRI) as a noninvasive method to assess periprosthetic joint infections (PJIs).

METHODS

The electronic databases PubMed and EMBASE were searched, since their inception up to March 27, 2022. The included studies evaluated the reproducibility and accuracy of MRI features to diagnose PJIs. The article quality assessment was conducted by the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2).

RESULTS

Among 1909 studies identified in the initial search, 8 studies were eligible for final systematic review. The included studies evaluated the reproducibility and accuracy of MRI features to diagnose PJIs. Seven of 8 studies showed good to excellent reliability, but only one article among them in which accuracy was evaluated had a low risk of bias. The intraclass correlation coefficient (ICC) and Cohen coefficient (κ) varied between 0.44 and 1.00. The accuracy varied between 63.9% and 94.4%. Potential MRI features, such as lamellated hyperintense synovitis, edema, fluid collection, or lymphadenopathy, might be valuable for diagnosing PJIs.

CONCLUSION

The quality of the evidence regarding the role of MRI for PJIs diagnosis was low. There is preliminary evidence that MRI has a noteworthy value of distinguishing suspected periprosthetic joint infection in patients with total knee arthroplasty or total hip arthroplasty, but the definition of specific MRI features related to PJIs diagnosis lacks consensus and standardization. Large-scale studies with robust quality were required to help make better clinical decisions in the future.

Validation of the first computerized indicator for orthopaedic surgical site infections in France: ISO-ORTHO

BACKGROUND

The French national authority for health (HAS) develops in-hospital indicators for improving quality of care, safety and patient outcome. Since 2017, it has developed a measurement of surgical site infections (SSI) after total hip or knee arthroplasty (TH/KA) by using a computerized indicator, called ISO-ORTHO, based on a hospital discharge database (HDD) algorithm. The aim of the study was to assess the performance of this new indicator .

METHODS

The ISO-ORTHO performance was estimated via its positive predictive value (PPV) among adult patients having undergone a TH/KA between January 1st and September 30th 2018, based on the orthopaedic procedure codes. Patients at very high risk of SSI and/or with SSI not related to the in-hospital care were excluded. SSI were detected from the date of admission up to 90 days after the TH/KA using the ISO-ORTHO algorithm, based on 15 combinations of ICD-10 and procedure codes. Its PPV was estimated by a chart review in volunteer healthcare organisations (HCO).

RESULTS

Over the study period, 777 HCO including 143,227 TH/KA stays were selected, providing 1,279 SSI according to the ISO-ORTHO indicator. The 90-day SSI rate was 0.89 per 100 TH/KA stays (0.98% for THA and 0.80% for TKA). Among the 448 HCO with at least 1 SSI, 250 HCO participated in reviewing 725 SSI charts; 665 were confirmed, giving a PPV of 90.3% [88.2-92.5%], 89.9% [87.1-92.8%] in THA and 90.9% [87.7-94.2%] in TKA.

CONCLUSIONS

The PPV of ISO-ORTHO over 90% confirms its validity for any use according to the HAS method. ISO-ORTHO and detailed information were provided in 2020 to HCO and used for quality assessment and in-hospital risk management.

Suction drainage fluid culture during septic orthopaedic surgery, a retrospective study

We evaluated the usefulness of suction drainage fluid culture after septic orthopaedic surgery to predict early surgical reintervention. We conducted a retrospective observational study, at the Groupe Hospitalier Paris Saint-Joseph between 2014 and 2019. All the patients undergoing septic orthopaedic surgery, with perioperative samples and a postoperative suction drainage device, were enrolled. We compared the group with positive or negative postoperative drainage fluid cultures, respectively, on surgical outcome. We included 246 patients. The drainage fluid culture was positive in 42.3% of the cases. Early surgical reintervention concerned 14.6% of the cases (n = 36), including 61.1% of patients with positive drainage fluid culture (n = 22/36). The risk factors associated with positive drainage fluid cultures were the debridement of the infected site (without orthopaedic device removal), an infection located at the spine, perioperative positive cultures to Staphylococcus aureus. The complete change of the orthopaedic device, and coagulase-negative staphylococci on the preoperative samples, was associated with negative drainage fluid cultures. Positive drainage fluid culture was predictive of early surgical reintervention, and coagulase-negative staphylococci in the preoperative samples and knee infection were predictive of surgical success. Postoperative drainage fluid cultures were predictive of early surgical reintervention. Randomized multicentric studies should be further conducted.

The mildly decreased preoperative bilirubin level is a risk factor for periprosthetic joint infection after total hip and knee arthroplasty

BACKGROUND

Many serologic markers are routinely tested prior to joint arthroplasty, but only few are commonly used to guide surgeons in determining patients most at risk of periprosthetic joint infection (PJI). The objective of this study was to investigate the association between preoperative bilirubin level and PJI after primary hip and knee arthroplasty.

METHODS

A retrospective analysis was performed on patients undergoing revision hip and knee arthroplasty at our hospital from January 2016 to December 2019. Laboratory biomarkers were collected before the primary arthroplasty, as well as general patient information. The association between the above serologic markers and postoperative PJI was analyzed.

RESULTS

A total of 72 patients (30 hips/42 knees) were analyzed, including 39 patients with PJI and 33 patients without PJI. Except for total bilirubin (TB) and direct bilirubin (DB), there was no significant difference between the remaining laboratory biomarkers. The preoperative TB and DB in the PJI group were 10.84 ± 0.61 μmol/L and 3.07 ± 0.19 μmol/L, respectively, which were lower than those in the non-PJI group (14.68 ± 0.75 μmol/L and 4.70 ± 0.39 μmol/L, P < 0.001). The area under the curve (AUC) of preoperative TB to predict PJI was 0.755 (P < 0.001, cutoff = 11.55 μmol/L, sensitivity = 66.67%, specificity = 75.76%). Meanwhile, the AUC of preoperative DB was 0.760 (P < 0.001, cutoff = 4.00 μmol/L, sensitivity = 84.62%, specificity = 54.45%).

CONCLUSIONS

The serum levels of TB and DB before the primary arthroplasty were lower in PJI patients than in non-PJI patients, and the preoperative values lower than 11.55 μmol/L and 4.00 μmol/L could be considered as a risk factor for postoperative PJI.

A computerized indicator for surgical site infection (SSI) assessment after total hip or total knee replacement: The French ISO-ORTHO indicator

OBJECTIVE

The French National Authority for Health (HAS), with a multidisciplinary working group, developed an indicator 'ISO-ORTHO' to assess surgical site infections (SSIs) after total hip arthroplasty or total knee arthroplasty (THA/TKA) based on the hospital discharge database. We present the ISO-ORTHO indicator designed for SSI automated detection and its relevance for quality improvement and hospital benchmarks.

METHODS

The algorithm is based on a combination of International Statistical Classification of Diseases, Tenth Revision (ICD-10) and procedure codes of the hospital stay. The target population was selected among adult patients who had a THA or TKA between January 1, 2017, and September 30, 2017. Patients at very high risk of SSI and/or with SSI not related to hospital care were excluded. We searched databases for SSIs up to 3 months after THA/TKA. The standardized infection ratio (SIR) of observed versus expected SSIs was calculated (logistic regression) and displayed as funnel plot with 2 and 3 standard deviations (SD) after adjustment for 13 factors known to increase SSI risk.

RESULTS

In total, 790 hospitals and 139,926 THA/TKA stays were assessed; 1,253 SSI were detected in the 473 included hospitals (incidence, 0.9%: 1.0% for THA, 0.80% for TKA). The SSI rate was significantly higher in males (1.2%), in patients with previous osteo-articular infection (4.4%), and those with cancer (2.3%), obesity, or diabetes. Most hospitals (89.9%) were within 2 SD; however, 12 hospitals were classified as outliers at more than +3 SD (1.6% of facilities), and 59 hospitals (7.9%) were outliers between +2 SD and +3 SD.

CONCLUSION

ISO-ORTHO is a relevant indicator for automated surveillance; it can provide hospitals a metric for SSI assessment that may contribute to improving patient outcomes.

Role of real-world digital data for orthopedic implant automated surveillance: a systematic review

INTRODUCTION

Data collection automation through the reuse of real-world digital data from clinical data warehouses (CDW) could represent a great opportunity to improve medical device monitoring. For instance, this approach is starting to be used for the design of automated decision support systems for joint replacement monitoring. However, a number of obstacles remains, such as data quality and interoperability through the use of common and regularly updated terminologies, and the use of a Unique Device Identifier (UDI).

AREAS COVERED

To present the existing models of automated surveillance of orthopedic devices, a systematic review of initiatives using real-world digital health data to monitor joint replacement surgery was performed following the PRISMA 2020 guidelines. The main objective was to identify the data sources, the target populations, the population size, the device location, and the main results of studies on such initiatives.

EXPERT OPINION

Analysis of the identified studies showed that real-world digital data offer many opportunities for improving the automation of monitoring in orthopedics. The contribution of real-world data, especially through natural language processing, UDI use in CDW and the integration of device databases, is needed for automated and more robust health surveillance.

FUrTIHF: French urinary tract infections in healthcare facilities - five-year historic cohort (2014-2018)

BACKGROUND

Urinary tract infections (UTIs) are common and diverse. Even when not severe, UTIs regularly lead to hospitalization, but their hospital burden remains unknown. This study aimed to estimate the national incidence of hospitalized UTIs in France.

METHODS

A historic five-year cohort of adult patients hospitalized with UTIs in France was extracted from the medico-administrative databases using an ICD-10 code algorithm built by a multidisciplinary team. The performance parameters were estimated blindly, by reviewing 1122 cases, using medical reports as the gold standard, giving a global predictive positive value of 70.4% (95% confidence interval 66.6-74.1). The national incidence of UTIs was then estimated.

RESULTS

A total of 2,083,973 patients with UTIs were hospitalized over the period, giving an adjusted incidence rate of ∼900 cases/100,000 inhabitants, stable over the period, higher in females and increasing with age; 1.2% were device-associated UTIs. Unspecific acute cystitis represented almost two-thirds of cases (63.5%); followed by pyelonephritis (23.6%) and prostatitis (12.4%). More than three-quarters of patients had at least one comorbid condition (76.8%).

CONCLUSIONS

This national cohort study is the first to date to estimate the incidence of UTI-related hospitalizations in France. UTIs represent a substantial burden of care. Further analysis will provide data for more informed goal-of-care discussions targeting each type of UTI, their management and outcomes.

How to save time in surveillance without losing quality: comparison of two methods of surgical site infection surveillance in orthopaedic prosthetics in a French university hospital

Surgical site infection (SSI) surveillance methods are not standardised and are often time-consuming. We compared an active method, based on orthopaedic department staff reporting suspected SSI, with a semi-automated method, based on computerised extraction of surgical revisions, after total hip and knee arthroplasty. Both methods allowed finding the same SSI cases. We found the same sensitivity but higher specificity with a straightforward time gain using the passive method. This represents an added value for the organisation of an effective SSI surveillance, based on existing hospital databases.

Measuring Surgical Site Infection From Linked Administrative Data Following Hip and Knee Replacement

BACKGROUND

Surgical site infections (SSIs) in hip and knee arthroplasty are increasing internationally. Current trends in SSI monitoring use single source administrative databases with data collection points commonly at 30 or 90 days. We hypothesize that SSI rates are being under-reported due to methodological biases.

METHODS

Data from multiple administrative data sets were contrasted and compared to look at the 90-day SSI rates for hip and knee arthroplasty in a single province from 2001 to 2015. SSI rates were calculated over time by year, and the differences in infection rates between single and multiple administrative data sets were calculated as an estimate of under reporting rates of SSIs. Days until diagnosis was measured for those diagnosed with an infection within 1 year.

RESULTS

Combining administrative data sets indicates that hospital-based data underestimate SSI rates by 0.44 (P < .0001) of a percentage point over all years, a clinically significant result given the overall infection rate of 2.2% over the period. Less than 50% of hip and knee arthroplasty was recorded as infected by 30 days and approximately 75% of cases were recorded as infected by 90 days.

CONCLUSION

Single source administrative data sets and short follow-up periods underestimate SSI rates. Administrative data sets should be combined and a minimum follow-up period of 90 days should be used to more accurately track SSI rates in hip and knee arthroplasty.

New diagnostic tools for prosthetic joint infection

The diagnosis of peri-prosthetic bone and joint infections relies on converging information from clinical, laboratory and imaging assessments. Clinical findings alone may suffice: a sinus tract is a major criterion that establishes the diagnosis of infection. Identifying the causative organism is crucial and requires the early collection of high-quality samples from sites in contact with the prosthetic material. The bacteriological samples may be obtained by aspiration or open surgery. Imaging techniques have undergone remarkable improvements over the last two decades. Ultrasonography can be performed early and can be used to guide a needle biopsy if appropriate. Computed tomography or magnetic resonance imaging shows the extent of bone and/or soft-tissue involvement, provided effective artefact-suppression techniques are applied. Nuclear medicine methods have an undefined place in the diagnostic strategy and their possible role must be evaluated during a multidisciplinary discussion. The array of new laboratory methods introduced in recent years includes microbiological culture techniques, molecular biology tests, antigen and antibody assays and tests for immune markers in blood and/or joint fluid. When the first-line investigations fail to provide a definitive diagnosis, a multidisciplinary discussion at a referral centre for complex osteo-articular infections makes a major contribution to defining the subsequent diagnostic strategy. This lecture focusses on the following six questions: does the clinical assessment still have diagnostic relevance? What is the diagnostic contribution of imaging studies? Must the infection be documented pre-operatively and if so, how? Which microbiological techniques should be used? Which non-microbiological investigations help to diagnosis peri-prosthetic bone and joint infections? What role do referral centres for complex bone and joint infections play in the diagnostic strategy?

Prevention of Postoperative Wound Infections

Surgery creates most hospital infections, injuries, accidents, invalidity and death in the global healthcare system. The number of surgically treated patients per year is high and increasing.

Surgical site infection (SSI) is dependent on type of operation and may occur in 5–20% after surgery, triggers 7–11 extra postoperative days in hospitals and results in 2–11 times higher risk of death than comparable, noninfected patients. Up to 60% of SSI can be prevented. Prevention of postoperative wound infection is done by good general hygiene, operative sterility and effective barriers against transmission of infections, before, during and after surgery. A basic support by hospital leaders, knowledge and skill of the surgical teams, enough resources, excellent treatment of the complete patient admission and monitoring patients after discharge may lead to significant reduction of SSIs, lower death rates and a less expensive health system.

The Michigan Arthroplasty Registry Collaborative Quality Initiative Experience: Improving the Quality of Care in Michigan

The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) is a regional quality improvement effort that is focused on hip and knee arthroplasty. From its inception in 2012, MARCQI has grown to include data from 66 hospitals and surgery centers, and contains over 209,000 fully abstracted cases in its database. Using high-quality risk-standardized outcomes data, MARCQI drives quality improvement through a collaborative and nonpunitive structure. Quality improvement initiatives have included transfusion reduction, infection prevention, venous thromboembolism reduction, and reduction of discharge to nursing homes. In addition, MARCQI focuses on postmarket surveillance of implants by computing revision-risk estimates based on the cases that were registered prior to the end of 2016. This paper describes the impact of MARCQI on the quality of hip and knee arthroplasty care in the state of Michigan since its inception in 2012, and it briefly summarizes the recently released 5-year report.

Key features of bone and joint infections following the implementation of reference centers in France

OBJECTIVES

French reference centers for bone and joint infections (BJI) were implemented from 2009 onwards to improve the management of complex BJIs. This study compared BJI burden before and after the implementation of these reference centers.

PATIENTS AND METHODS

BJI hospital stays were selected from the 2008 and 2013 national hospital discharge database using a validated algorithm, adding the new complex BJI code created in 2011. Epidemiology and economic burden were assessed.

RESULTS

BJI prevalence increased in 2013 (70 vs. 54/100,000 in 2008). Characteristics of BJI remained similar between 2008 and 2013: septic arthritis (50%), increasing prevalence with age and sex, case fatality 5%, mean length of stay 17.5 days, rehospitalization 20%. However, device-associated BJIs increased (34 vs. 26%) as well as costs (€421 million vs. €259 in 2008). Similar device-associated BJI characteristics between 2008 and 2013 were: septic arthritis (70%), case fatality (3%), but with more hospitalizations in reference centers (34 vs. 30%) and a higher cost per stay. Among the 7% of coded complex BJIs, the mean length of stay was 22.2 days and mean cost was €11,960.

CONCLUSIONS

BJI prevalence highly increased in France. Complex BJI prevalence assessment is complicated by the absence of clinical consensus and probable undercoding. A validation of clinical case definition of complex BJI is required.

[The use of administrative health databases in infectious disease epidemiology and public health]

BACKGROUND

The public health burden resulting from infectious diseases requires efforts in surveillance and evaluation of health care. The use of administrative health databases (AHD) and in particular the French national health insurance database (SNIIRAM) is an opportunity to improve knowledge in this field. The SNIIRAM data network (REDSIAM) workshop dedicated to infectious diseases conducted a narrative literature review of studies using French AHD. From the results, benefits and limits of these new tools in the field of infectious diseases are presented.

METHODS

Publications identified by the members of the workgroup were collected using an analytical framework that documented the pathology of interest, the aim of the study, the goal of the developed algorithm, the kind of data, the study period, and the presence of an evaluation or a discussion of the performance of the performed algorithm.

RESULTS

Fifty-five articles were identified. A majority focused on the field of vaccination coverage and joint infections. Excluding vaccine coverage field, the aim of 28 studies was epidemiological surveillance. Twenty-six studies used hospital databases exclusively, 18 used ambulatory databases exclusively and 4 used both. Validation or discussion of the performed algorithm was present in 18 studies.

CONCLUSIONS

The literature review confirmed the interest of the French AHD in the infectious diseases field. The AHD are additional tools of the existing surveillance systems and their use will probably be more frequent in the coming years given their advantage and reliability. However, incoming users need to be assisted. Thus, the workgroup will contribute to a reasonable use of AHD and support future developments.

Periprosthetic Infection following Primary Hip and Knee Arthroplasty: The Impact of Limiting the Postoperative Surveillance Period

BACKGROUND

Hip and knee arthroplasty infections are associated with considerable healthcare costs. The merits of reducing the postoperative surveillance period from 1 year to 90 days have been debated.

OBJECTIVES

To report the first pan-Canadian hip and knee periprosthetic joint infection (PJI) rates and to describe the implications of a shorter (90-day) postoperative surveillance period.

METHODS

Prospective surveillance for infection following hip and knee arthroplasty was conducted by hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) using standard surveillance definitions.

RESULTS

Overall hip and knee PJI rates were 1.64 and 1.52 per 100 procedures, respectively. Deep incisional and organ-space hip and knee PJI rates were 0.96 and 0.71, respectively. In total, 93% of hip PJIs and 92% of knee PJIs were identified within 90 days, with a median time to detection of 21 days. However, 11%–16% of deep incisional and organ-space infections were not detected within 90 days. This rate was reduced to 3%–4% at 180 days post procedure. Anaerobic and polymicrobial infections had the shortest median time from procedure to detection (17 and 18 days, respectively) compared with infections due to other microorganisms, including Staphylococcus aureus.

CONCLUSIONS

PJI rates were similar to those reported elsewhere, although differences in national surveillance systems limit direct comparisons. Our results suggest that a postoperative surveillance period of 90 days will detect the majority of PJIs; however, up to 16% of deep incisional and organ-space infections may be missed. Extending the surveillance period to 180 days could allow for a better estimate of disease burden.

Infect Control Hosp Epidemiol 2017;38:147–153

Derivation and Validation of the Surgical Site Infections Risk Model Using Health Administrative Data

OBJECTIVE Surgical site infections (SSIs) are common hospital-acquired infections. Tracking SSIs is important to monitor their incidence, and this process requires primary data collection. In this study, we derived and validated a method using health administrative data to predict the probability that a person who had surgery would develop an SSI within 30 days. METHODS All patients enrolled in the National Surgical Quality Improvement Program (NSQIP) from 2 sites were linked to population-based administrative datasets in Ontario, Canada. We derived a multivariate model, stratified by surgical specialty, to determine the independent association of SSI status with patient and hospitalization covariates as well as physician claim codes. This SSI risk model was validated in 2 cohorts. RESULTS The derivation cohort included 5,359 patients with a 30-day SSI incidence of 6.0% (n=118). The SSI risk model predicted the probability that a person had an SSI based on 7 covariates: index hospitalization diagnostic score; physician claims score; emergency visit diagnostic score; operation duration; surgical service; and potential SSI codes. More than 90% of patients had predicted SSI risks lower than 10%. In the derivation group, model discrimination and calibration was excellent (C statistic, 0.912; Hosmer-Lemeshow [H-L] statistic, P=.47). In the 2 validation groups, performance decreased slightly (C statistics, 0.853 and 0.812; H-L statistics, 26.4 [P=.0009] and 8.0 [P=.42]), but low-risk patients were accurately identified. CONCLUSION Health administrative data can effectively identify postoperative patients with a very low risk of surgical site infection within 30 days of their procedure. Records of higher-risk patients can be reviewed to confirm SSI status.

Surgical Site Infection After Primary Hip and Knee Arthroplasty: A Cohort Study Using a Hospital Database

BACKGROUND

Hip or knee arthroplasty infection (HKAI) leads to heavy medical consequences even if rare.

OBJECTIVE

To assess the routine use of a hospital discharge detection algorithm of prosthetic joint infection as a novel additional tool for surveillance.

METHODS

A historic 5-year cohort study was built using a hospital database of people undergoing a first hip or knee arthroplasty in 1 French region (2.5 million inhabitants, 39 private and public hospitals): 32,678 patients with arthroplasty code plus corresponding prosthetic material code were tagged. HKAI occurrence was then tracked in the follow-up on the basis of a previously validated algorithm using International Statistical Classification of Disease, Tenth Revision, codes as well as the surgical procedures coded. HKAI density incidence was estimated during the follow-up (up to 4 years after surgery); risk factors were analyzed using Cox regression.

RESULTS

A total of 604 HKAI patients were identified: 1-year HKAI incidence was1.31%, and density incidence was 2.2/100 person-years in hip and 2.5/100 person-years in knee. HKAI occurred within the first 30 days after surgery for 30% but more than 1 year after replacement for 29%. Patients aged 75 years or older, male, or having liver diseases, alcohol abuse, or ulcer sore had higher risk of infection. The inpatient case fatality in HKAI patients was 11.4%.

CONCLUSIONS

The hospital database method used to measure occurrence and risk factors of prosthetic joint infection helped to survey HKAI and could optimize healthcare delivery.

Infect Control Hosp Epidemiol 2015;36(10):1198–1207