Six weeks of antibiotic treatment is sufficient following surgery for septic arthroplasty

Debridement, antibiotics and implant retention (DAIR) following hip and knee arthroplasty: results and findings of a multidisciplinary approach from a non-specialist prosthetic infection centre

INTRODUCTION

Prosthetic joint infection (PJI) is a catastrophic complication following arthroplasty surgery. Recently a debridement, antibiotics and implant retention (DAIR) procedure has gained popularity for PJI where a thorough debridement, irrigation and modular component exchange is undertaken.

METHOD

We present the outcome for DAIR, data collected prospectively, in a busy orthopaedic unit but not one specialising in PJI. All patients with PJI were included without loss of data or patients from 2012 to 2018 with a minimum follow-up of 5 years.

RESULTS

Four total knee replacements, 17 total hip replacements, one revision total hip replacement and three hip hemiarthroplasties are included with an average duration from onset of symptoms to the DAIR procedure of 11 days (range 1-22 days). Staphylococcus aureus (24%) and Staphylococcus epidermidis (32%) were the most common causative organisms, and the most common antibiotic regimens included intravenous teicoplanin and flucloxacillin. Average follow-up was 67 months (range 9-104 months). Only four patients went on to require revision surgery. An analysis of midterm patient outcome measures for 6 of the total hip replacement (THR) DAIR patients were compared with a database of 792 THRs (with a minimum two-year follow-up) carried out by the same surgeon revealed no significant difference in Oxford hip scores at one-year post-surgery (OHS DAIR 36.2 vs 39 for control group).

CONCLUSION

This study includes 25 consecutive patients treated with DAIR with only one reinfection, with a mean follow-up period of 5 years. Using a strict protocol, DAIR appears to offer a successful treatment strategy for the management of early PJI.

Periprosthetic hip infection: Current concepts and the Wrightington experience

Total hip arthroplasty (THA) is a highly successful operation performed worldwide in increasing numbers for a wide range of indications. There has been a corresponding rise in the incidence of periprosthetic joint infection of the hip (PJIH), which is a devastating complication. There is a significant variation in the definition, diagnosis and management of PJIH largely due to a lack of high-level evidence. The current standard of practice is largely based on cohort studies from high-volume centres, consensus publications amongst subject experts, and national guidance. This review describes our philosophy and practical approach of managing PJIH at a regional tertiary high-volume joint replacement centre.

Appropriate Duration of Antimicrobial Treatment for Prosthetic Joint Infections: A Narrative Review

Prosthetic joint infections are considered difficult to treat they needing aggressive surgery and long antimicrobial treatments. However, the exact duration of these therapies has been established empirically. In the last years, several studies have explored the possibility of reducing the length of treatment in this setting, with conflicting results. In this narrative review, we critically appraise the published evidence, considering the different surgical approaches (implant retention [DAIR] and one-step and two-step exchange procedures) separately. In patients managed with DAIR, usually treated for at least 12 weeks, a large, randomized trial failed to show that 6 weeks were non-inferior. However, another randomized clinical trial supports the use of 8 weeks, as long as the surgical conditions are favorable and antibiotics with good antibiofilm activity can be administered. In patients managed with a two-step exchange procedure, usually treated during 6 weeks, a randomized clinical trial showed the efficacy of a 4-week course of antimicrobials. Also, the use of local antibiotics may allow the use of even shorter treatments. Finally, in the case of one-step exchange procedures, there is a trend towards reducing the length of therapy, and the largest randomized clinical trial supports the use of 6 weeks of therapy.

Suppressive Antibiotic Therapy After Debridement, Antibiotics, and Implant Retention is Well-Tolerated Without Inducing Resistance: A Multicenter Study

BACKGROUND

Suppressive antibiotic therapy (SAT) after total joint arthroplasty (TJA) debridement, antibiotics, and implant retention (DAIR) maximizes reoperation-free survival. We evaluated SAT after DAIR of acutely infected primary TJA regarding: 1) adverse drug reaction (ADR)/intolerance; 2) reoperation for infection; and 3) antibiotic resistance.

METHODS

Patients who underwent total knee arthroplasty (TKA) or total hip arthroplasty (THA) DAIR for acute periprosthetic joint infection at two academic medical centers from 2015 to 2020 were identified (n = 115). Data were collected on patient demographics, infecting organisms, antibiotics, ADR/intolerances, reoperations, and antibiotic resistances. Median SAT duration was 11 months. Stepwise multivariate logistic regressions were used to identify covariates significantly associated with outcomes of interest.

RESULTS

There were 11.1 and 16.3% of TKA and THA DAIR patients, respectively, who had ADR/intolerance to SAT. Patients prescribed trimethoprim/sulfamethoxazole (P = .0014) or combination antibiotic therapy (P = .0169) after TKA DAIR had increased risk of ADR/intolerance. There was no difference in reoperation-free survival between TKA (83.3%) and THA (65.1%) DAIR (P = .5900) at mean 2.8-year follow-up. Risk of reoperation for infection was higher among TKA Staphylococcus aureus infections (P = .0004) and lower with increased SAT duration (P < .0450). The optimal duration of SAT was nearly 2 years. No cases of antibiotic resistance developed due to SAT.

CONCLUSIONS

Consider SAT after TJA DAIR due to improved reoperation-free survival and favorable safety profile. Prolonged SAT did not induce antibiotic resistance. Use trimethoprim/sulfamethoxazole with caution because of the increased likelihood of ADR/intolerance.

LEVEL OF EVIDENCE

Therapeutic Level III.

Early switch from intravenous to oral antibiotic treatment in bone and joint infections

OBJECTIVES

The timing of the switch from intravenous (i.v.) to oral antibiotic therapy for orthopaedic bone and joint infections (BJIs) is debated. In this narrative article, we discuss the evidence for and against an early switch in BJIs.

DATA SOURCES

We performed a PubMed and internet search investigating the association between the duration of i.v. treatment for BJI and remission of infection among adult orthopaedic patients.

CONTENT

Among eight randomized controlled trials and multiple retrospective studies, we failed to find any minimal duration of postsurgical i.v. therapy associated with clinical outcomes. We did not find scientific data to support the prolonged use of i.v. therapy or to inform a minimal duration of i.v.

THERAPY

Growing evidence supports the safety of an early switch to oral medications once the patient is clinically stable.

IMPLICATIONS

After surgery for BJI, a switch to oral antibiotics within a few days is reasonable in most cases. We recommend making the decision on the time point based on clinical criteria and in an interdisciplinary team at the bedside.

Debridement, Antibiotics and Implant Retention: A Systematic Review of Strategies for Treatment of Early Infections after Revision Total Knee Arthroplasty

GOAL

The purpose of this review is to provide a systematic and comprehensive overview of the available literature on the treatment of an early prosthetic joint infection (PJI) after revision total knee arthroplasty (TKA) and provide treatment guidelines.

METHODS

This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The search was conducted using the electronic databases of PubMed, Trip, Cochrane, Embase, LILACS and SciElo. After the inclusion of the relevant articles, we extracted the data and results to compose a treatment algorithm for early and acute PJI after revision TKA.

RESULTS

After applying the in- and exclusion criteria, seven articles were included in this systematic review focusing on debridement, antibiotics and implant retention (DAIR) for PJI following revision TKA, of which one was prospective and six were retrospective. All studies were qualified as level IV evidence.

CONCLUSIONS

The current literature suggests that DAIR is a valid treatment option for early infections after revision TKA with success rates of 50-70%. Repeat DAIR shows success rates of around 50%. Further research should be aimed at predicting successful (repeat/two-stage) DAIRs in larger study populations, antibiotic regimes and the cost effectiveness of a second DAIR after revision TKA.

Two-Stage Revision Arthroplasty for Resistant Gram-Positive Periprosthetic Joint Infections Using an Oral Linezolid-Based Antibiotic Regime

BACKGROUND

Increasing antibiotic resistance has been reported as an issue in the systemic treatment of periprosthetic joint infection (PJI). Linezolid offers the advantages of high oral bioavailability and little resistance; however, efficacy in the treatment of PJI varies considerably, and studies reporting consistent surgical treatment are scarce.

METHODS

This is a retrospective, single-center analysis of two-stage revisions performed between 2008 and 2017. We identified 111 patients who met the inclusion criteria. Oral linezolid was given for 28 days following 14 days of intravenous tailored antibiotics in resistant gram-positive PJI. A total of 64% of the patients had methicillin-resistant coagulase-negative staphylococci. The median follow-up was 43 (interquartile range (IQR) 30-57) months.

RESULTS

22% (24/111) of the patients underwent surgery for subsequent infection. The 5-year infection-free survival probability was 77% (95% confidence interval (CI) 69-85). A total of 5% of the patients (6/111) had the same organism at the time of reinfection. The patients with infections caused by other organisms than Coagulase-negative staphylococci tended to have a worse reinfection-free survivorship at five years (70% vs. 81%, p = 0.09). Furthermore, the patients with obesity tended to have reduced reinfection-free survivorship at five years (69% vs. 84%, p = 0.08). Overall, 5% (6/111) of the patients had blood count abnormalities with no treatment discontinuations.

CONCLUSION

Two-stage revision arthroplasty with systemic oral linezolid treatment for resistant gram-positive PJI results in an infection control of 77% at the mid-term.

Factors Influencing the Clinical Outcomes of Two-Stage Re-Implantation in Patients With Periprosthetic Joint Infection After Total Knee Arthroplasty

Introduction Infection is one of the most distressing complications of total knee arthroplasty (TKA), requiring a long treatment process and may negatively affect patient satisfaction. All surgeons aim to achieve infection-free survival, painless, functional, and stable knee after treatment of periprosthetic joint infection (PJI) with two-stage revision treatment. Many factors play a role in determining clinical outcomes. We aimed to evaluate the factors influencing the clinical outcomes of patients undergoing two-stage revision knee arthroplasty for PJI. Methods Forty-nine patients were retrospectively evaluated. Forty-four patients met the inclusion criteria. Spacer types, growth rates in culture, types and amount of antibiotics added to the cement, and intervals between stages were evaluated. Pre- and post-treatment infection parameters, changes in the range of motion (ROM), clinical and functional (C&F) Knee Society Score (KSS) results, and complications were also studied. Results After a mean follow-up of 48.8 ± 16.5 months, re-infection was detected in five out of 44 patients (10.4%). No significant difference was noted regarding C&F KSS when comparing time intervals between the two stages, whether they were shorter or longer than 10 weeks. However, better ROM results were obtained in patients with less than 10 weeks between stages. The relationship between spacer type, ROM, and C&F KSS was not found to be significant. Particularly, the addition of 4g of teicoplanin to the cement shortened the time between the two stages. Conclusion C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels can be considered safe parameters for diagnosis, reimplantation timing, and follow-up. The use of dynamic spacers or reimplantation performed within 10 weeks after the first stage is associated with better ROM outcomes. Additionally, the addition of teicoplanin to the cement shortened the duration of antibiotic therapy.

The Impact of Antimicrobial Therapy Duration in the Treatment of Prosthetic Joint Infections Depending on Surgical Strategies: A Systematic Review and Meta-analysis

The aim of this systematic review was to address the question if short antibiotic treatment (SAT; at least 4 but <12 weeks) versus long antibiotic treatment (LAT) affects outcomes in prosthetic joint infections (PJIs). Database research (Medline, Embase, Web of Science, Scopus, Cochrane) retrieved 3740 articles, of which 10 studies were included in the analysis. Compared to LAT, 11% lower odds of treatment failure in the SAT group were found, although the difference was not statistically significant (pooled odds ratio, 0.89 [95% confidence interval, .53-1.50]). No difference in treatment failure was found between SAT and LAT once stratified by type of surgery, studies conducted in the United States versus Europe, study design, and follow-up. There is still no conclusive evidence that antibiotic treatment of PJIs for 12 weeks or longer is associated with better outcomes, irrespective of the type of surgical procedure. Most recent, high-quality studies tend to favor longer antibiotic courses, making them preferable in most situations.

One- or two-stage reimplantation for infected total knee prosthesis?

A prosthetic joint infection (PJI) is possibly the most significant potential complication of total knee arthroplasty (TKA) and is associated with substantial morbidity and socioeconomic burden. It is a devastating complication for both the patient and the surgeon alike. A two-stage revision approach for infected TKA has been the standard for surgical management; however, there is growing interest in single-stage revision surgery due to fewer procedures, reduced inpatient hospital stay and reduced costs to healthcare systems. A one-stage exchange is indicated when there is no sign of systemic sepsis and in cases where a microorganism has been isolated. It involves removal of the old prosthesis, debridement of all infected tissue, a copious washout and re-draping, and finally, re-implantation of a new prosthesis. The two-stage approach involves the use of an antibiotic spacer before the second stage is carried out. The length of time between the stages is discussed. Patients with a PJI should be managed by a multidisciplinary team. We recommend these patients are managed in specialist arthroplasty centres by high volume revision arthroplasty specialists.

Influence of the Type of Bone Cement Used in Two-Stage Exchange Arthroplasty for Chronic Periarticular Joint Infection on the Spacer Replacement and Reinfection Rate

BACKGROUND

Antibiotic-loaded bone cement (ALBC) spacers are used in the first stage when treating periprosthetic joint infection (PJI). This study aimed to investigate whether a spacer made from commercial ALBC or plain bone cement with additional antibiotics could affect the spacer exchange rate before reimplantation.

METHODS

Patients undergoing two-stage exchange arthroplasty due to chronic PJI from January 2014 to August 2021 were retrospectively reviewed. The exclusion criteria included arthroplasty in the setting of septic arthritis, megaprosthesis, atypical pathogen infection, spacer placement unrelated to PJI, and spacer exchange due to mechanical complications. The patient demographics, brand of cement, and microbiology were recorded manually. The primary outcome was the incidence of spacer exchange due to persistent infection and the secondary outcome was the incidence of reinfection after reimplantation. A multivariate logistic regression analysis and Chi-square test were conducted to identify the effect of cement type on the spacer exchange.

RESULTS

A total of 334 patients underwent two-stage exchange arthroplasty for PJI. The spacer exchange rates in the commercial and non-commercial ALBC groups were 6.4% and 25.1%, respectively (p = 0.004). After controlling for confounding factors, there were significant differences between the commercial group and non-commercial groups in the spacer exchange rate (adjusted OR = 0.25; 95% CI = 0.72-0.87, p = 0.029). The use of commercial ALBC was not associated with a lower reinfection rate after reimplantation (p = 0.160).

CONCLUSIONS

In a two-stage exchange arthroplasty scenario, the spacer comprised of commercial ALBC resulted in a lower spacer exchange rate than the plain bone cement, both of which had additional antibiotics. However, the use of commercial ALBC was not associated with a lower incidence of reinfection following reimplantation.

A simple method to improve the antibiotic elution profiles from polymethylmethacrylate bone cement spacers by using rapid absorbable sutures

OBJECTIVE

Antibiotic-loaded bone cement beads and spacers have been widely used for orthopaedic infection. Poor antibiotic elution is not capable of eradicating microbial pathogens and could lead to treatment failure. The elution profiles differ among different cement formulations. Although Simplex P cement has the least release amount, it is widely used due to its ready availability. Previous methods aiming to improve the elution profiles were not translated well to clinical practice. We sought to address this by using easily available materials to improve the elution profile of antibiotics from PMMA, which allows clinicians to implement the method intraoperatively.

METHODS

Vancomycin was mixed with Simplex P cement. We used Vicryl Rapide sutures to fabricate sustained-release cement beads by repetitively passing the sutures through the beads and/or mixing suture segments into the cement formulation. Vancomycin elution was measured for 49 days. The mechanism of antibiotic release was observed with gross appearance and scanning electron microscopic images. The antimicrobial activities against MRSA were tested using an agar disk diffusion bioassay.

RESULTS

Passing Vicryl Rapide sutures through cement beads significantly improved the elution profiles in the 7-week period. The increased ratios were 9.0% on the first day and 118.0% from the 2nd day to the 49th day. Addition of suture segments did not increase release amount. The Vicryl Rapide sutures completely degraded at the periphery and partially degraded at the center. The antibiotic particles were released around the suture, while antibiotic particles kept densely entrapped in the control group. The antimicrobial activities were stronger in passing suture groups.

CONCLUSION

Passing fast absorbable sutures through PMMA cement is a feasible method to fabricate sustained-release antibiotic bone cement. Intra-cement tunnels can be formed, and the effect can last for at least 7 weeks. It is suitable for a temporary spacer between two stages of a revision surgery.

Intravenous antibiotic duration in the treatment of prosthetic joint infection: systematic review and meta-analysis

Introduction: Long antibiotic courses, including intravenous (IV) and oral administrations, are utilized in prosthetic joint infection (PJI) treatment. This meta-analysis examines the non-inferiority of short courses ( <  4 weeks) of IV antibiotics compared to long courses in treating PJI. Critical review of IV treatment is necessary due to the clinical, physical, and financial burden associated with it and its continued prolonged use in the US without much evidence to support the practice. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), databases were searched using predefined medical subject headings (MeSH). Results: The nine included studies reported 521 total hip arthroplasties (THAs) and 530 total knee arthroplasties (TKAs). There was no significant difference in the overall success rate in short- vs. long-duration IV antibiotics for PJI treatment: odds ratio (OR) of 1.65, 95 % confidence interval (CI) of 0.78-3.46, and p = 0 .18. However, due to the moderate to high heterogeneity (I 2 = 68  %, p   <  0.01) amongst studies, an adjusted success rate was calculated after the exclusion of two studies. This showed a statistically significant difference between both groups (OR of 2.45, 95 % CI of 1.21-4.96, p   <  0.001) favoring a short course of antibiotics and reflecting a more homogenous population (I 2 = 51  %, p = 0 .06). Conclusion: This study highlights the limited data available for evaluating IV antibiotic duration in the setting of PJI. We found that a shorter duration of IV antibiotics was non-inferior to a longer duration, with an improved OR of 2.45 for treatment success, likely shortening inpatient stay as well as lessening side effects and antimicrobial resistance with a lower cost to patients and overall healthcare.

A review of current practices in periprosthetic joint infection debridement and revision arthroplasty

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.

Differences in Efficacy between Short- and Long-Course Antibiotic Agents for Joint Prosthesis Infection: A Systematic Review and Meta-Analysis

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.

Intra-articular versus systemic vancomycin for the treatment of periprosthetic joint infection after debridement and spacer implantation in a rat model

Aims

Treatment outcomes for methicillin-resistant Staphylococcus aureus (MRSA) periprosthetic joint infection (PJI) using systemic vancomycin and antibacterial cement spacers during two-stage revision arthroplasty remain unsatisfactory. This study explored the efficacy and safety of intra-articular vancomycin injections for PJI control after debridement and cement spacer implantation in a rat model.

Methods

Total knee arthroplasty (TKA), MRSA inoculation, debridement, and vancomycin-spacer implantation were performed successively in rats to mimic first-stage PJI during the two-stage revision arthroplasty procedure. Vancomycin was administered intraperitoneally or intra-articularly for two weeks to control the infection after debridement and spacer implantation.

Results

Rats receiving intra-articular vancomycin showed the best outcomes among the four treatment groups, with negative bacterial cultures, increased weight gain, increased capacity for weightbearing activities, increased residual bone volume preservation, and reduced inflammatory reactions in the joint tissues, indicating MRSA eradication in the knee. The vancomycin-spacer and/or systemic vancomycin failed to eliminate the MRSA infections following a two-week antibiotic course. Serum vancomycin levels did not reach nephrotoxic levels in any group. Mild renal histopathological changes, without changes in serum creatinine levels, were observed in the intraperitoneal vancomycin group compared with the intra-articular vancomycin group, but no changes in hepatic structure or serum alanine aminotransferase or aspartate aminotransferase levels were observed. No local complications were observed, such as sinus tract or non-healing surgical incisions.

Conclusion

Intra-articular vancomycin injection was effective and safe for PJI control following debridement and spacer implantation in a rat model during two-stage revision arthroplasties, with better outcomes than systemic vancomycin administration.

Cite this article: Bone Joint Res 2022;11(6):371–385.

Do Serum C-Reactive Protein Trends Predict Treatment Outcome in Patients with Knee Periprosthetic Joint Infection Undergoing Two-Stage Exchange Arthroplasty?

Two-stage exchange arthroplasty is the standard treatment for knee periprosthetic joint infection (PJI). This study aimed to determine whether serial changes in C-reactive protein (CRP) values can predict the prognosis in patients with knee PJI. We retrospectively enrolled 101 patients with knee PJI treated with two-stage exchange arthroplasty at our institution from 2010 to 2016. We excluded patients with spacer complications and confounding factors affecting CRP levels. We tested the association between treatment outcomes and qualitative CRP patterns or quantitative CRP levels. Of the 101 patients, 24 (23.8%) had recurrent PJI and received surgical intervention after two-stage reimplantation. Patients with a fluctuating CRP pattern were more likely to receive antibiotics for a longer period (p < 0.001). There was greater risk of treatment failure if the CRP levels were higher when antibiotics were switched from an intravenous to oral form (p = 0.023). The patients who received antibiotics for longer than six weeks (p = 0.017) were at greater risk of treatment failure after two-stage arthroplasty. Although CRP patterns cannot predict treatment outcomes, CRP fluctuation in the interim period was associated with longer antibiotic duration, which was related to a higher treatment failure rate.

A Retrospective Observational Cohort Study of Periprosthetic Hip Infection Treated by one-stage Method Including Cases With Bone Graft Reconstruction

Purpose:

Prosthetic joint infection (PJI) is a devastating complication that can affect hip arthroplasty. Its treatment is extremely difficult, and issues regarding the optimal treatment remain unanswered. This study intended to show the effectiveness of the one-stage treatment of PJI.

Materials and Methods:

A retrospective observational cohort study performed from July 2014- August 2018. All patients with suspected PJI were included. Major and minor criteria developed by the International Consensus on Periprosthetic Joint Infection (ICPJI) was used to define infection. Laboratory tests and image exams were performed, and all patients were followed for at least 2 years.

Outcomes:

Success rate (2018 ICPJI definition to success) in treatment of PJI using one-stage revision method. Clinical and functional outcomes defined by Harris Hip Score (HHS).

Results:

Thirty-one patients were screened and 18 analyzed. 69.85 ± 9.76 years was the mean age. Mean follow-up time was 63.84 ± 18.55 months. Ten patients had acetabular defects and required bone graft reconstruction. Sixteen patients were classified as Tier 1, 1 as Tier 3D, and as 1 Tier 3E. Almost 90% of patients submitted to one-stage revision with acetabulum graft reconstruction were free of infection. The overall infection survival rate was 78.31±6.34 months. Candida albicans and sinus tract were statistically significant in univariate Cox’s analysis. The predictor of one-stage revision surgery failure that remained final Cox’s regression model was C. albicans (hazard ratio [HR]: 4.47).

Conclusion:

Treatment through one-stage revision surgery associated with 6 months of antimicrobial is a viable option with acceptable results even when bone graft reconstruction is necessary. C. albicans was a strong predictor of failure in this cohort.

Comparison of the success rate after debridement, antibiotics and implant retention (DAIR) for periprosthetic joint infection among patients with or without a sinus tract

BACKGROUND

The relevance between the presence of a sinus tract and the failure risk after debridement, antibiotics and implant retention (DAIR) for periprosthetic joint infection (PJI) after hip or knee arthroplasty is still unclear. This study aimed to compare the success rate of DAIR between patients with or without a sinus tract and to explore the possible risk factors for failure after DAIR in patients with a sinus tract.

METHODS

Consecutive DAIR cases for PJI after hip or knee arthroplasty between January 2009 and June 2019 with a minimum 1-year follow-up in two tertiary joint arthroplasty centers were included. Patients were classified into the sinus tract group and the non-sinus tract group according to the presence of a sinus tract. The success rate after DAIR were compared using Kaplan-Meier survival analysis. Potential risk factors for failure in the sinus group were also explored.

RESULTS

One hundred seven patients were included. At a median 4.4 years of follow-up, 19 of 52 (36.5%) cases failed in the sinus tract group, while 15 of 55 (27.3%) cases failed in the non-sinus tract group. The 1-year and 5-year cumulative success rates were 71.2% (95% confidence interval (CI): 59.8-84.6%) and 56.8% (95% CI: 42.6-75.7%) in the sinus tract group, respectively, which were similar to the counterparts in the non-sinus tract group (P = 0.214). Among patients with a sinus tract, DAIR with the exchange of modular components showed a higher success rate (75.8% versus 47.4%, P = 0.038).

CONCLUSIONS

The presence of a sinus tract does not affect the success rate of DAIR. Modular component exchange in DAIR was proposed for patients with a sinus tract for an improved infection control rate.

Osteoarticular infections: a specific program for older patients?

BACKGROUND

With the increasing number of elderly patients, arthroplasties, fractures and diabetic foot infections, the worldwide number of osteoarticular infections (OAI) among the elderly is concomitantly expected to rise.

AIMS

We explore existing scientific knowledge about OAI in the frail elderly population.

METHODS

We performed a literature search linking OAIs to geriatric patients and comparing elderly patients (> 65 years) with average adults (range 18-65 years).

RESULTS

In this literature, financial aspects, comparison of diverse therapies on quality of life, reimbursement policies, or specific guidelines or nursing recommendations are missing. Age itself was not an independent factor related to particular pathogens, prevention of OAI, nursing care, and outcomes of OAI. However, geriatric patients were significantly more exposed to adverse events of therapy. They had more co-morbidities and more conservative surgery for OAI.

CONCLUSION

Available literature regarding OAI management among elderly patients is sparse. In recent evaluations, age itself does not seem an independent factor related to particular epidemiology, pathogens, prevention, nursing care, rehabilitation and therapeutic outcomes of OAI. Future clinical research will concern more conservative surgical indications, but certainly reduce inappropriate antibiotic use.

Trends in the treatment of infected knee arthroplasty

Essential treatment methods for infected knee arthroplasty involve DAIR (debridement, antibiotics, and implant retention), and one and two-stage exchange arthroplasty.Aggressive debridement with the removal of all avascular tissues and foreign materials that contain biofilm is mandatory for all surgical treatment modalities.DAIR is a viable option with an acceptable success rate and can be used as a first surgical procedure for patients who have a well-fixed, functioning prosthesis without a sinus tract for acute-early or late-hematogenous acute infections with no more than four weeks (most favourable being < seven days) of symptoms. Surgeons must focus on the isolation of the causative organism with sensitivities to bactericidal treatment as using one-stage exchange.One-stage exchange is indicated when the patients have:minimal bone loss/soft tissue defect allowing primary wound closure,easy to treat micro-organisms,absence of systemic sepsis andabsence of extensive comorbidities.There are no validated serum or synovial biomarkers to determine optimal timing of re-implantation for two-stage exchange.Antibiotic-free waiting intervals and joint aspiration before the second stage are no longer recommended. The decision to perform aspiration should be made based on the index of suspicion for persistent infection.Re-implantation can be performed when the treating medical team feels that the clinical signs of infection are under control and serological tests are trending downwards. Cite this article: EFORT Open Rev 2020;5:672-683. DOI: 10.1302/2058-5241.5.190069.

Short-course versus long-course antibiotics in prosthetic joint infections: a systematic review and meta-analysis of one randomized controlled trial plus nine observational studies

BACKGROUND

Prosthetic joint infections (PJIs) often require long-course antibiotic therapy. However, recent studies argue against the current practice and raise concerns such as the development of antibiotic resistance, side effects of medications and medical costs.

OBJECTIVES

To review and compare the outcomes of short-course and long-course antibiotics in PJIs.

METHODS

We conducted a systemic review and meta-analysis using a predefined search term in PubMed and EMBASE databases. Studies that met the inclusion criteria from inception to June 2018 were included. The quality of the included studies was assessed.

RESULTS

A total of 10 articles and 856 patients were analysed, comprising 9 observational studies and 1 randomized controlled trial. Our meta-analysis showed no significant difference between short-course and long-course antibiotics (relative risk = 0.87, 95% CI = 0.62-1.22). Additionally, the older the studied group was, the more short-course antibiotics were favoured.

CONCLUSIONS

When treating PJI patients following debridement, antibiotics and implant retention, an 8 week course of antibiotic therapy for total hip arthroplasty and a 75 day course for total knee arthroplasty may be a safe approach. For two-stage exchange, a shorter duration of antibiotic treatment during implant-free periods is also generally safe with the usage of antibiotic-loaded cement spacers.

Four versus six weeks of antibiotic therapy for osteoarticular infections after implant removal: a randomized trial

BACKGROUND

The optimal duration of antibiotic therapy for treating orthopaedic implant infections after surgical drainage and complete implant removal is unknown.

METHODS

This was a single-centre, unblinded, prospective trial randomizing (1:1) eligible patients to either 4 or 6 weeks of systemic, pathogen-targeted antibiotic therapy. Clinical trial registration number: ClinicalTrials.gov (NCT0362209).

RESULTS

We analysed 123 eligible patients (62 in the 4 week antibiotic arm and 61 in the 6 week arm) in the ITT analysis. The patients' median age was 64 years, 75 (61%) were men and 38 (31%) were immunocompromised. The most common types of infection treated included: two-stage exchange procedure for prosthetic joint infection (n = 38); orthopaedic plate infection (44) and infected nail implants (11). The median duration of post-explant intravenous antibiotic therapy was 4 days. Overall, 120 episodes (98%) were cured microbiologically and 116 (94%) clinically after a median follow-up period of 2.2 years. During follow-up, four patients had a clinical recurrence with a pathogen other than the initial causative agent. We noted recurrence of clinical infection in four patients in the 4 week arm and three patients in the 6 week arm (4/62 versus 3/61; χ2 test; P = 0.74); in all cases, this occurred at around 2 months following the end of antibiotic treatment.

CONCLUSIONS

We found no statistically significant difference in the rates of clinical or microbiological remission between patients randomized to only 4 compared with 6 weeks of systemic antibiotic therapy after removal of an infected osteoarticular implant.

Longitudinal Model of Periprosthetic Joint Infection in the Rat

The majority of periprosthetic joint infections occur shortly after primary joint replacement (<3 months) and require the removal of all implant components for the treatment period (~4 months). A clinically relevant animal model of periprosthetic infection should, therefore, establish an infection with implant components in place. Here, we describe a joint replacement model in the rat with ultrahigh molecular weight polyethylene (UHMWPE) and titanium components inoculated at the time of surgery by methicillin-sensitive Staphylococcus aureus (S. aureus), which is one of the main causative microorganisms of periprosthetic joint infections. We monitored the animals for 4 weeks by measuring gait, weight-bearing symmetry, von Frey testing, and micro-CT as our primary endpoint analyses. We also assessed the infection ex vivo using colony counts on the implant surfaces and histology of the surrounding tissues. The results confirmed the presence of a local infection for 4 weeks with osteolysis, loosening of the implants, and clinical infection indicators such as redness, swelling, and increased temperature. The utility of specific gait analysis parameters, especially temporal symmetry, hindlimb duty factor imbalance, and phase dispersion was identified in this model for assessing the longitudinal progression of the infection, and these metrics correlated with weight-bearing asymmetry. We propose to use this model to study the efficacy of using different local delivery regimens of antimicrobials on addressing periprosthetic joint infections. Statement of clinical significance: We have established a preclinical joint surgery model, in which postoperative recovery can be monitored over a multi-week course by assessing gait, weight-bearing, and allodynia. This model can be used to study the efficacy of different combinations of implant materials and medication regimens. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:1101-1112, 2020.

Six-week antibiotic therapy after one-stage replacement arthroplasty for hip and knee periprosthetic joint infection

OBJECTIVES

One-stage replacement arthroplasty for treatment of periprosthetic joint infection (PJI) results in similar cure rate than two-stage (around 85-92%), but antibiotic therapy duration is not well established. The aim of this study was to evaluate the efficacy of a short six-week antibiotic course in periprosthetic joint infections after onstage exchange.

PATIENTS AND METHODS

Retrospective, observational study conducted at Orthopaedic Department of Cochin Hospital, Paris, between 1st January 2010 and 31 December 2015. Patients with a microbiologically proven PJI, treated with one-stage replacement and 6 weeks (+/1week) of antimicrobial therapy were included. Pearson's-χ² and Wilcoxon tests were used to compare categorical and continuous variables.

RESULTS

Fifty patients with periprosthetic joint infections (42 hip, 8 knee PJI) treated with one-stage replacement arthroplasty were included. Median age was 69.3 years (IQR 24.5-97.4). Infections occurred after a mean of 36 months (IQR 1-216). Bone biopsy cultures were positive for Staphylococcus spp. in 29 patients (58%), Cutibacterium acnes in 19 (38%), Gram-negative bacilli in 6 (12%). Polymicrobial infections occurred in 12 (24%). Intravenous antibiotics were administered for a median of 11 days (IQR 4-45) and 46 patients (92%) were switched to an oral therapy. Medium follow-up was of 32 months (IQR 12-101). Overall remission rate was 90%.

CONCLUSIONS

A six-week course of antibiotics in knee and hip PJIs treated with one-stage RA has a satisfactory remission rate in this open study.

Optimization of the antibiotic management of diabetic foot infections: protocol for two randomized controlled trials

BACKGROUND

Few studies have addressed the appropriate duration of antibiotic therapy for diabetic foot infections (DFI) with or without amputation. We will perform two randomized clinical trials (RCTs) to reduce the antibiotic use and associated adverse events in DFI.

METHODS

We hypothesize that shorter durations of postdebridement systemic antibiotic therapy are noninferior (10% margin, 80% power, alpha 5%) to existing (long) durations and we will perform two unblinded RCTs with a total of 400 DFI episodes (randomization 1:1) from 2019 to 2022. The primary outcome for both RCTs is remission of infection after a minimal follow-up of 2 months. The secondary outcomes for both RCTs are the incidence of adverse events and the overall treatment costs. The first RCT will allocate the total therapeutic amputations in two arms of 50 patients each: 1 versus 3 weeks of antibiotic therapy for residual osteomyelitis (positive microbiological samples of the residual bone stump); or 1 versus 4 days for remaining soft tissue infection. The second RCT will randomize the conservative approach (only surgical debridement without in toto amputation) in two arms with 50 patients each: 10 versus 20 days of antibiotic therapy for soft tissue infections; and 3 versus 6 weeks for osteomyelitis. All participants will have professional wound debridement, adequate off-loading, angiology evaluation, and a concomitant surgical, re-educational, podiatric, internist and infectiology care. During the surgeries, we will collect tissues for BioBanking and future laboratory studies.

DISCUSSION

Both parallel RCTs will respond to frequent questions regarding the duration of antibiotic use in the both major subsets of DFIs, to ensure the quality of care, and to avoid unnecessary excesses in terms of surgery and antibiotic use.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04081792. Registered on 4 September 2019.

Loading capacity of dynamic knee spacers: a comparison between hand-moulded and COPAL spacers

Background

The two-stage revision protocol represents the current gold standard for treating infected total knee replacement implants. Allowing early mobility with weight-bearing between staged procedures will enable early restoration to knee function. So, the mechanical performance of knee spacers is a key issue. Commercially available moulds are often used as they are easy to prepare and produce smoother surfaces of the articulating parts. However, they are costly, and only for single use. A cost-effective alternative is the surgeon-made hand-moulded spacers. In this study, we wanted to determine how the hand-moulded spacers will compare biomechanically with the commercially available COPAL spacers.

Methods

Seven cadaveric knees were implanted with knee spacers fabricated using COPAL knee moulds. The same surgeon implanted eight cadaveric knees with hand-moulded spacers. In the first test protocol, an axial load was applied at 200 mm/min till failure. In the second test protocol, the knees were cyclically loaded in five steps of 1000 cycles each from 30-400 N, 30-600 N, 30-800 N, 30-1000 N, 30-1200 N at 1.5 Hz.

Results

COPAL knee spacers demonstrated a maximum load and mean stiffness of 5202 (± 486.9) N and 1098 (± 201.5) N/mm respectively. The hand-moulded knee spacers demonstrated a mean stiffness of 4509 (± 1092.6) N and 1008.7 (± 275.4) N/mm respectively. The maximum axial displacement was 1.19 ± 0.57 mm and 0.89 ± 0.30 mm for specimens implanted with COPAL knee spacers and hand-moulded spacers respectively. The differences between COPAL and hand-moulded knee spacers were not statistically different.

Conclusions

Our study demonstrated that dynamic knee spacers may be able to withstand more than the touch-down load permitted in previous studies, and this may allow more weight-bearing during ambulation. Previous studies have demonstrated that hand-moulded knee spacers have similar advantages to commercially available dynamic spacers with respect to mobility, pain, bone loss, and reinfection rate. Given that ambulation with weight-bearing up to 1200 N is permitted during rehabilitation, it may be more cost-effective to fabricate hand-moulded spacers in revision total knee arthroplasty.

What Is the Optimal (Type, Dose and Route of Administration) Antibiotic Treatment for Patients With Infected Total Ankle Arthroplasty (TAA)?

RECOMMENDATION

Though literature specific to total ankle arthroplasty (TAA) is lacking, based on recommendations for the management of hip and knee arthroplasties, the choice of antibiotic should be made based on the identification and sensitivities of the infecting organism(s). Dosing, frequency, and route of administration of antibiotics may be determined in consultation with an infectious disease specialist and by taking into account the patient's weight and comorbidities, such as renal impairment and the antibiogram.

LEVEL OF EVIDENCE

Consensus.

DELEGATE VOTE

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

Partial two-stage exchange at the site of periprosthetic hip joint infections

INTRODUCTION

In the past 10 years an increasing number of studies about partial two-stage exchange arthroplasty in the management of periprosthetic hip infections have been published. The aim of the present work was to systematically review the current knowledge about this procedure, and critically verify the success as well as the complications of this treatment option.

MATERIALS-METHODS

A literature search was performed through PubMed until June 2018. Search terms were "partial two stage hip" and "partial retention hip", and "retaining well fixed hip".

RESULTS

A total of 7 studies reporting on a total of 80 patients could be identified. All studies had a level of evidence IV. The great majority of the studies reported on the isolated removal of the acetabular cup and placement of an antibiotic-loaded cement spacer head onto the retained, well-fixed stem. Most of the periprosthetic infections were caused by staphylococci. The infection eradication rate varied between 81.3 and 100% at a mean follow-up between 19 and 70 months. Poor outcome was observed at the site of MRSA infections.

CONCLUSIONS

The partial two-stage exchange arthroplasty appears to be a possible option in the management of PJI when one prosthetic component is well-fixed so that their removal might result in significant bone loss and compromise of fixation at the time of the later prosthesis reimplantation, and the causative organisms are not multiresistant. The small numbers published about this protocol does not allow for a generalization of application and should be only applied in highly selected patients. Future studies with larger collectives and longer follow-ups are welcome to evaluate the clinical success of this option and its possible role in the management of PJI.

The Benefice of Mobile Parts' Exchange in the Management of Infected Total Joint Arthroplasties with Prosthesis Retention (DAIR Procedure)

Background: The management of prosthetic joint infections (PJI) with debridement and retention of the implant (DAIR) has its rules. Some authors claim that lacking the exchange of mobile prosthetic parts is doomed to failure, while others regard it as optional. Methods: Single-center retrospective cohort in PJIs treated with DAIR. Results: We included 112 PJIs (69 total hip arthroplasties, 9 medullary hip prostheses, 41 total knee arthroplasties, and 1 total shoulder arthroplasty) in 112 patients (median age 75 years, 52 females (46%), 31 (28%) immune-suppressed) and performed a DAIR procedure in all cases-48 (43%) with exchange of mobile parts and 64 without. After a median follow-up of 3.3 years, 94 patients (84%) remained in remission. In multivariate Cox regression analysis, remission was unrelated to PJI localization, pathogens, number of surgical lavages, duration of total antibiotic treatment or intravenous therapy, choice of antibiotic agents, immune-suppression, or age. In contrast, the exchange of mobile parts was protective (hazard ratio 1.9; 95% confidence interval 1.2⁻2.9). Conclusions: In our retrospective single-center cohort, changing mobile parts of PJI during the DAIR approach almost doubled the probability for long-term remission.

Remission in diabetic foot infections: Duration of antibiotic therapy and other possible associated factors

AIM

To determine the most appropriate duration of antibiotic therapy for diabetic foot infections (DFIs).

METHODS

Using a clinical pathway for adult patients with DFIs (retrospective cohort analysis), we created a cluster-controlled Cox regression model to assess factors related to remission of infection, emphasizing antibiotic-related variables. We excluded total amputations as a result of DFI and DFI episodes with a follow-up time of <2 months.

RESULTS

Among 1018 DFI episodes in 482 patients, we identified 392 episodes of osteomyelitis, 626 soft tissue infections, 246 large abscesses, 322 episodes of cellulitis and 335 episodes of necrosis; 313 cases involved revascularization. Patients underwent surgical debridement for 824 episodes (81%), of which 596 (59%) required amputation. The median total duration of antibiotic therapy was 20 days. After a median follow-up of 3 years, 251 of the episodes (24.7%) were followed by ≥1 additional episode(s). Comparing patients with and without additional episodes, risk of recurrence was lower in those who underwent amputation, had type 1 diabetes, or underwent revascularization. On multivariate analysis including the entire study population, risk of remission was inversely associated with type 1 diabetes (hazard ratio [HR] 0.3, 95% confidence interval [CI] 0.2-0.6). Neither duration of antibiotic therapy nor parenteral treatment affected risk of recurrence (HR 1.0, 95% CI 0.99-1.01 for both). Similarly, neither >3 weeks versus <3 weeks of therapy, nor >1 week versus <1 week of intravenous treatment affected recurrence. In stratified analyses for both soft tissue DFIs or osteomyelitis separately, we did not observe associations of antibiotic duration with microbiological or clinical recurrences of DFI. The HRs were 1.0 (95% CI 0.6-1.8) for an antibiotic duration >3 weeks overall and 0.6 (95% CI 0.2-1.3) for osteomyelitis cases only. Plotting of duration of antibiotic therapy failed to identify any optimal threshold for preventing recurrences.

CONCLUSIONS

Our analysis found no threshold for the optimal duration or route of administration of antibiotic therapy to prevent recurrences of DFI. These limited data might support possibly shorter treatment duration for patients with DFI.

Role of Rifampin against Staphylococcal Biofilm Infections In Vitro, in Animal Models, and in Orthopedic-Device-Related Infections

Rifampin has been used as an agent in combination therapy in orthopedic device-related infections (ODRI) for almost three decades. The aim of this review is to provide data regarding the role of rifampin against biofilm infection in vitro, in animal models, and in clinical ODRI. Available data are gathered in order to present the rational use of rifampin combinations in patients with periprosthetic joint infection (PJI). The role of rifampin is well defined in patients with PJI and is indicated in those who fulfill the Infectious Diseases Society of America criteria for debridement and implant retention or one-stage exchange. It should be used with care because of the danger of rapid emergence of resistance. Potential drug interactions should be considered.

Debridement, antibiotics and implant retention for periprosthetic joint infections: A systematic review and meta-analysis of treatment outcomes

OBJECTIVES

We aimed to assess infection control rates after DAIR in patients with periprosthetic joint infection (PJI) following joint arthroplasty and evaluate factors associated with infection control using a systematic review and meta-analysis.

METHODS

We searched MEDLINE, EMBASE, Web of Science, Cochrane databases and reference lists of relevant studies up to May 2017. Longitudinal studies conducted in patients with PJI treated exclusively by DAIR were eligible. Infection control rates were meta-analysed using random-effect models after arcsine transformation.

RESULTS

We included 93 articles based on 99 unique observational studies with data on 4897 PJIs treated by DAIR. The infection control rate for DAIR ranged from 11.1% to 100% with an overall pooled estimate of 61.4% (95% CI, 57.3-65.4) and a 95% prediction interval of 25.5% to 91.8%. Infection control rates remained generally similar for several relevant characteristics, except for evidence of variation by age, geographical location, type of infection and joint affected, duration of parenteral antibiotic therapy after the DAIR procedure, and period (year) of DAIR procedure.

CONCLUSIONS

The DAIR approach remains an option for the treatment of PJI as it is associated with acceptable infection control rates, particularly in acute postoperative infections and infections of the hip and shoulder joints.

The proper timing of second-stage revision in treating periprosthetic knee infection: reliable indicators and risk factors

Background

Two-stage revision is the standard procedure for periprosthetic knee infection. But when to perform the second-stage is still under debate. We attempt to search the reliable indicators, risk factors, and proper timing for the second-stage revision.

Methods

We reviewed and followed 81 infected total knee arthroplasty patients who underwent two-stage revision from January 2010 to January 2014. Our cohort included 56 males and 25 females, all patients were confirmed as PJI with the same phenotypic cultures. The average age was 64.8 ± 8.21 (range 36–78) months. The mean follow-up time was 46.5 ± 17.6 (range 12–72) months after the second-stage surgeries. The diagnostic parameters including serum C-reaction protein, erythrocyte sedimentation rate, and intraoperative frozen section at the time of re-implantation were analyzed. The spacer detention time and antibiotic treatment time were compared.

Results

Ten of them went through failed first- or second-stage surgeries. The overall success rate was 87.7%. The intraoperative frozen section is a good indicator at the time of re-implantation; the sensitivity and specificity is 90 and 83.1%. Serum CRP and ESR showed poor diagnostic value at time of re-implantation. Atypical pathogen infection, positive FS, and previous sinus were high-risk factors for failure of two-stage revision. Spacer detention time between 12 and 16 weeks had higher success rate than over 16 weeks.

Conclusion

The proper timing of re-implantation should be combined with disappearance of clinical symptoms and negative intraoperative FS with spacer detention time at 12 to 16 weeks.

Ozone therapy in conjunction with oral antibiotics as a successful primary and sole treatment for chronic septic prosthetic joint: review and case report

The world is facing crisis in management of infectious diseases. The mainstay of treatment has been chemical anti-infectives. These drugs are failing, as superbugs emerge and medicine becomes more sophisticated with treatments such as prosthetic devices, which can harbor bacteria protected by biofilm. This case report describes a 68-year-old woman who received bilateral artificial hips on October 27, 2015. The right hip prosthesis subsequently became septic by June 2016. Three orthopedic surgeons offered her a several month program, which included removal of the prosthesis, implantation of an antibiotic impregnated “spacer” and months of intravenous antibiotics. Instead, she sought and received intravenous ozone therapy, local joint ozone gas injection, and nutritional supplements. She quickly improved. Subsequently, she was given oral Augmentin (875 mg three times daily) beginning at September 19, 2016 for 1 month, when a third culture returned positive for two oral organisms. She experienced even more rapid improvement. By October 12, she reported total resolution of symptoms. A subsequent MRI on November 30, 2016 showed total clearance of infection. This is the first report of a septic prosthetic joint infection completely resolving without some form of surgical intervention, debridement at the least. It is also the first to report such cure without the use of any parenteral antibiotics. This case and world literature suggest that ozone therapy could be considered as a useful adjunctive treatment for hard to treat infection and biofilm.

Prosthetic Joint Infections: an Update

PURPOSE OF REVIEW

Prosthetic joint infection (PJI) is a rare but serious complication that is frequently misdiagnosed. We aimed to highlight the nuances of PJI diagnosis and antimicrobial therapies and provide clarity in key areas of management.

RECENT FINDINGS

Current research in PJI centers on a potential role for diagnostic biomarkers, molecular techniques, and implant sonication to reduce culture-negativity rates. The optimal duration of antimicrobial therapy remains controversial. A high clinical index of suspicion for PJI combined with data from multiple preoperative and intraoperative tests enables timely diagnosis and treatment. Biomarkers, molecular methods, and implant sonication are currently adjunctive to traditional diagnostic techniques. Shorter courses of antimicrobial therapies as well as the role of chronic suppressive therapy need confirmation by randomized controlled trials. Existing practices for preoperative dental prophylaxis and treatment of asymptomatic bacteriuria warrant revision based on evidence arguing against risk for PJI.

[Treatment of periprosthetic infections]

The increasing number of prosthesis implantations and higher life expectancy lead to a growing number of periprosthetic infections (PPI). Optimal therapy necessitates interdisciplinary coordination of surgical and antimicrobial treatment. Challenges in the treatment are the increased occurrence of resistant pathogens, selection of adequate antimicrobial and surgical treatment strategies, inappropriate pretreatment and comorbidities of patients. Current treatment concepts lead to a high success rate in terms of infection eradication, when correctly applied. The individual expectations and underlying conditions of each patient must be considered when determining the therapy concept. The first step is to distinguish between acute and chronic infections. In acute infections the prosthesis can be retained but chronic infections necessitate a complete exchange of the prosthesis. Complicating factors, such as compromising soft tissue and bone conditions, osteomyelitis and infections caused by difficult-to-treat bacteria should, however, always be treated by a complete exchange of the prosthesis, even for acute infections. The antimicrobial treatment must be tailored to the causative agent, the surgical strategy as well as comorbidities and drug intolerances of the patient. It is important to distinguish between biofilm-active eradication therapy with rifampicin for gram-positive pathogens and quinolones for gram-negative organisms and suppression therapy. This article gives a structured presentation of the therapy algorithm.

Periprosthetic knee infection: two stage revision surgery

Periprosthetic joint infection (PJI) remains a serious complication following a total joint replacement.  Diagnosis and management of PJI is challenging for surgeons since there is no "gold standard". This challenging condition requires a coordinated management approach to achieve good patient outcomes. Further difficulties involve choosing the optimal method to treat the periprosthetic joint infection. In this article, it is stressed the role of the two-stage revision: implant removal, debridement and placement of an antibiotic spacer, and antibiotic therapy with cessation prior to reimplantation. Published literature shows that two stage revision is a valid treatment option for periprosthetic joint infection.

Peri-Prosthetic Knee Infection Management: Spacers Loaded with Two or Three Antibiotic Agents

BACKGROUND

The purpose of this work was to compare pre-made antibiotic-loaded spacers with two commercially available antibiotic agents and custom-made cements with three antibiotic agents added. We evaluated: (a) the validity of our procedures, (b) the control of the rate of infection in the long term, (c) complications, and (d) quality of life and patient satisfaction.

METHODS

A retrospective cohort study was performed on 112 consecutively treated patients between January 2010 and December 2013; 56 patients were treated with a pre-formed cement spacer (clindamycin + gentamicin), and 56 patients were treated with a spacer loaded with three antibiotic agents (clindamycin + gentamicin + vancomycin). Demographic data were collected: Classification of infection according to criteria of Cierny-Mader; microbiologic results; number of previous operations; and years of disease. Infection control or relapse after at least 18 months of follow-up was evaluated. Complications were recorded. Every patient completed the SF-36 test and Oxford Knee Score.

RESULTS

With a follow-up of 32.87 months (standard deviation 12.04), at the end of treatment, amputation occurred in three of 112 patients because of recurrence of infection, and one patient died from other causes not related to the infection. The study population presented a rate of recurrence of infection of 2.70%.

CONCLUSIONS

Our results suggest that a two stage re-implant with three antibiotic agents added to the spacer should be considered to avoid rescue procedures, especially in patients with multi-resistant micro-organism infections.

Proposal for shorter antibiotic therapies

OBJECTIVES

Reducing antibiotic consumption has now become a major public health priority. Reducing treatment duration is one of the means to achieve this objective. Guidelines on the therapeutic management of the most frequent infections recommend ranges of treatment duration in the ratio of one to two. The Recommendation Group of the French Infectious Diseases Society (SPILF) was asked to collect literature data to then recommend the shortest treatment durations possible for various infections.

METHODS

Analysis of the literature focused on guidelines published in French and English, supported by a systematic search on PubMed. Articles dating from one year before the guidelines publication to August 31, 2015 were searched on the website.

RESULTS

The shortest treatment durations based on the relevant clinical data were suggested for upper and lower respiratory tract infections, central venous catheter-related and uncomplicated primary bacteremia, infective endocarditis, bacterial meningitis, intra-abdominal, urinary tract, upper reproductive tract, bone and joint, skin and soft tissue infections, and febrile neutropenia. Details of analyzed articles were shown in tables.

CONCLUSION

This work stresses the need for new well-conducted studies evaluating treatment durations for some common infections. Following the above-mentioned work focusing on existing literature data, the Recommendation Group of the SPILF suggests specific study proposals.

The DAIR (debridement, antibiotics and implant retention) procedure for infected total knee replacement - a literature review

Prosthetic joint infection (PJI) is a devastating complication in total knee arthroplasty (TKA) and third most common cause of revision of TKA with significant morbidity and surgical challenges. Treatment options include non-operative measures with long term antibiotic suppression, debridement and implant retention (DAIR), one- or two-stage revision arthroplasty, arthrodesis and amputation. Implant retention without infection is ideal and DAIR has been reported to have variable success rates depending on patient factors, duration of infection, infecting micro-organisms, choice of procedure, single or multiple debridement procedures, arthroscopic or open, antibiotic choice and duration of antibiotic use. We present a thorough literature review of DAIR for infected TKA. The important factors contributing to failure are presence of sinus, immunocompromised patient, delay between onset of infection and debridement procedure, Staphylococcal infection in particular Meticillin Resistant Staphylococcal aureus, multiple debridement procedures, retention of exchangeable components and short antibiotic duration. In conclusion DAIR can be successful procedure to eradicate infection in TKA in selective patients with factors contributing to failure taken into account.

Variables associated with remission in spinal surgical site infections

BACKGROUND

There is few medical literature regarding factors associated with remission after surgical and medical treatment of postoperative spine infections.

METHODS

Single-centre case-control study 2007-2014. Cluster-controlled Cox regression model with emphasis on surgical and antibiotic-related parameters.

RESULTS

Overall, we found 66 episodes in 48 patients (49 episodes with metalwork) who had a median follow-up of 2.6 years (range, 0.5 to 6.8 years). The patients had a median of two surgical debridements. The median duration of antibiotic therapy was 8 weeks, of which 2 weeks parenteral. Clinical recurrence after treatment was noted in 13 episodes (20%), after a median interval of 2 months. In 53 cases (80%), the episodes were considered as in remission. By multivariate analyses, no variable was associated with remission. Especially, the following factors were not significantly related to remission: number of surgical interventions [hazard ratio (HR) 0.9; 95% confidence interval (CI), 0.8-1.1]; infection due to Staphylococcus aureus (HR 0.9; 0.8-1.1), local antibiotic therapy (HR 1.2; 0.6-2.4), and, duration of total (HR 1.0; 0.99-1.01) (or just parenteral) (HR 1.0; 0.99-1.01) antibiotic use.

CONCLUSIONS

In patients with post-operative spine infections, remission is achieved in 80%. The number of surgical debridement or duration of antibiotic therapy shows no association with recurrence, suggesting that individual risk factors might be more important than the duration of antibiotic administration.

An update on surgical and antimicrobial therapy for acute periprosthetic joint infection: new challenges for the present and the future

Periprosthetic joint infection (PJI) is a devastating complication that can occur following any arthroplasty procedure. Approximately half of these infections develop within the first year after arthroplasty, mainly in the first 1 to 3 months. These infections are known as early PJI. It is widely accepted that many early PJIs can be successfully managed by debridement, irrigation, and prosthetic retention, followed by a course of biofilm-effective antibiotics (debridement, antibiotics, implant retention procedure), but candidate patients should meet the requirements set down in Zimmerli's algorithm. The best antibiotic regimen for acute PJI treated without implant removal remains uncertain. Rifampin-containing regimens, when feasible, are recommended in gram-positive infections, and fluoroquinolones in gram-negative cases. The duration, dosage, and administration route of antibiotics and the use of combined therapy are matters that requires further clarification, as the current level of evidence is low and most recommendations are based on experimental data, studies in small series, and expert experience.

Orthopaedic device-related infection: current and future interventions for improved prevention and treatment

Orthopaedic and trauma device-related infection (ODRI) remains one of the major complications in modern trauma and orthopaedic surgery.Despite best practice in medical and surgical management, neither prophylaxis nor treatment of ODRI is effective in all cases, leading to infections that negatively impact clinical outcome and significantly increase healthcare expenditure.The following review summarises the microbiological profile of modern ODRI, the impact antibiotic resistance has on treatment outcomes, and some of the principles and weaknesses of the current systemic and local antibiotic delivery strategies.The emerging novel strategies aimed at preventing or treating ODRI will be reviewed. Particular attention will be paid to the potential for clinical impact in the coming decades, when such interventions are likely to be critically important.The review focuses on this problem from an interdisciplinary perspective, including basic science innovations and best practice in infectious disease. Cite this article: Moriarty TF, Kuehl R, Coenye T, et al. Orthopaedic device related infection: current and future interventions for improved prevention and treatment. EFORT Open Rev 2016;1:89-99. DOI: 10.1302/2058-5241.1.000037.

Three-step sequential management for knee arthroplasty after severe ballistic injury: Two cases

Management of knee bone loss after gunshot trauma requires a multidisciplinary approach. Two cases of knee arthroplasty after devastating ballistic trauma are reported. Treatment comprised several steps: sampling, bone resection, reinforced cement spacer, latent sepsis control, and prosthetic reconstruction. The patients showed no neurovascular disorder and had a functioning extensor mechanism. At follow-up of at least 2 years, results were satisfactory, with return to unaided walking and mean International Knee Society (IKS) score improved from 18 to 59 points. In light of these observations, knee reconstruction arthroplasty using a sequential strategy can provide satisfactory functional outcome after severe ballistic trauma.