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Cortes-Penfield N, Krsak M, Damioli L, Henry M, Seidelman J, Hewlett A, Certain L. How We Approach Suppressive Antibiotic Therapy Following Debridement, Antibiotics, and Implant Retention for Prosthetic Joint Infection. Clin Infect Dis 2024; 78:188-198. [PMID: 37590953 DOI: 10.1093/cid/ciad484] [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] [Received: 06/07/2023] [Revised: 08/03/2023] [Accepted: 08/14/2023] [Indexed: 08/19/2023] Open
Abstract
The optimal treatment of prosthetic joint infection (PJI) remains uncertain. Patients undergoing debridement, antibiotics, and implant retention (DAIR) receive extended antimicrobial treatment, and some experts leave patients at perceived highest risk of relapse on suppressive antibiotic therapy (SAT). In this narrative review, we synthesize the literature concerning the role of SAT to prevent treatment failure following DAIR, attempting to answer 3 key questions: (1) What factors identify patients at highest risk for treatment failure after DAIR (ie, patients with the greatest potential to benefit from SAT), (2) Does SAT reduce the rate of treatment failure after DAIR, and (3) What are the rates of treatment failure and adverse events necessitating treatment discontinuation in patients receiving SAT? We conclude by proposing risk-benefit stratification criteria to guide use of SAT after DAIR for PJI, informed by the limited available literature.
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Affiliation(s)
- Nicolas Cortes-Penfield
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Martin Krsak
- Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laura Damioli
- Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Michael Henry
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
- Department of Medicine, Division of Infectious Diseases, Hospital for Special Surgery, New York, New York, USA
| | - Jessica Seidelman
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Angela Hewlett
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Laura Certain
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
- Department of Internal Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, Utah, USA
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Russo A, Gatti A, Felici S, Gambardella A, Fini M, Neri MP, Zaffagnini S, Lazzarotto T. Piezoelectric ultrasonic debridement as new tool for biofilm removal from orthopedic implants: A study in vitro. J Orthop Res 2023; 41:2749-2755. [PMID: 37165699 DOI: 10.1002/jor.25599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/21/2023] [Accepted: 05/08/2023] [Indexed: 05/12/2023]
Abstract
Pulse lavage (PL) debridement is the standard treatment used in Debridement, Antibiotics and Implant Retention (DAIR) for bacterial biofilm removal during acute and early postoperative cases of periprosthetic joint infection (PJI). The failure rate of DAIR is still high due to the inadequacy of PL in removing the biofilm. Ultrasound-based techniques are a well-established tool for PJI diagnosis due to their ability to completely eradicate the biofilm from implant surfaces. Hence, this study investigates the efficiency of a piezoelectric ultrasonic scalpel (PUS) in removing bacterial biofilm from different orthopedic implant materials in vitro and compares the results with PL. Biofilms of methicillin-resistant Staphylococcus aureus strains were grown on titanium alloy (Ti6Al4V ELI), stainless steel (AISI 316L), and ultrahigh molecular weight polyethylene (UHMWPE) disks for 24 h. The disks of each material were divided into three groups: (i) a control group (no lavage/debridement), (ii) a group treated with PL, (iii) a group treated with PUS. The disks were then sonicated for viable cell count to measure the residual biofilm content. Compared to the initial cell count (105 CFU/mL for each material), PL showed a two-log reduction of CFU/mL (p < 0.001 for each material), while for PUS a four-log reduction was found (p < 0.001 for each material). The comparison between the two lavage/debridement displayed a two-log reduction of CFU/mL (p < 0.001 for each material) of PUS compared with PL. Its increased efficiency compared with PL promotes the use of PUS in removing bacterial biofilm from orthopedic implants, suggesting its implementation to improve the success rate of DAIR.
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Affiliation(s)
- Alessandro Russo
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Gatti
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Silvia Felici
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessandro Gambardella
- Complex Structure of Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Milena Fini
- Scientific Direction, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Maria Pia Neri
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Tiziana Lazzarotto
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Hudek R. [Shoulder periprosthetic infections-what to do? : Diagnosis and treatment]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:85-97. [PMID: 36662261 DOI: 10.1007/s00132-022-04341-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/16/2022] [Indexed: 01/21/2023]
Abstract
Treatment of an infected shoulder prosthesis differs significantly from other joint infections because of the unique microbiome, dominated by Cutibacterium acnes. The cause of an infection, its time of onset, the bacterial spectrum and comorbidities have to be considered for evaluation and treatment. The diagnostic workup is sometimes complex, and the recognition of a chronic and low-grade infection is often difficult because typical clinical and laboratory markers may be normal. Treatment is surgical; the therapeutic spectrum ranges from arthroscopic irrigation and open debridement with the exchange of components to one- and two-stage revisions using antibiotic-loaded spacers. Early detection and a targeted, appropriate therapy are crucial to avoid extensive soft tissue and bone damage.
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Affiliation(s)
- Robert Hudek
- ATOS Klinik Fleetinsel Hamburg, Admiralitätstr. 3-4, 20459, Hamburg, Deutschland.
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Mian HM, Lyons JG, Perrin J, Froehle AW, Krishnamurthy AB. A review of current practices in periprosthetic joint infection debridement and revision arthroplasty. ARTHROPLASTY 2022; 4:31. [PMID: 36045436 PMCID: PMC9434893 DOI: 10.1186/s42836-022-00136-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Periprosthetic joint infection remains a significant challenge for arthroplasty surgeons globally. Over the last few decades, there has been much advancement in terms of treatment and diagnosis, however, the fight rages on. As management of periprosthetic joint infections continues to evolve, it is critical to reflect back on current debridement practices to establish common ground as well as identify areas for future research and improvement. BODY: In order to understand the debridement techniques of periprosthetic joint infections, one must also understand how to diagnose a periprosthetic joint infection. Multiple definitions have been elucidated over the years with no single consensus established but rather sets of criteria. Once a diagnosis has been established the decision of debridement method becomes whether to proceed with single vs two-stage revision based on the probability of infection as well as individual patient factors. After much study, two-stage revision has emerged as the gold standard in the management of periprosthetic infections but single-stage remains prominent with further and further research. CONCLUSION Despite decades of data, there is no single treatment algorithm for periprosthetic joint infections and subsequent debridement technique. Our review touches on the goals of debridement while providing a perspective as to diagnosis and the particulars of how intraoperative factors such as intraarticular irrigation can play pivotal roles in infection eradication. By providing a perspective on current debridement practices, we hope to encourage future study and debate on how to address periprosthetic joint infections best.
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Affiliation(s)
- Humza M Mian
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St. Suite #2200, Dayton, OH, 45409, USA.
| | - Joseph G Lyons
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St. Suite #2200, Dayton, OH, 45409, USA
| | - Joshua Perrin
- Wright State University Boonshoft School of Medicine, Wright State Physicians Bldg, 725 University Blvd., Dayton, OH, 45435, USA
| | - Andrew W Froehle
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St. Suite #2200, Dayton, OH, 45409, USA
- School of Nursing, Kinesiology and Health, Wright State University, 3640 Colonel Glenn Hwy., Dayton, OH, 45435, USA
| | - Anil B Krishnamurthy
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St. Suite #2200, Dayton, OH, 45409, USA
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Jia Y, Chen J, Liang W, Xiong Y, Peng Z, Wang G. Differences in Efficacy between Short- and Long-Course Antibiotic Agents for Joint Prosthesis Infection: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2022; 23:616-624. [PMID: 35950957 DOI: 10.1089/sur.2022.157] [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: 11/13/2022] Open
Abstract
Background: To evaluate systematically the failure rate of short versus long courses of antibiotic agents for prosthetic joint infections (PJIs). Methods: PubMed, Embase, and Cochrane Library databases were searched for controlled studies of short- and long-course antibiotic agents for joint prosthesis infections, all from the time of database creation to April 2022. Literature search, quality evaluation, and data extraction were performed independently by two researchers, and the primary outcome was the rate of surgical failure after antibiotic treatment. Stata 11.0 software was then applied for meta-analysis. Publication bias was assessed using Begg test. Heterogeneity was assessed using the I2 test, and fixed or random effects models were used accordingly. Meta-regression was used to determine the causes of heterogeneity. Results: A total of 14 articles involving 1,971 participants met the inclusion criteria, including 12 observational studies and two randomized controlled trials. Meta-analysis showed no difference between short and long courses of antibiotic agents (relative risk, 1.08; 95% confidence interval [CI], 0.89-1.32). The results of the subgroup analysis showed no differences between the failure rates of patients with PJI treated with short and long courses of antibiotic agents in studies with different study areas, different treatment modalities, and different locations of the artificial joints. Conclusions: Patients with PJIs may not require long-term or lifelong antibiotic agents after surgical treatment, and short-term (four to six weeks) antibiotic therapy is usually safe.
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Affiliation(s)
- Yukun Jia
- The People's Hospital of Baoan Shenzhen
| | - Jie Chen
- The People's Hospital of Baoan Shenzhen
| | | | - Yu Xiong
- The People's Hospital of Baoan Shenzhen
| | - Zhan Peng
- The People's Hospital of Baoan Shenzhen
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Zhang T, Lian X, Chen Y, Cai B, Xu J. Clinical Outcome of Postoperative Surgical Site Infection in Patients with Posterior Thoracolumbar and Lumbar Instrumentation. J Hosp Infect 2022; 128:26-35. [PMID: 35788013 DOI: 10.1016/j.jhin.2022.06.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/20/2022] [Accepted: 06/27/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Postoperative surgical site infection (SSI) is associated with greater rates of disability, especially in instrumented spinal surgeries. The management of implant-associated surgical site infections (SSI) is challenging. We analyzed the data from our hospital databases to assess the incidence and characteristics related to postoperative surgical site infection (SSI) after posterior thoracolumbar and lumbar instrumentation. METHODS Patient demographics, infection characteristics, details of treatment, and perioperative factors were reviewed (Jan 2010 to Dec 2020). The Oswestry disability index (ODI), Patient Health Questionnaire-9 (PHQ-9), and Visual Analog Scale (VAS) scores for back and leg pain were analyzed preoperatively and postoperatively until last follow-up. RESULTS Of the 27,881 procedures collected from the databases, 521 were diagnosed with SSI (1.8%), and 191(36.7%) received at least one revision surgery for SSI. Infection rate was significantly higher in patients with lumbar spinal stenosis than those with scoliosis or kyphosis (P<0.01). Methicillin-sensitive Staphylococcus aureus (43.4%) was the most commonly isolated pathogen. The rate of complication secondary to antibiotics treatment was 7.8%, and long-term antibiotic suppression was reported in 15.2% of patients. Instrumentation was retained in 175 patients (91.6%) and all SSIs were controlled without recurrence during the follow-up. CONCLUSION Analysis of 27,881 patients showed an average SSI rate of 1.8%. Patients with deep wound SSI can be successfully treated in most cases with retention of instrumentation. Early diagnosis, positive revision surgery with strict irrigation, thorough debridement, and a long-term course of antibiotics are critical for eradicating infection, retaining implants, decreasing morbidity, and achieving wound healing.
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Affiliation(s)
- Tao Zhang
- Orthopaedic department, Shanghai sixth people's hospital, Shanghai Jiaotong University Affiliated, 600 Yishan Rd, Shanghai, China
| | - Xiaofeng Lian
- Orthopaedic department, Shanghai sixth people's hospital, Shanghai Jiaotong University Affiliated, 600 Yishan Rd, Shanghai, China
| | - Yuanyuan Chen
- Orthopaedic department, Shanghai sixth people's hospital, Shanghai Jiaotong University Affiliated, 600 Yishan Rd, Shanghai, China.
| | - Bin Cai
- Orthopaedic department, Shanghai sixth people's hospital, Shanghai Jiaotong University Affiliated, 600 Yishan Rd, Shanghai, China
| | - Jianguang Xu
- Orthopaedic department, Shanghai sixth people's hospital, Shanghai Jiaotong University Affiliated, 600 Yishan Rd, Shanghai, China
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Wiratnaya IGE, Nugraha HK, Kawiyana IKS, Subawa IW, Sutheno A. Arthroscopic debridement for infection after fracture fixation (IAFF) of the ankle: A case report. Int J Surg Case Rep 2022; 91:106772. [PMID: 35051886 PMCID: PMC8777380 DOI: 10.1016/j.ijscr.2022.106772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/10/2022] [Accepted: 01/10/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Infection after fracture fixation (IAFF) is one of the most challenging issues for the lower-middle class socioeconomic. It is also related to unsatisfactory outcome of the treatment. Arthroscopy usually used to treat joint disease, but the evidence of arthroscopic management in IAFF is still limited. CASE PRESENTATION We present a case of 54-year-old female with IAFF of the ankle. An arthroscopic debridement and soft tissue release procedure were performed in this patient in one stage because the irrigation and debridement were sufficient. It showed a good result good functional outcome. CLINICAL DISCUSSION The aims of IAFF treatment are to eradicate the infection, promote healing of soft tissue, prevent osteomyelitis, restore the joint function, and fracture consolidation. Arthroscopy in IAFF has been found to be safe and effective. In this case, arthroscopy was done in one stage because the debridement and irrigation were sufficient while the delay of the release would result in further pain and morbidity for the patient. CONCLUSION Arthroscopic debridement with simultaneous release of impingement and stiffness is a novel, safe, and promising option in to eliminate both IAFF and its further complications of the ankle region.
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Affiliation(s)
- I Gede Eka Wiratnaya
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University of Udayana, / Sanglah General Hospital, Denpasar, Bali, Indonesia
| | - Hans Kristian Nugraha
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University of Udayana, / Sanglah General Hospital, Denpasar, Bali, Indonesia.
| | - I Ketut Siki Kawiyana
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University of Udayana, / Sanglah General Hospital, Denpasar, Bali, Indonesia
| | - I Wayan Subawa
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University of Udayana, / Sanglah General Hospital, Denpasar, Bali, Indonesia
| | - Andrew Sutheno
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University of Udayana, / Sanglah General Hospital, Denpasar, Bali, Indonesia
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Fatal Clostridium Infection in a Leg-Amputated Patient after Unsuccessful Knee Arthroplasty. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18179186. [PMID: 34501775 PMCID: PMC8430686 DOI: 10.3390/ijerph18179186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/17/2021] [Accepted: 08/27/2021] [Indexed: 12/22/2022]
Abstract
Prosthetic joint infection (PJI) is a possible complication occurring after prosthesis implantation. We describe the case of a patient with early postoperative multidrug-resistant polymicrobial PJI and mixed infection of the surgical wound. Despite the removal of the prosthesis, the positioning of double-stage exchange, and dehiscence debridement of the surgical wound, the infection continued. Positioning of an external fixator, plastic reconstruction with a skin graft, and continuous (two years) multiple antimicrobial therapy led to the resolution of the knee infection; a knee prosthesis was implanted, but a new infection of the extensus apparatus by multidrug-resistant Klebsiella pnumoniae followed. It was complicated by surgical wound dehiscence, forcing us to remove the prosthesis, put a new external fixator, and continue with the antibiotic treatment, with no results, and, finally, proceed to a leg amputation. Fourteen days after, the patient was discharged in good clinical condition but, fifteen days later, during rehabilitation in another hospital, the patient developed a severe Clostridium difficilis infection with profuse, intense diarrhea, toxic megacolon, and septic shock; despite colectomy and treatment in an intensive care unit, he died four months later. Patients affected by polymicrobial PJI are at high risk of treatment failure and, therefore, should be given a warning, in good time and appropriate form, of the likelihood of leg amputation.
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