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Markel DC, Powell D, Wu B, Pawlitz P, Bou-Akl T, Chen L, Shi T, Ren W. Therapeutic Efficacy of an Erythromycin-Loaded Coaxial Nanofiber Coating in a Rat Model of S. aureus-Induced Periprosthetic Joint Infection. Int J Mol Sci 2024; 25:7926. [PMID: 39063169 PMCID: PMC11276967 DOI: 10.3390/ijms25147926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 07/11/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Implant surface nanofiber (NF) coatings represent an alternative way to prevent/treat periprosthetic joint infection (PJI) via local drug release. We developed and characterized a coaxial erythromycin (EM)-doped PLGA/PCL-PVA NF coating. The purpose of this study was to determine the efficacy of EM-NF coatings (EM0, no EM, EM100 (100 mg/mL), and EM1000 (1000 mg/mL) wt/wt) in a rat PJI model. A strong bond of the EM-NF coating to the surface of titanium (Ti) pins was confirmed by in vitro mechanical testing. Micro-computed tomography (mCT) analysis showed that both EM100 and EM1000 NF effectively reduced periprosthetic osteolysis compared to EM0 at 8 and 16 weeks after implantation. Histology showed that EM100 and EM1000 coatings effectively controlled infection and enhanced periprosthetic new bone formation. The bone implant contact (BIC) of EM100 (35.08%) was higher than negative controls and EM0 (3.43% and 0%, respectively). The bone area fraction occupancy (BAFO) of EM100 (0.63 mm2) was greater than controls and EM0 (0.390 mm2 and 0.0 mm2, respectively). The BAFO of EM100 was higher than that of EM1000 (0.3 mm2). These findings may provide a basis for a new implant surface fabrication strategy aimed at reducing the risks of defective osseointegration and PJI.
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Affiliation(s)
- David C. Markel
- The CORE Institute, 26750 Providence Pkwy #200, Novi, MI 48374, USA;
- Department of Biomedical Engineering, Wayne State University, 818 W. Hancock, Detroit, MI 48201, USA; (L.C.); (T.S.)
- Section of Orthopaedic Surgery, Ascension Providence Hospital Orthopaedic Research Laboratory, 16001 West Nine Mile Road, Southfield, MI 48075, USA; (D.P.); (B.W.); (P.P.); (W.R.)
| | - Dexter Powell
- Section of Orthopaedic Surgery, Ascension Providence Hospital Orthopaedic Research Laboratory, 16001 West Nine Mile Road, Southfield, MI 48075, USA; (D.P.); (B.W.); (P.P.); (W.R.)
| | - Bin Wu
- Section of Orthopaedic Surgery, Ascension Providence Hospital Orthopaedic Research Laboratory, 16001 West Nine Mile Road, Southfield, MI 48075, USA; (D.P.); (B.W.); (P.P.); (W.R.)
| | - Paula Pawlitz
- Section of Orthopaedic Surgery, Ascension Providence Hospital Orthopaedic Research Laboratory, 16001 West Nine Mile Road, Southfield, MI 48075, USA; (D.P.); (B.W.); (P.P.); (W.R.)
| | - Therese Bou-Akl
- Section of Orthopaedic Surgery, Ascension Providence Hospital Orthopaedic Research Laboratory, 16001 West Nine Mile Road, Southfield, MI 48075, USA; (D.P.); (B.W.); (P.P.); (W.R.)
| | - Liang Chen
- Department of Biomedical Engineering, Wayne State University, 818 W. Hancock, Detroit, MI 48201, USA; (L.C.); (T.S.)
| | - Tong Shi
- Department of Biomedical Engineering, Wayne State University, 818 W. Hancock, Detroit, MI 48201, USA; (L.C.); (T.S.)
| | - Weiping Ren
- Section of Orthopaedic Surgery, Ascension Providence Hospital Orthopaedic Research Laboratory, 16001 West Nine Mile Road, Southfield, MI 48075, USA; (D.P.); (B.W.); (P.P.); (W.R.)
- John D. Dingell VA Medical Center, 4646 John R St., Detroit, MI 48201, USA
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Dimofte F, Dimofte C, Ungurianu S, Serban C, Țocu G, Cârneciu N, Filip I, Bezman L, Ciuntu BM, Abdulan IM, Mihailov R, Necula RD, Sabou FL, Firescu D. The Efficacy of Antibiotic-Loaded Calcium Sulfate Beads (Stimulan) in Patients with Hip Arthroplasty Infections. J Clin Med 2024; 13:4004. [PMID: 39064042 PMCID: PMC11277588 DOI: 10.3390/jcm13144004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 07/05/2024] [Accepted: 07/06/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Given the increasing rate of infections following hip arthroplasty, one of the current options is the application of a biocomposite at the site of the infection. One of the products used is Stimulan, a completely resorbable calcium sulfate, designed to treat acute and chronic infections. This biocomposite has a controlled purity, is easy to mix with liquid, powder, and antibiotics, and can be applied directly to the site of infection, or it can be injected. Methods: We analyzed data from 76 patients, who were admitted to the County Clinical Hospital of Emergency "St. Apostol Andrei" in Galati during January 2017-September 2023, with a diagnosis of infection associated with hip arthroplasty. Results: In 69.73% of cases (52 patients), we decided to keep the implant in place. In this subgroup, Stimulan was applied in 26 cases (57.78%). Of these, 100% were cured-compared to the subgroup in which Stimulan was not applied, where this percentage was lower. All patients underwent chemical and mechanical toileting, and for 24 patients (20.27%), it was necessary to ablate the implant with or without the application of Stimulan, then reimplantation of the prosthesis. Conclusions: The patients with Stimulan had a longer average length of hospitalization, almost half of them required intervention in two periods, and a quarter required the implantation of spacers. However, the cure rate was higher, only in three people could we not control the infection, and there was no death. This study confirms the effectiveness of the treatment when using a biocomposite in addition to the classical treatment for both acute and chronic cases.
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Affiliation(s)
- Florentin Dimofte
- General Surgery Clinic, “St. Apostol Andrei” County Emergency Clinical Hospital, Strada Brăilei 177, 800578 Galati, Romania; (F.D.); (C.S.); (G.Ț.); (N.C.); (I.F.)
- Department of Orthopedic, Faculty of Medicine, “Dunarea de Jos” University of Medicine and Pharmacy, 800008 Galati, Romania;
| | - Cristina Dimofte
- Department Radiology, “Saint John” Emergency Children Hospital, Str. Gheorghe Asachi, Nr.2, 800487 Galati, Romania;
| | - Sorin Ungurianu
- Department of Orthopedic, Faculty of Medicine, “Dunarea de Jos” University of Medicine and Pharmacy, 800008 Galati, Romania;
| | - Cristina Serban
- General Surgery Clinic, “St. Apostol Andrei” County Emergency Clinical Hospital, Strada Brăilei 177, 800578 Galati, Romania; (F.D.); (C.S.); (G.Ț.); (N.C.); (I.F.)
- Department of General Surgery, Faculty of Medicine, “Dunarea de Jos” University of Medicine and Pharmacy, 800008 Galati, Romania; (R.M.); (D.F.)
| | - George Țocu
- General Surgery Clinic, “St. Apostol Andrei” County Emergency Clinical Hospital, Strada Brăilei 177, 800578 Galati, Romania; (F.D.); (C.S.); (G.Ț.); (N.C.); (I.F.)
- Department of Laboratory Medicine, Faculty of Medicine, “Dunarea de Jos” University of Medicine and Pharmacy, 800008 Galati, Romania
| | - Nicoleta Cârneciu
- General Surgery Clinic, “St. Apostol Andrei” County Emergency Clinical Hospital, Strada Brăilei 177, 800578 Galati, Romania; (F.D.); (C.S.); (G.Ț.); (N.C.); (I.F.)
- Department of Ophtalmology, Faculty of Medicine, “Dunarea de Jos” University of Medicine and Pharmacy, 800008 Galati, Romania;
| | - Iulia Filip
- General Surgery Clinic, “St. Apostol Andrei” County Emergency Clinical Hospital, Strada Brăilei 177, 800578 Galati, Romania; (F.D.); (C.S.); (G.Ț.); (N.C.); (I.F.)
- Department of Anesthesia, Faculty of Medicine, “Dunarea de Jos” University of Medicine and Pharmacy, 800008 Galati, Romania
| | - Laura Bezman
- Department of Ophtalmology, Faculty of Medicine, “Dunarea de Jos” University of Medicine and Pharmacy, 800008 Galati, Romania;
| | - Bogdan Mihnea Ciuntu
- Department of General Surgery, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Irina Mihaela Abdulan
- Department of Medical Specialties I, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Raul Mihailov
- Department of General Surgery, Faculty of Medicine, “Dunarea de Jos” University of Medicine and Pharmacy, 800008 Galati, Romania; (R.M.); (D.F.)
| | - Radu Dan Necula
- Department of General Surgery, “Transilvania” Faculty of Medicine, 500019 Brașov, Romania; (R.D.N.); (F.L.S.)
| | - Florin Lucian Sabou
- Department of General Surgery, “Transilvania” Faculty of Medicine, 500019 Brașov, Romania; (R.D.N.); (F.L.S.)
| | - Dorel Firescu
- Department of General Surgery, Faculty of Medicine, “Dunarea de Jos” University of Medicine and Pharmacy, 800008 Galati, Romania; (R.M.); (D.F.)
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3
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Hanssen J, van der Wal R, van der Linden H, van Prehn J, Scheper H, de Boer M. Dosing and treatment duration of suppressive antimicrobial therapy in orthopedic implant infections: a cohort study. J Bone Jt Infect 2024; 9:149-159. [PMID: 38903857 PMCID: PMC11187703 DOI: 10.5194/jbji-9-149-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/24/2024] [Indexed: 06/22/2024] Open
Abstract
Introduction: Limited data inform about the optimal dosing and duration of suppressive antimicrobial therapy (SAT) for orthopedic implant infection (OII). We aimed to compare the effectiveness of low-dosage with standard-dosage SAT and evaluate the safety of stopping SAT. Methods: All patients with OII treated with SAT from 2011 to 2022 were retrospectively included. Data were extracted from electronic patient files. Low-dosage SAT was defined as antimicrobial therapy dosed lower than the standard dosage recommended for OII. The association of dosing strategy and other factors with failure-free survival were assessed by Kaplan-Meier and Cox proportional hazard models. Results: One-hundred-and-eight patients were included. The median follow-up time after SAT initiation was 21 months (interquartile range (IQR) 10-42 months). SAT was successful in 74 patients (69 %). Low-dosage SAT ( n = 82 ) was not associated with failure in univariate (hazard ratio (HR) 1.23, 95 % confidence interval (CI) 0.53-2.83) and multivariate analyses (HR 1.24, 95 % CI 0.54-2.90). In 25 patients (23 %), SAT was stopped after a median treatment duration of 26 months. In this group, one patient (4 %) developed a relapse. Conclusions: In this study, low-dosage SAT was as effective as standard dosage SAT. Moreover, stopping SAT after 2 to 3 years may be justified in patients with a good clinical course. These findings warrant further research on optimal dosing and duration of SAT and on the durability of in vivo biofilms.
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Affiliation(s)
- Jaap L. J. Hanssen
- Leiden University Center for Infectious Diseases (LU-CID), Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Joffrey van Prehn
- Leiden University Center for Infectious Diseases (LU-CID), Medical Microbiology and Infection Control, Leiden University Medical Center, Leiden, the Netherlands
| | - Henk Scheper
- Leiden University Center for Infectious Diseases (LU-CID), Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark G. J. de Boer
- Leiden University Center for Infectious Diseases (LU-CID), Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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4
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Cortés-Penfield N, Beekmann SE, Polgreen PM, Ryan K, Marschall J, Sekar P. Variation in North American Infectious Disease Specialists' Practice Regarding Oral and Suppressive Antibiotics for Adult Osteoarticular Infections: Results of an Emerging Infections Network (EIN) Survey. Open Forum Infect Dis 2024; 11:ofae280. [PMID: 38868304 PMCID: PMC11167670 DOI: 10.1093/ofid/ofae280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/09/2024] [Indexed: 06/14/2024] Open
Abstract
Background Osteoarticular infections (OAIs) are commonly treated with prolonged intravenous (IV) antimicrobials. The Oral versus Intravenous Antibiotics for Bone and Joint Infection (OVIVA) trial demonstrated that oral (PO) antibiotics are noninferior to IV antibiotics in the treatment of OAIs. We surveyed infectious disease (ID) physicians about their use of PO antibiotics in the treatment of OAIs. Methods An Emerging Infection Network survey with 9 questions regarding antibiotic prescribing for the treatment of OAIs was sent to 1475 North American ID physicians. The questions were mostly multiple choice and focused on the use of definitive oral antibiotic therapy (defined as oral switch within 2 weeks of starting antibiotics) and chronic suppressive antibiotic therapy (SAT). Results Of the 413 physicians who reported treating OAIs, 91% used oral antibiotics at least sometimes and 31% used them as definitive therapy, most often for diabetic foot osteomyelitis and native joint septic arthritis. The oral antibiotics most frequently used for OAIs included trimethoprim-sulfamethoxazole, doxycycline/minocycline, and linezolid for Staphylococcus aureus, amoxicillin/cefadroxil/cephalexin for streptococci, and fluoroquinolones for gram-negative organisms. The most common rationales for not transitioning to oral antibiotics included nonsusceptible pathogens, comorbidities preventing therapeutic drug levels, and concerns about adherence. SAT use was variable but employed by a majority in most cases of periprosthetic joint infection managed with debridement and implant retention. Conclusions North American ID physicians utilize oral antibiotics and SAT for the management of OAIs, although significant practice variation exists. Respondents voiced a need for updated guidelines.
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Affiliation(s)
- Nicolás Cortés-Penfield
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Susan E Beekmann
- Division of Infectious Diseases, Carver College of Medicine University of Iowa, Iowa City, Iowa, USA
| | - Philip M Polgreen
- Division of Infectious Diseases, Carver College of Medicine University of Iowa, Iowa City, Iowa, USA
| | - Keenan Ryan
- Inpatient Pharmacy Department, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Jonas Marschall
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Poorani Sekar
- Division of Infectious Diseases, Carver College of Medicine University of Iowa, Iowa City, Iowa, USA
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5
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Furukawa D, Dunning M, Shen S, Chang A, Aronson J, Amanatullah D, Suh G, Kappagoda S. No differences in outcomes with stopping or continuing antibiotic suppression in periprosthetic joint infections. J Bone Jt Infect 2024; 9:143-148. [PMID: 38899055 PMCID: PMC11184613 DOI: 10.5194/jbji-9-143-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 04/03/2024] [Indexed: 06/21/2024] Open
Abstract
The data on long-term antibiotic use following debridement, antibiotics, and implant retention (DAIR) for treatment of periprosthetic joint infections are limited. In this single-center retrospective study, we show that patients with eventual cessation of antibiotic suppression after DAIR had similar outcomes to those who remained on chronic antibiotic suppression.
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Affiliation(s)
- Daisuke Furukawa
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, California 94304, USA
| | - Megan Dunning
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, California 94304, USA
| | - Sa Shen
- Quantitative Sciences Unit, Stanford University, Stanford, California 94304, USA
| | - Amy Chang
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, California 94304, USA
| | - Jenny Aronson
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, California 94304, USA
| | - Derek F. Amanatullah
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California 94063, USA
| | - Gina A. Suh
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota 55902, USA
| | - Shanthi Kappagoda
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, California 94304, USA
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6
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Tai DBG, Tande AJ, Langworthy B, Abdel MP, Berbari EF, ten Have B, Jutte P, Soriano A, Suh GA, Zijlstra W, Wouthuyzen-Bakker M. Role of Routine Suppressive Antibiotic Therapy After Debridement, Antibiotics, and Implant Retention for Acute Periprosthetic Joint Infections. Open Forum Infect Dis 2024; 11:ofae216. [PMID: 38778861 PMCID: PMC11109604 DOI: 10.1093/ofid/ofae216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/15/2024] [Indexed: 05/25/2024] Open
Abstract
Background The first-line management strategy for acute periprosthetic joint infections (PJIs) is debridement, antibiotics, and implant retention (DAIR). Suppressive antibiotic therapy (SAT) after DAIR is proposed to improve outcomes, yet its efficacy remains under scrutiny. Methods We conducted a multicenter retrospective study in patients with acute PJI of the hip or knee who were treated with DAIR in centers from Europe and the United States. We analyzed the effect of SAT using a Cox model landmarked at 12 weeks. The primary covariate of interest was SAT, which was analyzed as a time-varying covariate. Patients who experienced treatment failure or were lost to follow-up within 12 weeks were excluded from the analysis. Results The study included 510 patients with 66 treatment failures with a median follow-up of 801 days. We did not find a statistically significant association between SAT and treatment failure (hazard ratio, 1.37; 95% CI, .79-2.39; P = .27). Subgroup analyses for joint, country cohort, and type of infection (early or late acute) did not show benefit for SAT. Secondary analysis of country cohorts showed a trend toward benefit for the US cohort (hazard ratio, 0.36; 95% CI, .11-1.15; P = .09), which also had the highest risk of treatment failure. Conclusions The utility of routine SAT as a strategy for enhancing DAIR's success in acute PJI remains uncertain. Our results suggest that SAT's benefits might be restricted to specific groups of patients, underscoring the need for randomized controlled trials. Identifying patients most likely to benefit from SAT should be a priority in future studies.
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Affiliation(s)
- Don Bambino Geno Tai
- Division of Infectious Diseases and International Medicine, Medical School, University of Minnesota, Rochester, Minnestota, USA
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnestota, USA
| | - Aaron J Tande
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnestota, USA
| | - Benjamin Langworthy
- Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Rochester, Minnestota, USA
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnestota, USA
| | - Elie F Berbari
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnestota, USA
| | - Bas ten Have
- Department of Orthopedic Surgery, Martini Hospital, Groningen, the Netherlands
| | - Paul Jutte
- Department of Orthopedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clinic of Barcelona, University of Barcelona, CIBER in Infectious Diseases (CIBERINFEC), Spain
| | - Gina A Suh
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnestota, USA
| | - Wierd Zijlstra
- Department of Orthopedic Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Lora-Tamayo J, Mancheño-Losa M, Meléndez-Carmona MÁ, Hernández-Jiménez P, Benito N, Murillo O. Appropriate Duration of Antimicrobial Treatment for Prosthetic Joint Infections: A Narrative Review. Antibiotics (Basel) 2024; 13:293. [PMID: 38666969 PMCID: PMC11047716 DOI: 10.3390/antibiotics13040293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/16/2024] [Accepted: 03/19/2024] [Indexed: 04/29/2024] Open
Abstract
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.
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Affiliation(s)
- Jaime Lora-Tamayo
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, 28041 Madrid, Spain; (M.M.-L.); (P.H.-J.)
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
- CIBERINFEC—CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Mikel Mancheño-Losa
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, 28041 Madrid, Spain; (M.M.-L.); (P.H.-J.)
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
| | - María Ángeles Meléndez-Carmona
- Department of Microbiology, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, 28041 Madrid, Spain;
| | - Pilar Hernández-Jiménez
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, 28041 Madrid, Spain; (M.M.-L.); (P.H.-J.)
| | - Natividad Benito
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
- CIBERINFEC—CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- UQ Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane 4072, Australia
| | - Oscar Murillo
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
- CIBERINFEC—CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Department of Infectious Diseases, Hospital Universitario Bellvitge, IDIBELL (Instituto de Investigación Biomédica de Bellvitge), 08908 L’Hospitalet de Llobregat, Spain
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8
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Kalyanasundaram G, Feng JE, Congiusta F, Iorio R, DiCaprio M, Anoushiravani AA. Treating Hepatitis C Before Total Knee Arthroplasty is Cost-Effective: A Markov Analysis. J Arthroplasty 2024; 39:307-312. [PMID: 37604270 DOI: 10.1016/j.arth.2023.08.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Patients who have the hepatitis C virus (HCV) have increased mortality and complication rates following total knee arthroplasty (TKA). Recent advances in HCV therapy have enabled clinicians to eradicate the disease using direct-acting antivirals (DAAs); however, its cost-effectiveness before TKA remains to be demonstrated. The aim of this study was to perform a cost-effectiveness analysis comparing no therapy to DAAs before TKA. METHODS A Markov model using input values from the published literature was performed to evaluate the cost-effectiveness of DAA treatment before TKA. Input values included event probabilities, mortality, cost, and health state quality-adjusted life-year (QALY) values for patients who have and do not have HCV. Patients who have HCV were modeled to have an increased rate of periprosthetic joint infection (PJI) infection (9.9 to 0.7%). The incremental cost-effectiveness ratio (ICER) of no therapy versus DAA was compared to a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses were performed to investigate the effects of uncertainty associated with input variables. RESULTS Total knee arthroplasty in the setting of no therapy and DAA added 8.1 and 13.5 QALYs at a cost of $25,000 and $114,900. The ICER associated with DAA in comparison to no therapy was $16,800/QALY, below the willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses demonstrated that the ICER was affected by patient age, inflation rate, DAA cost and effectiveness, HCV-associated mortality, and DAA-induced reduction in PJI rate. CONCLUSION Direct-acting antiviral treatment before TKA reduces risk of PJI and is cost-effective. Strong consideration should be given to treating patients who have HCV before elective TKA. LEVEL OF EVIDENCE Cost-effectiveness Analysis; Level III.
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Affiliation(s)
| | - James E Feng
- Department of Orthopaedic Surgery, Beaumont Health, Royal Oak, Michigan
| | | | - Richard Iorio
- Department of Surgery, Brigham Women's Health, Boston, Massachusetts
| | - Matthew DiCaprio
- Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York
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9
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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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10
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Lastinger AM, Lokant MS, Giertych B, Lerfald N, Makani A, Dietz MJ. A Pilot Study Using a Standardized Method of Measuring Distress Demonstrates Higher Levels in Septic Revisions. Arthroplast Today 2023; 24:101255. [PMID: 38205061 PMCID: PMC10776323 DOI: 10.1016/j.artd.2023.101255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 09/16/2023] [Accepted: 09/20/2023] [Indexed: 01/12/2024] Open
Abstract
Background Combined Orthopaedic Infectious Disease Clinics facilitate care for prosthetic joint infection (PJI) patients similar to multidisciplinary care in cancer centers. The National Comprehensive Cancer Network developed a standardized distress thermometer (DT) to measure distress in cancer patients. We propose using this tool to assess distress in PJI patients. Methods In this pilot study, a retrospective review of patients treated in our combined clinic over 2 years was conducted. In addition to providing information surrounding their treatment, patients completed a questionnaire and DT, adapted with permission from the National Comprehensive Cancer Network. DT scores were compared to a chronologically collected matched aseptic control group. Results There were 122 patients in the septic group and 40 patients in the aseptic group. On a scale of 0-10 (10, the highest level of distress), the septic group reported a mean DT score of 6.18 (±3.2), which was significantly higher than the aseptic mean score of 3.33 (±2.06) [P < .0001]. Over 75% of patients in the septic group reported a DT score ≥4, the cutoff used in most cancer centers to warrant additional support. Twenty-one percent of the septic group (26/122) reported extreme distress (defined as a score ≥10) compared to 0/40 of aseptic patients. Conclusions Patients treated for PJI experience significantly higher levels of distress compared to aseptic revision patients. More attention is needed to measure and clinically address distress. Improved screening for distress would allow us to provide more comprehensive care and possibly improve compliance, outcomes, and resources available for the treatment of PJI patients.
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Affiliation(s)
| | - Matthew S. Lokant
- Department of Medicine, West Virginia University, Morgantown, WV, USA
| | - Benjamin Giertych
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | - Nathan Lerfald
- Department of Medicine, West Virginia University, Morgantown, WV, USA
| | - Ankur Makani
- Department of Medicine, West Virginia University, Morgantown, WV, USA
| | - Matthew J. Dietz
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
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11
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Reinecke P, Morovic P, Niemann M, Renz N, Perka C, Trampuz A, Meller S. Adverse Events Associated with Prolonged Antibiotic Therapy for Periprosthetic Joint Infections-A Prospective Study with a Special Focus on Rifampin. Antibiotics (Basel) 2023; 12:1560. [PMID: 37998762 PMCID: PMC10668752 DOI: 10.3390/antibiotics12111560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/17/2023] [Accepted: 10/21/2023] [Indexed: 11/25/2023] Open
Abstract
Periprosthetic Joint Infection (PJI) is a significant contributor to patient morbidity and mortality, and it can be addressed through a range of surgical interventions coupled with antibiotic therapies. Following surgical intervention(s), prolonged administration of oral antibiotics is recommended to cure PJI. There is a lack of reports on the adverse events (AEs) associated with oral antibiotics, particularly rifampin. This investigation sought to elucidate the occurrence of antibiotic-related AEs after an initial regimen of intravenous antibiotic administration, supplemented by an extended course of oral antibiotics. A prospective study of patients diagnosed with PJI of the hip, knee, or shoulder who underwent single-stage exchange arthroplasty (SSE) (10%), two-stage exchange arthroplasty (TSE) (81%), or debridement, antibiotics, and implant retention (DAIR) (6%) was performed. The primary outcome of interest was the detection of AEs, the secondary outcome the detection of a correlation between rifampin use and the incidence of AEs, and the tertiary outcome was whether oral antibiotic treatment needed to be adjusted or discontinued due to AEs. In addition, subjective tolerability was monitored throughout the study. A total of 336 events were identified for 73 out of 80 patients. The most frequently used antibiotics were rifampin and co-trimoxazole. Most AEs occurred in the gastrointestinal tract (46%). The most frequent AEs were nausea, inappetence, diarrhea, and skin rash. In 6% of cases, the AEs led to antibiotic discontinuation, and in 29% of cases, a dose adjustment of the oral therapy occurred, mainly with amoxicillin or co-trimoxazole. The majority of patients (55%) rated the subjective tolerability as good. In conclusion, AEs during antibiotic treatment for PJI are common. They mainly affect the gastrointestinal tract. Rifampin use might be a reason for the higher incidence of AEs compared to non-rifampin antibiotic treatment.
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Affiliation(s)
| | | | | | | | | | | | - Sebastian Meller
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Augustenburger Platz 1, 13353 Berlin, Germany; (P.R.); (P.M.); (M.N.); (N.R.); (C.P.); (A.T.)
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12
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Tidd JL, Pasqualini I, McConaghy K, Higuera CA, Deren ME, Visperas A, Klika AK, Piuzzi NS. The Use of Oral Antibiotics After Total Joint Arthroplasty: A Critical Analysis Review. JBJS Rev 2023; 11:01874474-202310000-00004. [PMID: 37812675 DOI: 10.2106/jbjs.rvw.23.00083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
» There is conflicting and insufficient evidence that extended oral antibiotic (EOA) therapy prevents infection in high-risk patients undergoing primary total joint arthroplasty (TJA), limiting recommendation for or against the practice.» In the case of aseptic revision TJA, the evidence is also conflicting and limited by underlying confounders, preventing recommendation for use of EOA.» There is fair evidence that use of EOA after debridement antibiotic therapy and implant retention of the prosthesis prolongs infection-free survival, but randomized controlled trials are needed. On the other hand, there is strong evidence that patients undergoing 2-stage revision should receive a period of suppressive oral antibiotics after the second stage.» The optimal duration of EOA in primary TJA, aseptic revision, and debridement antibiotic therapy and implant retention of the prosthesis is unknown. However, there is strong evidence that 3 months of EOA suppression may be appropriate after reimplantation as part of 2-stage exchange arthroplasty.» Complications secondary to EOA are reported to be between 0% and 13.7%, yet are inconsistently reported and poorly defined. The risks associated with antibiotic use, including development of antimicrobial resistance, must be weighed against a possible decrease in infection rate.
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Affiliation(s)
- Joshua L Tidd
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | | | - Kara McConaghy
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Carlos A Higuera
- Levitetz Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Matthew E Deren
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Anabelle Visperas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio
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13
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Huotari K, Vuorinen M, Vasara A. Debridement, antimicrobials, and implant retention in the treatment of late acute and early acute Staphylococcus aureus prosthetic joint infections. Infect Dis (Lond) 2023; 55:525-532. [PMID: 37255321 DOI: 10.1080/23744235.2023.2217898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 05/15/2023] [Accepted: 05/21/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Staphylococcus aureus is the most common microbe in prosthetic joint infections (PJIs). Debridement, antimicrobials, and implant retention (DAIR) are often-recommended treatment modality for acute PJIs, even though it has had relatively poor outcomes in some studies. In this study, we wanted to examine treatment results with a multidisciplinary team in a specialised centre and obtain further information for treatment decisions in acute Staphylococcus aureus PJIs. METHODS All consecutive haematogenous late acute and postoperative early acute hip and knee Staphylococcus aureus PJIs treated with DAIR during 2011-2016 were included in this retrospective study. DAIR within three weeks from symptom onset and the exchange of modular parts were required. RESULTS Eighty-five acute Staphylococcus aureus PJIs were treated with DAIR in 83 patients: 28 late acute and 57 early acute PJIs. The late acute PJI patients were older and had malignancies more often than the early acute PJI patients. Bacteraemia was present in 50.6% of Staphylococcus aureus PJI patients, more often in late acute (73.1%) than in early acute (40.4%) patients (p = .006). The implant was retained in 80.0%: 89.3% of the late acute and 75.4% of the early acute PJIs. In 17 joints, DAIR failed and the joint had to be removed. Fourteen of these joints were successfully replaced. One infection-related death occurred. The one-year all-cause mortality rate was 3.6%. Suppressive antimicrobial treatment was given to 22 (26.5%) patients. CONCLUSIONS Reasonably good treatment results for acute Staphylococcus aureus PJIs are achievable by DAIR in a specialised centre with a strict treatment protocol and a multidisciplinary team. If the DAIR fails, a two-stage exchange is usually still possible, with good results.
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Affiliation(s)
- Kaisa Huotari
- Department of Infectious Diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Markku Vuorinen
- Department of Orthopedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anna Vasara
- Department of Orthopedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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14
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Parker DM, Koch JA, Gish CG, Brothers KM, Li W, Gilbertie J, Rowe SE, Conlon BP, Byrapogu VKC, Urish KL. Hydrogen Peroxide, Povidone-Iodine and Chlorhexidine Fail to Eradicate Staphylococcus aureus Biofilm from Infected Implant Materials. Life (Basel) 2023; 13:1230. [PMID: 37374013 DOI: 10.3390/life13061230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/18/2023] [Accepted: 05/18/2023] [Indexed: 06/29/2023] Open
Abstract
Hydrogen peroxide, povidone-iodine, and chlorhexidine are antiseptics that are commonly added to irrigants to either prevent or treat infection. There are little clinical data available that demonstrate efficacy of adding antiseptics to irrigants in the treatment of periprosthetic joint infection after biofilm establishment. The objective of the study was to assess the bactericidal activity of the antiseptics on S. aureus planktonic and biofilm. For planktonic irrigation, S. aureus was exposed to different concentrations of antiseptics. S. aureus biofilm was developed by submerging a Kirschner wire into normalized bacteria and allowing it to grow for forty-eight hours. The Kirschner wire was then treated with irrigation solutions and plated for CFU analysis. Hydrogen peroxide, povidone-iodine, and chlorhexidine were bactericidal against planktonic bacteria with over a 3 log reduction (p < 0.0001). Unlike cefazolin, the antiseptics were not bactericidal (less than 3 log reduction) against biofilm bacteria but did have a statistical reduction in biofilm as compared to the initial time point (p < 0.0001). As compared to cefazolin treatment alone, the addition of hydrogen peroxide or povidone-iodine to cefazolin treatment only additionally reduced the biofilm burden by less than 1 log. The antiseptics demonstrated bactericidal properties with planktonic S. aureus; however, when used to irrigate S. aureus biofilms, these antiseptics were unable to decrease biofilm mass below a 3 log reduction, suggesting that S. aureus biofilm has a tolerance to antiseptics. This information should be considered when considering antibiotic tolerance in established S. aureus biofilm treatment.
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Affiliation(s)
- Dana M Parker
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - John A Koch
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Charles G Gish
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Kimberly M Brothers
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - William Li
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Jessica Gilbertie
- Center for One Health Research, Edward Via College of Osteopathic Medicine, Blacksburg, VA 24060, USA
| | - Sarah E Rowe
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Brian P Conlon
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Marsico Lung Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Venkata K C Byrapogu
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15261, USA
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15
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Ceccarelli G, Perciballi B, Russo A, Martini P, Marchetti F, Capparuccia MR, Iaiani G, Fabris S, Ciccozzi M, Villani C, Venditti M, D'Ettorre G, De Meo D. Chronic Suppressive Antibiotic Treatment for Staphylococcal Bone and Joint Implant-Related Infections. Antibiotics (Basel) 2023; 12:antibiotics12050937. [PMID: 37237840 DOI: 10.3390/antibiotics12050937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
Prosthetic joint infection (PJI) and fracture-related infection (FRI) are difficult-to-treat conditions in patients with severe comorbidity or significant surgical risk. In cases not eligible for standard strategy, debridement procedures with the retention of prosthesis or internal fixation device, combined with long-term antibiotic treatment and subsequent indefinite chronic oral antimicrobial suppression (COAS), can be the only reasonable choice. The aim of this study was to investigate the role of COAS and its follow-up in the management of these cases. We retrospectively analyzed a cohort of 16 patients with a follow-up of at least 6 months (mean age 75 yo, 9F, 7M, 11 PJI, 5 FRI). All microbiological isolates were tetracycline-susceptible staphylococci and for this reason a minocycline-based COAS was adopted after debridement and 3 months of antibiogram-guided antibiotic treatment. Patient monitoring was carried out on a clinical basis, with bimonthly execution of the inflammation indices and serial radiolabeled leukocyte scintigraphy (LS). The overall median time of COAS follow-up was 15 months (min 6-max 30). Moreover, 62.5% of patients were still taking COAS with no relapse after cure at the last evaluation available. Clinical failure with a relapse of the infection was observed in 37.5% of patients; interestingly, 50% of them had previously stopped COAS due to side effects of the antibiotic used. In the COAS follow-up, a combination of clinical, laboratory and LS evaluation seems to monitor the infection properly. COAS can be considered as an interesting approach in patients not suitable for standard treatments of PJI or FRI but it requires careful monitoring.
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Affiliation(s)
- Giancarlo Ceccarelli
- Department of Internal Medicine, Endocrine-Metabolic Sciences and Infectious Diseases, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- Department of Public Health an Infectious Diseases, Sapienza University of Rome, 00161 Rome, Italy
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I University Hospital, 00161 Rome, Italy
| | - Beatrice Perciballi
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- Department of Anatomical, Histological, Forensic Medicine and Musculoskeletal System Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Alessandro Russo
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, 88100 Catanzaro, Italy
| | - Paolo Martini
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- Department of Anatomical, Histological, Forensic Medicine and Musculoskeletal System Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Francesco Marchetti
- Plastic Surgery Outpatient Clinic, Villa Mafalda Hospital, 00199 Rome, Italy
| | - Marco Rivano Capparuccia
- Department of Internal Medicine, Endocrine-Metabolic Sciences and Infectious Diseases, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I University Hospital, 00161 Rome, Italy
| | - Giancarlo Iaiani
- Department of Internal Medicine, Endocrine-Metabolic Sciences and Infectious Diseases, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I University Hospital, 00161 Rome, Italy
| | - Silvia Fabris
- National Center for Control and Emergency Against Animal Diseases and Central Crisis Unit, Office III, Directorate General for Animal Health and Veterinary Drugs, Italian Ministry of Health, 00153 Rome, Italy
| | - Massimo Ciccozzi
- Unit of Medical Statistics and Molecular Epidemiology, University Campus Bio-Medico of Rome, 00128 Rome, Italy
| | - Ciro Villani
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- Department of Anatomical, Histological, Forensic Medicine and Musculoskeletal System Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Mario Venditti
- Department of Internal Medicine, Endocrine-Metabolic Sciences and Infectious Diseases, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- Department of Public Health an Infectious Diseases, Sapienza University of Rome, 00161 Rome, Italy
| | - Gabriella D'Ettorre
- Department of Internal Medicine, Endocrine-Metabolic Sciences and Infectious Diseases, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- Department of Public Health an Infectious Diseases, Sapienza University of Rome, 00161 Rome, Italy
| | - Daniele De Meo
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I University Hospital, 00161 Rome, Italy
- Department of Anatomical, Histological, Forensic Medicine and Musculoskeletal System Sciences, Sapienza University of Rome, 00161 Rome, Italy
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16
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Brothers KM, Parker DM, Taguchi M, Ma D, Mandell JB, Thurlow LL, Byrapogu VC, Urish KL. Dose optimization in surgical prophylaxis: sub-inhibitory dosing of vancomycin increases rates of biofilm formation and the rates of surgical site infection. Sci Rep 2023; 13:4593. [PMID: 36944677 PMCID: PMC10030625 DOI: 10.1038/s41598-023-30951-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 03/03/2023] [Indexed: 03/23/2023] Open
Abstract
Antibiotic stewardship is viewed as having great public health benefit with limited direct benefit to the patient at the time of administration. The objective of our study was to determine if inappropriate administration of antibiotics could create conditions that would increase the rates of surgical infection. We hypothesized that sub-MIC levels of vancomycin would increase Staphylococcus aureus growth, biofilm formation, and rates of infection. S. aureus MRSA and MSSA strains were used for all experiments. Bacteria were grown planktonically and monitored using spectrophotometry. Quantitative agar culture was used to measure planktonic and biofilm bacterial burden. A mouse abscess model was used to confirm phenotypes in vivo. In the planktonic growth assay, increases in bacterial burden at ¼ MIC vancomycin were observed in USA300 JE2 by 72 h. Similar findings were observed with ½ MIC in Newman and SH1000. For biofilm formation, USA300 JE2 at ¼ and ½ MIC vancomycin increased biofilm formation by approximately 1.3- and 2.3-fold respectively at 72 h as compared to untreated controls. Similar findings were observed with Newman and SH1000 with a 2.4-fold increase in biofilm formation at ½ MIC vancomycin. In a mouse abscess model, there was a 1.2-fold increase with sub-MIC vancomycin at 3 days post infection. Our study showed that Sub-optimal vancomycin dosing promoted S. aureus planktonic growth and biofilm formation, phenotypic measures of bacterial virulence. This phenotype induced by sub-MIC levels of vancomycin was also observed to increase rates of infection and pathogenesis in our mouse model. Risks of exposure to sub-MIC concentrations with vancomycin in surgical procedures are greater as there is decreased bioavailability in tissue in comparison to other antibiotics. This highlights the importance of proper antibiotic selection, stewardship, and dosing for both surgical prophylaxis and treatment of infection.
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Affiliation(s)
- Kimberly M Brothers
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dana M Parker
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Masashi Taguchi
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedic Surgery, Ageo Medical Clinic, 3133 Haraichi, Ageo-Shi, Saitama, Japan
| | - Dongzhu Ma
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan B Mandell
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lance L Thurlow
- Department of Microbiology and Immunology, University of North Carolina, Chapel Hill, NC, USA
| | - Venkata C Byrapogu
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- Arthritis and Arthroplasty Design Group, and The Bone and Joint Center, Department of Orthopaedic Surgery, Department of Bioengineering, Department of Biomedical Engineering, and Clinical and Translational Science Institute, Magee Womens Hospital of the University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, 15219, USA.
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17
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Wu Y, Sun K, Liu R, Wu L, Zeng Y, Li M, Xu J, Shen B. C-reactive protein/albumin and C-reactive protein/fibrinogen ratios for the diagnosis of periprosthetic joint infection in revision total joint arthroplasty. Int Immunopharmacol 2023; 115:109682. [PMID: 36623413 DOI: 10.1016/j.intimp.2023.109682] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/22/2022] [Accepted: 12/31/2022] [Indexed: 01/09/2023]
Abstract
AIM Testing for systemic inflammation markers is considered a simpler method for diagnosing periprosthetic joint infection (PJI). Changes in the C-reactive protein/albumin ratio (CRP/Alb ratio) and C-reactive protein/fibrinogen ratio (CRP/Fib ratio) are associated with PJI. This study aimed to evaluate the application of CRP/Alb and CRP/Fib ratios as novel inflammation-based markers for the diagnosis of PJI. METHODS We retrospectively evaluated 445 patients who underwent total hip and knee revision arthroplasties between January 2010 and February 2021. Of these, 129 patients were also independently evaluated for PJI with coagulation-related comorbidities. The patients were divided into two groups: the aseptic revision (268 patients) and PJI revision groups (187 patients). Subsequently, we evaluated the diagnostic value of the CRP/Alb and CRP/Fib ratios compared to other inflammation-based diagnoses using the area under the curve (AUC) values. RESULTS The AUC values of the CRP/Alb and CRP/Fib ratios were 0.880 and 0.872, respectively, suggesting similar diagnostic potentials for PJI. The CRP/Alb and CRP/Fib ratios were better than the erythrocyte sedimentation rate (ESR), Alb, and Fib, whose AUC values were 0.765, 0.352, and 0.730, respectively, for the diagnosis of PJI. The optimal cut-off for the CRP/Alb ratio was 0.13, with good sensitivity (85.0%) and specificity (78.4%). The optimal cut-off CRP/Fib ratio was 2.04, with good sensitivity (81.3%) and specificity (80.6%). Notably, the CRP/Alb and CRP/Fib ratios had the highest sensitivity, followed by four conventional inflammatory markers, namely, CRP, ESR, Alb, and Fib, which had sensitivities of 80.2%, 67.4%, 50.8%, and 54.0%, respectively. Similar findings were observed in patients with coagulation-related comorbidities. CONCLUSION Both the CRP/Alb and CRP/Fib ratios were significantly higher in patients with PJI than in those with aseptic failure and showed better sensitivity and specificity for diagnosing PJI than classical inflammatory markers.
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Affiliation(s)
- Yuangang Wu
- Department of Orthopedics Surgery, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Kaibo Sun
- Department of Orthopedics Surgery, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Ran Liu
- Engineering Research Center of Medical Information Technology, Ministry of Education, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Liming Wu
- Department of Orthopedics Surgery, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Yi Zeng
- Department of Orthopedics Surgery, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Mingyang Li
- Department of Orthopedics Surgery, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Jiawen Xu
- Department of Orthopedics Surgery, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Bin Shen
- Department of Orthopedics Surgery, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China.
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18
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Affiliation(s)
- Robin Patel
- From the Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, and the Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
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19
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Jeon YS, Kim MK, Kwon DG, Lee SS, Park JW, Kang DS, Ryu DJ. Palliative arthroscopic debridement with continuous irrigation for infected total knee arthroplasty in high mortality risk patients. INTERNATIONAL ORTHOPAEDICS 2023; 47:175-186. [PMID: 36401020 DOI: 10.1007/s00264-022-05632-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/04/2022] [Indexed: 11/20/2022]
Abstract
PURPOSE This study aimed to evaluate the infection control rate of palliative arthroscopic debridement, antibiotics, and implant retention (DAIR) for the high mortality risk or terminal cancer stage patients. METHODS From March 2018 to August 2021, 21 patients met the following inclusion criteria: old age of more than 80, diagnosed as a terminal stage of cancer, high risk of mortality and morbidity representing as Charlson comorbidity index (CCI) ≥ 5, low daily activity with disabled extremity, and re-infection after two-stage revision. Each patient underwent arthroscopic DAIR and additional continuous irrigation for 48 hours. The need for subsequent re-arthroscopic DAIR or two-stage revision was determined by the post-operative trends of C-reactive protein (CRP) levels. Infection control was defined as continuing controlled status of infection based on clinical and laboratory results by one or two times of arthroscopic DAIR within initial two months. Treatment failure was defined as more than three times arthroscopic debridement, two-stage revision surgery, or expired due to uncontrolled infection. RESULTS Arthroscopic DAIR controlled the infection in 19 (90.5%) of the 21 cases. The other knee underwent a total of three times of re-arthroscopic DAIR and the other one underwent two-stage revision. Although five patients expired during the follow-up period due to worsening medical problems or terminal cancer, there were no deaths from uncontrolled infection, sepsis, or surgery-related complications. CONCLUSIONS Arthroscopic debridement with continuous irrigation for the infection TKA with high mortality risk or terminal cancer patients showed a 90.5% infection control rate. For high-risk patients, arthroscopic debridement with continuous irrigation can be an alternative treatment to improve the quality of life during survival.
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Affiliation(s)
- Yoon Sang Jeon
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Inhang-Ro 27, Jung-Gu, Incheon, 22322, South Korea
| | - Myung Ku Kim
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Inhang-Ro 27, Jung-Gu, Incheon, 22322, South Korea
| | - Dae Gyu Kwon
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Inhang-Ro 27, Jung-Gu, Incheon, 22322, South Korea
| | - Sung-Sahn Lee
- Department of Orthopaedic Surgery, Ilsan Paik Hospital, Inje University School of Medicine, Goyang-Si, Korea
| | - Joo Won Park
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Inhang-Ro 27, Jung-Gu, Incheon, 22322, South Korea
| | - Dong Seok Kang
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Inhang-Ro 27, Jung-Gu, Incheon, 22322, South Korea
| | - Dong Jin Ryu
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Inhang-Ro 27, Jung-Gu, Incheon, 22322, South Korea.
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20
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Humphrey TJ, Dunahoe JA, Nelson SB, Katakam A, Park ABK, Heng M, Bedair HS, Melnic CM. Peri-Prosthetic Joint Infection in Patients Prescribed Suppressive Antibiotic Therapy Undergoing Primary Total Joint Arthroplasty: A 1:4 Case Control Matched Study. Surg Infect (Larchmt) 2022; 23:917-923. [PMID: 36472508 DOI: 10.1089/sur.2022.261] [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: 12/12/2022] Open
Abstract
Background: Oral suppressive antibiotic therapy (SAT) has emerged as a potential means to increase rates of infection-free survival in many complex peri-prosthetic joint infection (PJI) cases after total joint arthroplasty (TJA). The purpose of the present study is to evaluate the risk of PJI of a new primary TJA in patients on oral SAT. Patients and Methods: A retrospective matched cohort study from five hospitals in a 20-year period within a large hospital network was performed. Inclusion criteria consisted of patients over age 18 undergoing primary TJA, with any order for oral long-term (>6 months duration) SAT, and minimum of one-year clinical follow-up. Patients were matched 1:4 on age, gender, body mass index (BMI), hip or knee surgery, diabetes mellitus, smoking status, and indication for primary TJA. Student t-test, Fisher exact, and χ2 tests were utilized for group comparisons. Our study was powered to detect a 10.5% increase in PJI incidence compared with a 1% baseline rate of PJI. Results: We identified 45 TJA in 33 patients receiving SAT, which were matched to 180 control cases. There was no difference in the rate of development of PJI at any time point within follow-up between the SAT cohort and control group (2.22% vs. 1.11%; p = 0.561). Conclusions: We found a 2.22% rate of PJI in a cohort of patients receiving SAT identified over a 20-year period. As the clinical scenario of primary TJA while on SAT is rare but likely to become more prevalent, future large-scale studies can be performed to better clarify rates and risk of PJI in this population.
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Affiliation(s)
- Tyler J Humphrey
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Kaplan Joint Center, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Jacqueline A Dunahoe
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sandra B Nelson
- Department of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Akhil Katakam
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Kaplan Joint Center, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Andy B K Park
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Kaplan Joint Center, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Marilyn Heng
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hany S Bedair
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Kaplan Joint Center, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Christopher M Melnic
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Kaplan Joint Center, Newton-Wellesley Hospital, Newton, Massachusetts, USA
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21
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Johns B, Dewar D, Loewenthal M, Manning L, Atrey A, Atri N, Campbell D, Dunbar M, Kandel C, Khoshbin A, Jones C, Lora-Tamayo J, McDougall C, Moojen D, Mulford J, Paterson D, Peel T, Solomon M, Young S, Davis J. A desirability of outcome ranking (DOOR) for periprosthetic joint infection - a Delphi analysis. J Bone Jt Infect 2022; 7:221-229. [PMID: 36420109 PMCID: PMC9677339 DOI: 10.5194/jbji-7-221-2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/14/2022] [Indexed: 10/28/2023] Open
Abstract
Background: Treatment outcomes in studies on prosthetic joint infection are generally assessed using a dichotomous outcome relating to treatment success or failure. These outcome measures neither include patient-centred outcome measures including joint function and quality of life, nor do they account for adverse effects of treatment. A desirability of outcome ranking (DOOR) measure can include these factors and has previously been proposed and validated for other serious infections. We aimed to develop a novel DOOR for prosthetic joint infections (PJIs). Methods: The Delphi method was used to develop a DOOR for PJI research. An international working group of 18 clinicians (orthopaedic surgeons and infectious disease specialists) completed the Delphi process. The final DOOR comprised the dimensions established to be most important by consensus with > 75 % of participant agreement. Results: The consensus DOOR comprised four main dimensions. The primary dimension was patient-reported joint function. The secondary dimensions were infection cure and mortality. The final dimension of quality of life was selected as a tie-breaker. Discussion: A desirability of outcome ranking for periprosthetic joint infection has been proposed. It focuses on patient-centric outcome measures of joint function, cure and quality of life. This DOOR provides a multidimensional assessment to comprehensively rank outcomes when comparing treatments for prosthetic joint infection.
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Affiliation(s)
- Brenton P. Johns
- The Bone and Joint Institute, Royal Newcastle Centre, New Lambton
Heights, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW,
Australia
| | - David C. Dewar
- The Bone and Joint Institute, Royal Newcastle Centre, New Lambton
Heights, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW,
Australia
| | - Mark R. Loewenthal
- Department of Immunology and Infectious Diseases, Royal Newcastle
Centre, New Lambton Heights, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW,
Australia
| | - Laurens A. Manning
- Medical School, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, Perth, WA, Australia
| | - Amit Atrey
- Division of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, OT, Canada
| | - Nipun Atri
- Department of Internal Medicine, Division of Infectious Diseases, Rush University Medical Centre, Chicago, IL, USA
| | - David G. Campbell
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Michael Dunbar
- Department of Orthopaedics, Halifax Infirmary & Dalhusie University, Halifax, NS, Canada
| | - Christopher Kandel
- Division of Infectious Diseases, University Health Network, Toronto, Ontario, Canada
| | - Amir Khoshbin
- Division of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, OT, Canada
| | - Christopher W. Jones
- Orthopaedic Research Foundation Western Australia and Curtin University, Perth, WA, Australia
| | - Jaime Lora-Tamayo
- Instituto de investigación, imas12 (CIBERINFEC), Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Catherine McDougall
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Orthopaedics, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia
| | - Dirk Jan F. Moojen
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
| | - Jonathan Mulford
- Department Orthopaedic Surgery, Launceston General Hospital, Launceston, TAS, Australia
| | - David L. Paterson
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Trisha Peel
- Department of Infectious Disease, Monash University and Alfred
Health, Melbourne, VIC, Australia
| | - Michael Solomon
- Department of Orthopaedics, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Simon W. Young
- Department of Orthopaedic Surgery, University of Auckland, North Shore Hospital, Auckland, New Zealand
| | - Joshua S. Davis
- Department of Immunology and Infectious Diseases, Royal Newcastle
Centre, New Lambton Heights, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW,
Australia
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22
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Doub JB, Nandi S, Putnam N. Retention of Minocycline Susceptibility When Gram-Positive Periprosthetic Joint Infection Isolates Are Non-Susceptible to Doxycycline. Infect Dis Rep 2022; 14:641-645. [PMID: 36136819 PMCID: PMC9498444 DOI: 10.3390/idr14050069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/24/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The treatment of hardware infections often utilizes chronic oral suppression antibiotics to prevent infection recurrence. However, when methicillin-resistant Staphylococcus aureus and other bacteria are non-susceptible to doxycycline, limited oral antibiotic options can be available that do not cause significant side effects and drug–drug interactions. Consequently, the purpose of this study was to evaluate the ability of Gram-positive clinical prosthetic joint infection isolates that were non-susceptible to doxycycline and to retain susceptibility to minocycline. Methods: Twenty-six Gram-positive prosthetic joint infection isolates that were not susceptible to doxycycline were evaluated for retained minocycline susceptibility with the use of minocycline gradient diffusion test strips. Results: All five of the coagulase-negative staphylococcal isolates and eight of the eleven methicillin-resistant S. aureus isolates were susceptible to minocycline, despite being doxycycline non-susceptible. None of the five Enterococcus faecium PJI isolates retained susceptibility to minocycline and only two of the five E. faecalis isolates (n = 5) were susceptible to minocycline. Conclusions: The findings have direct clinical implications supporting minocycline susceptibility testing for patients with PJI and other hardware-associated infections, which have isolates that are doxycycline non-susceptible to thereby provide alternative suppression antibiotic options.
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Affiliation(s)
- James B. Doub
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Correspondence:
| | - Sumon Nandi
- Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Nicole Putnam
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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23
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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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24
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Tai DBG, Berbari EF, Suh GA, Lahr BD, Abdel MP, Tande AJ. Truth in DAIR: Duration of Therapy and the Use of Quinolone/Rifampin-Based Regimens following Debridement and Implant Retention for Periprosthetic Joint Infections. Open Forum Infect Dis 2022; 9:ofac363. [PMID: 36072695 PMCID: PMC9439576 DOI: 10.1093/ofid/ofac363] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 07/21/2022] [Indexed: 11/17/2022] Open
Abstract
Background The optimal duration of antibiotic therapy after debridement and implant retention (DAIR) for periprosthetic joint infections (PJIs) is debated. Furthermore, the best antibiotic regimens for staphylococcal PJI are also unclear. In this study, we evaluated the impact of antibiotic therapy duration on the risk of failure. We assessed the utility of rifampin-based regimens for staphylococcal PJI managed with DAIR. Methods We performed a retrospective cohort study of patients 18 years and older diagnosed with hip and knee PJI who underwent DAIR between January 1, 2008 and 31 December 31, 2018 at Mayo Clinic, USA. The outcome was failure of DAIR. For statistical analysis, joint-stratified Cox regression models adjusted for age, sinus tract, symptom duration, and primary/revision arthroplasty were performed. Results We examined 247 cases of PJI with a median follow-up of 4.4 years (interquartile range [IQR], 2.3–7) after DAIR. The estimated 5-year cumulative incidence of failure was 28.1% (n = 65). There was no association between the duration of intravenous (IV) antibiotics (median 42 days; IQR, 38–42) and treatment failure (P = .119). A shorter duration of subsequent oral antibiotic therapy was associated with a higher risk of failure (P = .005; eg, 90-day vs 1-year duration; hazard ratio [HR], 3.50; 95% confidence interval [CI], 1.48–8.25). For staphylococcal knee PJI, both the use and longer duration of a rifampin-based regimen were associated with a lower risk of failure (both P = .025). There was no significant association between fluoroquinolone (FQ) use and failure (HR, 0.62; 95% CI, .31–1.24; P = .172). Conclusions The duration of initial IV antibiotic therapy did not correlate with treatment failure in this cohort of patients. Rifampin use is recommended for staphylococcal knee PJI. There was no apparent benefit of FQ use in staphylococcal PJI.
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Affiliation(s)
- Don Bambino Geno Tai
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine , Mayo Clinic , USA
| | - Elie F Berbari
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine , Mayo Clinic , USA
| | - Gina A Suh
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine , Mayo Clinic , USA
| | - Brian D Lahr
- Department of Quantitative Health Sciences , Mayo Clinic , USA
| | | | - Aaron J Tande
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine , Mayo Clinic , USA
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25
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Drain NP, Bertolini DM, Anthony AW, Feroze MW, Chao R, Onyekweli T, Longo SE, Hersh BL, Smith CN, Rothenberger SD, Shah NB, Urish KL. High Mortality After Total Knee Arthroplasty Periprosthetic Joint Infection is Related to Preoperative Morbidity and the Disease Process but Not Treatment. J Arthroplasty 2022; 37:1383-1389. [PMID: 35314288 DOI: 10.1016/j.arth.2022.03.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 02/23/2022] [Accepted: 03/12/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) mortality rate is approximately 20%. The etiology for high mortality remains unknown. The objective of this study was to determine whether mortality was associated with preoperative morbidity (frailty), sequalae of treatment, or the PJI disease process itself. METHODS A multicenter observational study was completed comparing 184 patients treated with septic revision total knee arthroplasty (TKA) to a control group of 38 patients treated with aseptic revision TKA. Primary outcomes included time and the cause of death. Secondary outcomes included preoperative comorbidities and Charlson Comorbidity Index (CCMI) measured preoperatively and at various postoperative timepoints. RESULTS The septic revision TKA cohort experienced earlier mortality compared to the aseptic cohort, with a higher mortality rate at 90 days, 1, 2, and 3 years after index revision surgery (P = .01). There was no significant difference for any single cause of death (P > .05 for each). The mean preoperative CCMI was higher (P = .005) in the septic revision TKA cohort. Both septic and aseptic cohorts experienced a significant increase in CCMI from the preoperative to 3 years postoperative (P < .0001 and P = .002) and time of death (P < .0001 both) timepoints. The septic revision TKA cohort had a higher CCMI 3 years postoperatively (P = .001) and at time of death (P = .046), but not one year postoperatively (P = .119). CONCLUSION Compared to mortality from aseptic revision surgery, septic revision TKA is associated with earlier mortality, but there is no single specific etiology. As quantified by changes in CCMI, PJI mortality was associated with both frailty and the PJI disease process, but not treatment.
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Affiliation(s)
- Nicholas P Drain
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Austin W Anthony
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Muhammad W Feroze
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Richard Chao
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Tito Onyekweli
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sadie E Longo
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Beverly L Hersh
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Clair N Smith
- Department of Physical Therapy and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Scott D Rothenberger
- Center for Research on Health Care Data Center, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Neel B Shah
- Division of Infectious Disease, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center; Department of Orthopaedic Surgery, Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh; Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
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26
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Tarity TD, Xiang W, Jones CW, Gkiatas I, Nocon A, Selemon NA, Carli A, Sculco PK. Do Antibiotic-Loaded Calcium Sulfate Beads Improve Outcomes After Debridement, Antibiotics, and Implant Retention? A Matched Cohort Study. Arthroplast Today 2022; 14:90-95. [PMID: 35252512 PMCID: PMC8891996 DOI: 10.1016/j.artd.2022.01.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/13/2022] [Indexed: 12/23/2022] Open
Abstract
Background Dissolvable antibiotic-loaded calcium sulfate beads are used as an intraoperative adjunct during debridement with antibiotics and implant retention (DAIR) for periprosthetic joint infections (PJI) to reduce the historically higher failure rates than one- or two-stage exchange. This study evaluated clinical outcomes after DAIRs performed with and without these antibiotic beads. The primary outcome was post-DAIR failure secondary to recurrent PJI at 2 years. The secondary outcome was early failure secondary to recurrent PJI within 90 days. Material and methods DAIRs performed for acute or acute hematogenous PJI at a single institution were retrospectively identified between 2013 and 2018. All DAIRs with adjunctive antibiotic beads (cases) were then exactly matched to a cohort of DAIRs without beads (controls) based on Charlson Comorbidity Index. The McNemar’s test and Wilcoxon signed-rank test were used to evaluate differences in outcomes and patient characteristics. Results Twenty DAIR cases (with antibiotic beads) were matched with 20 DAIR controls. There was no difference in age, sex, body mass index, joint, erythrocyte sedimentation rate, C-reactive protein, microbiology profile, antibiotic-resistance profile, or intraoperative lavage adjuncts between groups. There were no statistically significant differences between cases and controls for either overall infection-related failure at 2 years (P = .21) or early infection-related failure at 90 days (P = 1.00). Conclusion Adjunctive dissolvable antibiotic-loaded calcium sulfate beads did not reduce the incidence of recurrent PJIs at 2 years or 90 days postoperatively after DAIR. Given the added cost of these antibiotic dissolvable beads without clinical benefits, we cannot recommend their use as an adjunct treatment during DAIRs.
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Affiliation(s)
- T David Tarity
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - William Xiang
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Christopher W Jones
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Ioannis Gkiatas
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Allina Nocon
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Nicolas A Selemon
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Alberto Carli
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA.,Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Peter K Sculco
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA.,Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
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27
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Pannu TS, Villa JM, Higuera CA. Diagnosis and management of infected arthroplasty. SICOT J 2021; 7:54. [PMID: 34723789 PMCID: PMC8559719 DOI: 10.1051/sicotj/2021054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 10/09/2021] [Indexed: 12/19/2022] Open
Abstract
Periprosthetic joint infection (PJI) is one of the most dreadful complications after THA and TKA. Though prevention is of utmost importance in PJI management, the last decade has seen many remarkable developments in PJI diagnosis, including the introduction of several standardized PJI diagnostic definitions and biomarkers. Depending on the specific clinical situation, a myriad of treatment options for PJI are offered. Our review aims to summarize the pertinent information on PJI diagnosis and synthesize literature on the different treatment methods currently used in clinical practice. One of the most accepted PJI diagnostic definitions was developed by the Musculoskeletal Infection Society (MSIS) in 2011, later modified in the 2013 International Consensus Meeting (ICM). After promising results from studies, alpha-defensins and D-dimer were recently incorporated into the 2018 ICM PJI definition. The management choices for PJI include irrigation and debridement (DAIR), one-stage exchange arthroplasty, or two-stage exchange arthroplasty, to name a few. While two-stage revision has traditionally been the treatment of choice in the United States, there has been a growing body of evidence framing one-stage revision as a comparable choice. One-stage revision should be offered in patients meeting strict selection criteria: no sinus tract, proper soft tissue available for wound closure, appropriate bone stock, a favorable identifiable organism with encouraging antibiotic sensitivities (for cement and oral suppression later), and robust immunological status. DAIR can be considered in case of early infections with sensitive infecting organisms. Patients with multiple unsuccessful revisions or those who refuse further surgical intervention for PJI can be offered antibiotic suppression. If nothing seems to work, salvage procedures (resection arthroplasty and arthrodesis) are available as a last resort. Further research is encouraged to improve on diagnostic capabilities and develop evidence on the best treatment of choice for PJI.
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Affiliation(s)
- Tejbir S Pannu
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, 33331 FL, USA
| | - Jesus M Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, 33331 FL, USA
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, 33331 FL, USA
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28
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Lee SH, Chang CH, Hu CC, Chang Y, Hsieh PH, Lin YC. The Risk Factor and Outcome of Metachronous Periprosthetic Joint Infections: A Retrospective Analysis With a Minimum Ten-Year Follow-Up. J Arthroplasty 2021; 36:3734-3740. [PMID: 34419315 DOI: 10.1016/j.arth.2021.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/20/2021] [Accepted: 07/29/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with multiple prosthetic joints are at risk of developing periprosthetic joint infections (PJIs). We aimed to determine whether PJI development at one site may lead to infection at another prosthetic joint site and assess the risk factors leading to this subsequent infection. METHODS We reviewed all cases (294 patients with first-time PJI [159 hips, 135 knees]) with PJI treated at our institute between January 1994 and December 2020. The average follow-up period was 11.2 years (range 10.1-23.2). Patients were included if they had at least one other prosthetic joint at the time of developing a single PJI (96 patients). Patients with synchronous PJI were excluded from the study. The incidence of metachronous PJI was assessed, and the risk factors were determined by comparing different characteristics between patients without metachronous PJI. RESULTS Of the 96 patients, 19.79% developed metachronous PJI. The identified causative pathogen was the same in 63.16% of the patients. The time to developing a second PJI was 789.84 days (range 10-3386). The identified risk factors were PJI with systemic inflammatory response syndrome, ≥3 stages of resection arthroplasty, and PJI caused by methicillin-resistant Staphylococcus aureus. CONCLUSION PJI may predispose patients to subsequent PJI in another prosthesis with identified risks. Most causative organisms of metachronous PJI were the same species as those of the first PJI. We believe that bacteremia may be involved in pathogenesis, but further research is required.
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Affiliation(s)
- Sheng-Hsun Lee
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; College of Medicine, Chang Gung University (CGU), Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; College of Medicine, Chang Gung University (CGU), Taoyuan, Taiwan
| | - Chih-Chien Hu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; College of Medicine, Chang Gung University (CGU), Taoyuan, Taiwan
| | - Yuhan Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; College of Medicine, Chang Gung University (CGU), Taoyuan, Taiwan
| | - Pang-Hsin Hsieh
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; College of Medicine, Chang Gung University (CGU), Taoyuan, Taiwan
| | - Yu-Chih Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; College of Medicine, Chang Gung University (CGU), Taoyuan, Taiwan
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Antich-Isern P, Caro-Barri J, Aparicio-Blanco J. The combination of medical devices and medicinal products revisited from the new European legal framework. Int J Pharm 2021; 607:120992. [PMID: 34390808 DOI: 10.1016/j.ijpharm.2021.120992] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/20/2021] [Accepted: 08/08/2021] [Indexed: 02/06/2023]
Abstract
Medical devices and medicinal products have many similarities in their nature, scope or specific medical purposes, and despite the differences in their principal means of action, they are often used in combination. Indeed, many medicinal products depend on medical devices for their administration, and it is increasingly common for medical devices to contain medicinal substances to support their action. Therefore, the combination of medicinal products and medical devices provides additional benefits for patients. However, their higher technical complexity requires a strengthening of their authorisation and certification requirements. In this regard, more comprehensive requirements and classification rules are introduced by a new European regulation on medical devices that fully applies from May 26th 2021. On account of their therapeutic significance, this review aims at gaining insight into the borderline between medical devices and medicinal products in this new 2021 regulatory framework. For the first time, any item containing a medical device and a medicinal product will have both parts evaluated. Through exemplification of both marketed and investigational devices incorporating medicinal substances and drug-device combinations, the new European requirements and their implications are thoroughly illustrated herein.
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Affiliation(s)
- Pau Antich-Isern
- Department of Pharmaceutics and Food Technology, Faculty of Pharmacy, Complutense University of Madrid, Madrid, Spain
| | - Julia Caro-Barri
- Notified Body 0318, Spanish Agency of Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Juan Aparicio-Blanco
- Department of Pharmaceutics and Food Technology, Faculty of Pharmacy, Complutense University of Madrid, Madrid, Spain; Institute of Industrial Pharmacy, Complutense University of Madrid, Madrid, Spain.
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30
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Fehring TK, Fehring KA, Hewlett A, Higuera CA, Otero JE, Tande AJ. What's New in Musculoskeletal Infection. J Bone Joint Surg Am 2021; 103:1251-1258. [PMID: 34048412 DOI: 10.2106/jbjs.21.00311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Thomas K Fehring
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina.,Atrium Musculoskeletal Institute, Charlotte, North Carolina
| | | | | | | | - Jesse E Otero
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina.,Atrium Musculoskeletal Institute, Charlotte, North Carolina
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31
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Zlotnicki J, Gabrielli A, Urish KL, Brothers KM. Clinical Evidence of Current Irrigation Practices and the Use of Oral Antibiotics to Prevent and Treat Periprosthetic Joint Infection. Orthop Clin North Am 2021; 52:93-101. [PMID: 33752842 PMCID: PMC7990073 DOI: 10.1016/j.ocl.2020.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Jason Zlotnicki
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Bridgeside Point II, 450 Technology Drive, Pittsburgh, PA 15219, USA
| | - Alexandra Gabrielli
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Bridgeside Point II, 450 Technology Drive, Pittsburgh, PA 15219, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Bridgeside Point II, 450 Technology Drive, Pittsburgh, PA 15219, USA
| | - Kimberly M Brothers
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Bridgeside Point II, 450 Technology Drive, Pittsburgh, PA 15219, USA.
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Vollmer NJ, Rivera CG, Stevens RW, Oravec CP, Mara KC, Suh GA, Osmon DR, Beam EN, Abdel MP, Virk A. Safety and Tolerability of Fluoroquinolones in Patients with Staphylococcal Periprosthetic Joint Infections. Clin Infect Dis 2021; 73:850-856. [PMID: 33606003 DOI: 10.1093/cid/ciab145] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Fluoroquinolones (FQs) are known to be accompanied by significant risks. However, the incidence of adverse events (ADE) resulting in unplanned drug discontinuation when used for periprosthetic joint infections (PJI) is currently unknown. METHODS This study included 156 patients over the age of 18 treated for staphylococcal PJI with debridement, antibiotics, and implant retention (DAIR), between January 1, 2007 and November 21, 2019. Of the 156 patients, 64 had total hip arthroplasty (THA) and 92 had total knee arthroplasty (TKA) infections. The primary outcome was rate of unplanned drug discontinuation. Secondary outcomes included incidence of severe ADE, unplanned rifamycin discontinuation, mean time to unplanned regimen discontinuation, and all-cause mortality. RESULTS Overall, unplanned drug discontinuation occurred in 35.6% of patients in the FQ group and 3% of patients in the non-FQ group. The rate of unplanned discontinuation of FQ regimens as compared to non-FQ regimens was 27.5% vs 4.2% (p=0.021) in THA infections and 42% vs 2.4% (p<0.001) in TKA infections. There was no significant difference in severe ADEs between FQ and non-FQ regimens in both THA and TKA infections. The overall rate of non-severe ADEs in FQ compared to non-FQ regimens was 43.3% vs 6.1% (p<0.001). FQs were associated with tendinopathy, myalgia, arthralgia, and nausea. CONCLUSIONS A significantly higher rate of unplanned drug discontinuation was associated with FQ as compared to non-FQ regimens. This provides a real-world view of the implications of FQ related adverse events on unplanned discontinuation when used in prolonged durations for the management of staphylococcal PJIs.
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Affiliation(s)
| | | | - Ryan W Stevens
- Department of Pharmacy; Mayo Clinic Hospital-Rochester, MN, USA
| | - Caitlin P Oravec
- Division of Infectious Diseases; Mayo Clinic Hospital-Rochester, MN, USA
| | - Kristin C Mara
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics; Mayo Clinic Hospital-Rochester, MN, USA
| | - Gina A Suh
- Division of Infectious Diseases; Mayo Clinic Hospital-Rochester, MN, USA
| | - Douglas R Osmon
- Division of Infectious Diseases; Mayo Clinic Hospital-Rochester, MN, USA
| | - Elena N Beam
- Division of Infectious Diseases; Mayo Clinic Hospital-Rochester, MN, USA
| | - Matthew P Abdel
- Department of Orthopedics; Mayo Clinic Hospital-Rochester, MN, USA
| | - Abinash Virk
- Division of Infectious Diseases; Mayo Clinic Hospital-Rochester, MN, USA
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33
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Motififard M, Nazem K, Meshkati M. Determining the relation between total knee arthroplasty surgery site drainage in two weeks after surgery with periprosthetic joint infection (PJI) in two years. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2021; 11:62-68. [PMID: 33824787 PMCID: PMC8012868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/28/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Prosthetic joint infection (PJI) is a devastating complication in total knee arthroplasty (TKA) surgeries and prompt diagnosis and treatment are vital; however, no study has been conducted to determine the relationship between characteristics and duration of surgical site discharge and PJI. METHODS This is a longitudinal observational study that was performed at Al-Zahra and Kashani and Sadi university hospitals from 2017 until 2019. A total of 961 elective TKA were performed on 850 consecutive patients. Patients were followed up for two years after surgery. Data regarding the occurrence of discharges, types of discharges, duration of discharges, the incidence of PJI and superficial infections were collected. RESULTS The rate of superficial and prosthetic joint infection was 0.3% and 0.3%. Patients with infections (either PJI or superficial) had a longer duration of discharge (14.6 days and 13.3 days in PJI and superficial infections respectively, compared to 7.7 days in all of the study population); Bloody-purulent discharge was associated with the development of prosthetic and superficial infections. CONCLUSION Bloody purulent discharge reaching seven days postsurgical in TKA patients is highly suggestive of an underlying infection (PJI or superficial infection) but type and duration of discharge could not be used to differentiate between PJI and superficial infection. Other risk factors for PJI or superficial infection include women's gender, longer surgical duration, longer hospitalization and longer discharge duration.
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Affiliation(s)
- Mehdi Motififard
- Department of Orthopedic and Trauma, Isfahan University of Medical ScienceIsfahan, Iran
| | - Khalilolah Nazem
- Department of Orthopedic and Trauma, Isfahan University of Medical ScienceIsfahan, Iran
| | - Mehdi Meshkati
- Department of Orthopedic Surgery, School of Medicine, Isfahan University of Medical SciencesIsfahan, Iran
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Courjon J, Del Guidice P. Extended Antibiotic Treatment Duration After Debridement, Antibiotic Therapy, and Implant Retention. Clin Infect Dis 2021; 72:177. [PMID: 32518938 DOI: 10.1093/cid/ciaa389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Johan Courjon
- Infectiologie, Hôpital de l'Archet, Centre Hospitalier Universitaire de Nice, Nice, France.,Université Côte d'Azur, CHU, INSERM, C3M, France
| | - Pascal Del Guidice
- Unité́ de Maladies Infectieuses et Dermatologie, Hôpital Bonnet, Centre Hospitalier Intercommunal Fréjus Saint-Raphaël, Fréjus, France
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35
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Metsemakers WJ, Zalavras C, Schwarz EM, Chen AF, Trampuz A, Moriarty TF. Antimicrobial Resistance, the COVID-19 Pandemic, and Lessons for the Orthopaedic Community. J Bone Joint Surg Am 2021; 103:4-9. [PMID: 33259429 DOI: 10.2106/jbjs.20.01214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Antimicrobial resistance (AMR) is widely regarded as one of the most important global public health challenges of the twenty-first century. The overuse and the improper use of antibiotics in human medicine, food production, and the environment as a whole have unfortunately contributed to this issue. Many major international scientific, political, and social organizations have warned that the increase in AMR could cost the lives of millions of people if it is not addressed on a global scale. Although AMR is already a challenge in clinical practice today, it has taken on a new importance in the face of the coronavirus disease 2019 (COVID-19) pandemic. While improved handwashing techniques, social distancing, and other interventional measures may positively influence AMR, the widespread use of antibiotics to treat or prevent bacterial coinfections, especially in unconfirmed cases of COVID-19, may have unintended negative implications with respect to AMR. Although the exact number of bacterial coinfections and the rate at which patients with COVID-19 receive antibiotic therapy remain to be accurately determined, the pandemic has revived the discussion on antibiotic overuse and AMR. This article describes why the COVID-19 pandemic has increased our awareness of AMR and presents the immense global impact of AMR on society as a whole. Furthermore, an attempt is made to stress the importance of tackling AMR in the future and the role of the orthopaedic community in this worldwide effort.
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Affiliation(s)
- Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Edward M Schwarz
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Antonia F Chen
- Department of Orthopaedics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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36
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Barry JJ, Geary MB, Riesgo AM, Odum SM, Fehring TK, Springer BD. Irrigation and Debridement with Chronic Antibiotic Suppression Is as Effective as 2-Stage Exchange in Revision Total Knee Arthroplasty with Extensive Instrumentation. J Bone Joint Surg Am 2021; 103:53-63. [PMID: 33079900 DOI: 10.2106/jbjs.20.00240] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Extraction of implants because of periprosthetic infection (PJI) following complex revision total knee arthroplasty (rTKA) with extensive instrumentation is a daunting undertaking for surgeon and patient alike. The purpose of the present study was to evaluate whether infections following complex rTKA are better treated with 2-stage exchange or irrigation and debridement (I&D) with modular component exchange and antibiotic suppression in terms of infection control, reoperation, and function. METHODS We reviewed rTKAs that had been performed for the treatment of PJI from 2005 to 2016. Extensive instrumentation was defined as the presence ≥1 of the following: metaphyseal cones/sleeves, distal femoral replacement, periprosthetic fracture instrumentation, or fully cemented stems measuring >75 mm. Cases were categorized according to the initial treatment (I&D with antibiotic suppression or initiation of 2-stage exchange). RESULTS Eighty-seven patients with PJI and extensive instrumentation were identified: 56 patients who were managed with I&D with suppression and 31 who were managed with the initiation of 2-stage exchange. The rate of success (defined as no reoperation for infection) was similar for the 2 groups (62.5% the I&D group compared with 67.7% for the 2-stage group; p = 0.62). The rate of mortality was also similar (39.3% for the I&D group compared with 38.7% for the 2-stage group; p = 0.96). Of the 31 patients in the 2-stage group, 18 (58.1%) underwent reimplantation with a revision replacement. Of those 18 patients, 13 were still infection-free at the time of the most recent follow-up; however, when the analysis was expanded to all 31 patients in the 2-stage group, only 13 (41.9%) both had a successful reimplantation and did not require additional surgery for infection. Nine (29.0%) of the 31 patients in the 2-stage group never underwent the second stage, and 4 (12.9%) of the 31 required arthrodesis at the second stage. In contrast, 35 (62.5%) of the 56 patients in the I&D group were successfully managed, without additional surgery for the treatment of infection. At the time of the latest follow-up (mean, 3.2 years; range, 2 to 13 years), more patients in the I&D group were ambulatory (76.8% in the I&D group compared with 54.8% in the 2-stage group; p = 0.05) and maintained a functional bending knee joint (85.7% in the I&D group compared with 45.2% in the 2-stage group; p < 0.001). CONCLUSIONS In the treatment of periprosthetic infection of rTKA with extensive instrumentation, I&D with chronic antibiotic suppression was as effective as 2-stage exchange in terms of preventing reoperation for infection and was more effective in terms of maintaining function. These data apply to rTKA with extensive periarticular instrumentation and should not be extrapolated to primary or simple revision implants. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jeffrey J Barry
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina.,University of California, San Francisco, San Francisco, California
| | | | - Aldo M Riesgo
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina.,Cleveland Clinic Florida-Weston, Weston, Florida
| | - Susan M Odum
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina
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Adjunctive Use of Phage Sb-1 in Antibiotics Enhances Inhibitory Biofilm Growth Activity versus Rifampin-Resistant Staphylococcus aureus Strains. Antibiotics (Basel) 2020; 9:antibiotics9110749. [PMID: 33138034 PMCID: PMC7692760 DOI: 10.3390/antibiotics9110749] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/21/2020] [Accepted: 10/28/2020] [Indexed: 01/06/2023] Open
Abstract
Effective antimicrobials are crucial for managing Staphylococcus aureus implant-associated bone infections (IABIs), particularly for infections due to rifampin-resistant S. aureus (RRSA). Failure to remove the implant results in persistent infection; thus, prolonged suppressive antibiotic therapy may be a reasonable alternative. However, a high incidence of adverse events can necessitate the discontinuation of therapy. In this scenario, commercial Staphylococcal bacteriophage Sb-1 combined with antibiotics is an option, showing a promising synergistic activity to facilitate the treatment of biofilm infections. Therefore, we evaluated the efficacy of the inhibitory activity of five antibiotics (doxycycline, levofloxacin, clindamycin, linezolid, and rifampin) alone or combined with phage Sb-1 (106 PFU/mL) in a simultaneous and staggered manner, to combat five clinical RRSA strains and the laboratory strain MRSA ATCC 43300 in 72 h by isothermal microcalorimetry. The synergistic effects were observed when phage Sb-1 (106 PFU/mL) combined with antibiotics had at least 2 log-reduction lower concentrations, represented by a fractional biofilm inhibitory concentration (FBIC) of <0.25. Among the antibiotics that we tested, the synergistic effect of all six strains was achieved in phage/doxycycline and phage/linezolid combinations in a staggered manner, whereas a distinctly noticeable improvement in inhibitory activity was observed in the phage/doxycycline combination with a low concentration of doxycycline. Moreover, phage/levofloxacin and phage/clindamycin combinations also showed a synergistic inhibitory effect against five strains and four strains, respectively. Interestingly, the synergistic inhibitory activity was also observed in the doxycycline-resistant and levofloxacin-resistant profile strains. However, no inhibitory activity was observed for all of the combinations in a simultaneous manner, as well as for the phage/rifampin combination in a staggered manner. These results have implications for alternative, combined, and prolonged suppressive antimicrobial treatment approaches.
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Mihalko WM, Haider H, Kurtz S, Marcolongo M, Urish K. New materials for hip and knee joint replacement: What's hip and what's in kneed? J Orthop Res 2020; 38:1436-1444. [PMID: 32437026 DOI: 10.1002/jor.24750] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 04/24/2020] [Accepted: 05/01/2020] [Indexed: 02/04/2023]
Abstract
Over the last three decades there have been significant advancements in the knee and hip replacement technology that has been driven by an issue in the past concerning adverse local tissue reactions, aseptic and septic loosening. The implants and the materials we utilize have improved over the last two decades and in knee and hip replacement there has been a decrease in the failures attributed to wear and osteolysis. Despite these advancements there are still issues with patient satisfaction and early revisions due to septic and aseptic loosening in knee replacement patients. This article reviews the state of current implant material technology in hip and knee replacement surgery, discusses some of the unmet needs we have in biomaterials, and reviews some of the current biomaterials and technology that may be able to solve the most common issues in the knee and hip replacement surgery.
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Affiliation(s)
- William M Mihalko
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Hani Haider
- Orthopaedic Biomechanics and Advanced Surgical Technologies Laboratory, Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska
| | - Steven Kurtz
- Exponent Inc., Drexel University, Philadelphia, Pennsylvania
| | - Michele Marcolongo
- Department of Materials Science and Engineering, Drexel University, Philadelphia, Pennsylvania
| | - Kenneth Urish
- Department of Orthopaedic Surgery, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Bioengineering, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
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Abstract
Osteomyelitis, or inflammation of bone, is most commonly caused by invasion of bacterial pathogens into the skeleton. Bacterial osteomyelitis is notoriously difficult to treat, in part because of the widespread antimicrobial resistance in the preeminent etiologic agent, the Gram-positive bacterium Staphylococcus aureus Bacterial osteomyelitis triggers pathological bone remodeling, which in turn leads to sequestration of infectious foci from innate immune effectors and systemically delivered antimicrobials. Treatment of osteomyelitis therefore typically consists of long courses of antibiotics in conjunction with surgical debridement of necrotic infected tissues. Even with these extreme measures, many patients go on to develop chronic infection or sustain disease comorbidities. A better mechanistic understanding of how bacteria invade, survive within, and trigger pathological remodeling of bone could therefore lead to new therapies aimed at prevention or treatment of osteomyelitis as well as amelioration of disease morbidity. In this minireview, we highlight recent developments in our understanding of how pathogens invade and survive within bone, how bacterial infection or resulting innate immune responses trigger changes in bone remodeling, and how model systems can be leveraged to identify new therapeutic targets. We review the current state of osteomyelitis epidemiology, diagnostics, and therapeutic guidelines to help direct future research in bacterial pathogenesis.
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Drain NP, Gobao VC, Bertolini DM, Smith C, Shah NB, Rothenberger SD, Dombrowski ME, O'Malley MJ, Klatt BA, Hamlin BR, Urish KL. Administration of Tranexamic Acid Improves Long-Term Outcomes in Total Knee Arthroplasty. J Arthroplasty 2020; 35:S201-S206. [PMID: 32209286 PMCID: PMC7239733 DOI: 10.1016/j.arth.2020.02.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/17/2020] [Accepted: 02/22/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Blood transfusion in total knee arthroplasty (TKA) is associated with increased morbidity, including periprosthetic joint infection (PJI). Tranexamic acid (TXA) reduces blood transfusion rates, but there is limited evidence demonstrating improved outcomes in TKA resulting from TXA administration. The objectives of this study are determining whether TXA is associated with decreased rate of PJI, decreased rate of outcomes associated with PJI, and whether there are differences in rates of adverse events. METHODS A multicenter cohort study comprising 23,421 TKA compared 4423 patients receiving TXA to 18,998 patients not receiving TXA. Primary outcome was PJI within 2 years of TKA. Secondary outcomes included revision surgery, irrigation and debridement, transfusion, and length of stay. Adverse events included readmission, deep vein thrombosis, pulmonary emboli, myocardial infarction, or stroke. Adjusted odds ratios were determined using linear mixed models controlling for age, sex, thromboembolic prophylaxis, Charlson comorbidity index, year of TKA, and surgeon. RESULTS TXA administration reduced incidence of PJI by approximately 50% (odds ratio [OR], 0.55; P = .03). Additionally, there was decreased incidence of revision surgery at 2 years (OR, 0.66; P = .02). Patients receiving TXA had reductions in transfusion rate (OR, 0.15; P < .0001) and length of stay (P < .0001). There was no difference in the rate of pulmonary emboli (OR, 1.20; P = .39), myocardial infarction (OR, 0.78; P = .55), or stroke (OR, 1.17; P = .77). CONCLUSION Administration of TXA in TKA resulted in reduced rate of PJI and overall revision surgery. No difference in thromboembolic events were observed. The use of TXA is safe and improves outcomes in TKA. LEVEL OF EVIDENCE Level III, Observational Cohort Study.
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Affiliation(s)
| | | | | | - Clair Smith
- Department of Physical Therapy and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Neel B Shah
- Division of Infectious Disease, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Scott D Rothenberger
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Michael J O'Malley
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Brian A Klatt
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Brian R Hamlin
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Department of Orthopaedic Surgery, Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh; Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA
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Yang J, Parvizi J, Hansen EN, Culvern CN, Segreti JC, Tan T, Hartman CW, Sporer SM, Della Valle CJ. 2020 Mark Coventry Award: Microorganism-directed oral antibiotics reduce the rate of failure due to further infection after two-stage revision hip or knee arthroplasty for chronic infection: a multicentre randomized controlled trial at a minimum of two years. Bone Joint J 2020; 102-B:3-9. [DOI: 10.1302/0301-620x.102b6.bjj-2019-1596.r1] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to determine if a three-month course of microorganism-directed oral antibiotics reduces the rate of failure due to further infection following two-stage revision for chronic prosthetic joint infection (PJI) of the hip and knee. Methods A total of 185 patients undergoing a two-stage revision in seven different centres were prospectively enrolled. Of these patients, 93 were randomized to receive microorganism-directed oral antibiotics for three months following reimplantation; 88 were randomized to receive no antibiotics, and four were withdrawn before randomization. Of the 181 randomized patients, 28 were lost to follow-up, six died before two years follow-up, and five with culture negative infections were excluded. The remaining 142 patients were followed for a mean of 3.3 years (2.0 to 7.6) with failure due to a further infection as the primary endpoint. Patients who were treated with antibiotics were also assessed for their adherence to the medication regime and for side effects to antibiotics. Results Nine of 72 patients (12.5%) who received antibiotics failed due to further infection compared with 20 of 70 patients (28.6%) who did not receive antibiotics (p = 0.012). Five patients (6.9%) in the treatment group experienced adverse effects related to the administered antibiotics severe enough to warrant discontinuation. Conclusion This multicentre randomized controlled trial showed that a three-month course of microorganism-directed, oral antibiotics significantly reduced the rate of failure due to further infection following a two-stage revision of total hip or knee arthroplasty for chronic PJI. Cite this article: Bone Joint J 2020;102-B(6 Supple A):3–9.
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Affiliation(s)
- JaeWon Yang
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Erik N. Hansen
- Department of Orthopaedic Surgery, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Chris N. Culvern
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - John C. Segreti
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Timothy Tan
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Curtis W. Hartman
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Scott M. Sporer
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Craig J. Della Valle
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Deslouches B, Montelaro RC, Urish KL, Di YP. Engineered Cationic Antimicrobial Peptides (eCAPs) to Combat Multidrug-Resistant Bacteria. Pharmaceutics 2020; 12:pharmaceutics12060501. [PMID: 32486228 PMCID: PMC7357155 DOI: 10.3390/pharmaceutics12060501] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/25/2020] [Accepted: 05/27/2020] [Indexed: 12/12/2022] Open
Abstract
The increasing rate of antibiotic resistance constitutes a global health crisis. Antimicrobial peptides (AMPs) have the property to selectively kill bacteria regardless of resistance to traditional antibiotics. However, several challenges (e.g., reduced activity in the presence of serum and lack of efficacy in vivo) to clinical development need to be overcome. In the last two decades, we have addressed many of those challenges by engineering cationic AMPs de novo for optimization under test conditions that typically inhibit the activities of natural AMPs, including systemic efficacy. We reviewed some of the most promising data of the last two decades in the context of the advancement of the field of helical AMPs toward clinical development.
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Affiliation(s)
- Berthony Deslouches
- Department of Environmental and Occupational Health, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA 15261, USA;
- Correspondence: ; Tel.: +1-412-624-0103
| | - Ronald C. Montelaro
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA;
| | - Ken L. Urish
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA;
| | - Yuanpu P. Di
- Department of Environmental and Occupational Health, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA 15261, USA;
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Beta-hemolytic group a streptococcal orthopaedic infections: Our institutional experience and review of the literature. J Orthop 2020; 21:150-154. [PMID: 32255996 DOI: 10.1016/j.jor.2020.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 03/23/2020] [Indexed: 11/20/2022] Open
Abstract
Group A streptococcal (GAS) infections have high morbidity and mortality due to toxin production and tissue invasion. We reviewed all orthopaedic GAS infections at our medical centre between January 2017 and April 2019. Median age was 56 years. At least 60% had a body mass index (BMI) of ≥30 kg/m2. Median Charlson comorbidity score was 3 (range 0-7). Clinical cure at 90 days was achieved in only 62%. All 4 patients with underlying orthopaedic hardware were cured. Toxin-neutralizing antibiotics and intravenous immunoglobulin were underutilized. Our review confirms poor outcomes from GAS orthopaedic infections without optimal management.
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Wouthuyzen-Bakker M, Lora-Tamayo J, Soriano A. Antibiotic Use in Total Knee Arthroplasty Periprosthetic Joint Infection. Clin Infect Dis 2020; 70:1259-1260. [PMID: 31504318 DOI: 10.1093/cid/ciz631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Jaime Lora-Tamayo
- Department of Internal Medicine, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Madrid
| | - Alex Soriano
- Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Spain
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Shah NB, Hersh BL, Kreger A, Sayeed A, Bullock AG, Rothenberger SD, Klatt B, Hamlin B, Urish KL. Reply to Wouthuyzen-Bakker et al. Clin Infect Dis 2020; 70:1260-1261. [PMID: 31292620 PMCID: PMC7931842 DOI: 10.1093/cid/ciz632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Neel B Shah
- Division of Infectious Disease, Department of Internal Medicine, University of Pittsburgh Medical Center, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Beverly L Hersh
- University of Pittsburgh School of Medicine, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Alex Kreger
- University of Pittsburgh School of Medicine, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Aatif Sayeed
- University of Pittsburgh School of Medicine, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Andrew G Bullock
- University of Pittsburgh School of Medicine, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Scott D Rothenberger
- Center for Research on Health Care Data Center, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Brian Klatt
- Department of Orthopaedic Surgery, University of Pittsburgh, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Brian Hamlin
- Bone and Joint Center, and, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, Bone and Joint Center, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Carnegie Mellon University, Pittsburgh, Pennsylvania
- Department of Orthopaedic Surgery, Department of Bioengineering, Carnegie Mellon University, Pittsburgh, Pennsylvania and Clinical and Translational Science Institute, University of Pittsburgh
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
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