Increased risk of prosthetic joint infection associated with esophago-gastro-duodenoscopy with biopsy

Inflammatory bowel disease is associated with an increased risk of adverse events in patients undergoing joint arthroplasty

Aims

The present study aimed to investigate whether patients with inflammatory bowel disease (IBD) undergoing joint arthroplasty have a higher incidence of adverse outcomes than those without IBD.

Methods

A comprehensive literature search was conducted to identify eligible studies reporting postoperative outcomes in IBD patients undergoing joint arthroplasty. The primary outcomes included postoperative complications, while the secondary outcomes included unplanned readmission, length of stay (LOS), joint reoperation/implant revision, and cost of care. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model when heterogeneity was substantial.

Results

Eight retrospective studies involving 29,738 patients with IBD were included. Compared with non-IBD controls, patients with IBD were significantly more likely to have overall complications (OR 2.11 (95% CI 1.67 to 2.66), p < 0.001), medical complications (OR 2.15 (95% CI 1.73 to 2.68), p < 0.001), surgical complications (OR 1.43 (95% CI 1.21 to 1.70), p < 0.001), and 90-day readmissions (OR 1.42 (95% CI 1.23 to 1.65), p < 0.001). The presence of IBD was positively associated with the development of venous thromboembolism (OR 1.60 (95% CI 1.30 to 1.97), p < 0.001) and postoperative infection (OR 1.95 (95% CI 1.51 to 2.51), p < 0.001). In addition, patients with IBD tended to experience longer LOS and higher costs of care.

Conclusion

The findings suggest that IBD is associated with an increased risk of postoperative complications and readmission after joint arthroplasty, resulting in longer hospital stay and greater financial burden. Surgeons should inform their patients of the possibility of adverse outcomes prior to surgery and make appropriate risk adjustments to minimize potential complications.

Invasive Gastrointestinal Endoscopy Following Total Joint Arthroplasty Increases the Risk for Periprosthetic Joint Infection

BACKGROUND

The safety of postoperative colonoscopy and endoscopy following total joint arthroplasty (TJA) remains largely unknown. The objective of this study was to characterize the effect of gastrointestinal endoscopic procedures after TJA on the risk of postoperative periprosthetic joint infection (PJI).

METHODS

Using a large national database, patients who underwent an endoscopic procedure (colonoscopy or esophagogastroduodenoscopy (EGD)) within 12 months after primary TJA were identified and matched in a 1:1 fashion based on procedure (primary total knee arthroplasty (TKA) vs. total hip arthroplasty (THA), age, sex, Charlson Comorbidity Index (CCI), and smoking status with patients who did not undergo endoscopy. A total of 142,055 patients who underwent endoscopy within 12 months following TJA (96,804 TKA and 45,251 THA) were identified and matched. The impact of timing of endoscopy relative to TJA on postoperative outcomes was assessed. Pre-operative comorbidity profiles and 1-year complications were compared. Statistical analyses included Chi-squared tests and multivariate logistic regressions with outcomes considered significant at P <0.05.

RESULTS

Multivariate analyses revealed that endoscopy within 2 months following TKA and 1 month of THA was associated with a significantly increased odds of periprosthetic joint infection (Odds Ratio (OR): 1.29 [1.08-1.53]; P=.004; OR: 1.41 [1.01-1.90]; P=0.033, respectively). Patients who underwent endoscopy greater than 2 months from the timing of their TKA and 1 month from THA were not at significantly greater risk of developing PJI.

CONCLUSION

This data suggests that invasive endoscopic procedures should be delayed if possible by at least 2 months following TKA and 1 month following THA to minimize the risk of PJI.

Antibiotic Prophylaxis is Often Unnecessary for Screening Colonoscopies Following Total Knee Arthroplasty

INTRODUCTION

Incidence of bacteremia following screening colonoscopy is low, but risk of hematogenous spread causing prosthetic joint infection (PJI) may exist in total knee arthroplasty (TKA) patients. In multivariate analyses, we examined PJI risk among three TKA cohorts: (1) colonoscopy recipients given antibiotic prophylaxis; (2) colonoscopy recipients not given antibiotic prophylaxis; and (3) no colonoscopy. We assessed: 90-day to one-year (A) PJI risk, and (B) risk factors for post-colonoscopy PJI.

METHODS

We queried a national, all-payer database for primary TKA recipients from 2010 to 2020. Patients who had colonoscopies and who did (n=2,558) or did not have antibiotic prophylaxis (n=20,000) were identified. These were compared those who did not undergo colonoscopy (n=20,000). The 20,000 patients were randomly selected to mitigate type 1 errors. Multivariate regressions compared PJI risk factors, such as alcohol abuse (AA), rheumatoid arthritis (RA), and diabetes.

RESULTS

Both colonoscopy cohorts had no increased PJI risk compared to non-colonoscopy (odds ratio (OR)<2.20, P≥0.064). Alcohol abuse, diabetes, and RA were found to be risk factors further enhancing likelihood of PJI for TKA patients not receiving antibiotics undergoing colonoscopies (OR>1.35, P≤0.044).

CONCLUSION

Overall, antibiotic prophylaxis does not decrease PJI risk following colonoscopy TKA recipients. After adjusting for known risk factors, both colonoscopy cohorts demonstrated similar PJI risks compared to the non-colonoscopy cohort. However, AA, diabetes, and RA were associated with further increased PJI risk for TKA patients undergoing colonoscopies compared to those who did not. Therefore, if undergoing colonoscopy after TKA, our findings suggest that most patients do not need to have antibiotics except for these high-risk patients.

Diagnostic and Invasive Colonoscopy Are Not Risk Factors for Revision Surgery Due to Periprosthetic Joint Infection

BACKGROUND

Colonoscopy is routinely performed for colorectal cancer screening in patients who have a preexisting unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), or total hip arthroplasty (THA) prostheses. However, colonoscopy is theorized to provoke transient bacteremia, providing a potential nidus for periprosthetic joint infection. This study aimed to investigate the risk of aseptic and septic revision surgery in patients who underwent diagnostic colonoscopy or invasive colonoscopy within one year following UKA, TKA, or THA.

METHODS

A retrospective cohort analysis was performed using a national database. Patients were identified using Current Procedural Terminology. In total, 52,891 patients underwent UKA, 1,049,218 underwent TKA, and 526,296 underwent THA. Data were analyzed with univariate analysis preceding multivariable logistic regressions to investigate outcomes of interest at 2 and 3 years from the index procedure.

RESULTS

Diagnostic colonoscopy resulted in no increase in odds of all-cause or septic revision surgery for any prostheses. At both time points, invasive colonoscopy resulted in lower odds of all-cause revision (P < .05) for patients with UKA, decreased odds of septic revision (P < .001) for patients with TKA, and decreased odds of both all-cause and septic revision (P < .05) for patients with THA.

CONCLUSION

Our results show that diagnostic colonoscopy was not a significant risk factor for revision following UKA, TKA, or THA. Paradoxically, invasive colonoscopy was protective against revision, even with very minimal use of antibiotic prophylaxis observed. This study addresses the theory that colonoscopy procedures may threaten an existing joint prosthesis via transient bacteremia and shows no increase in revision outcomes following colonoscopy.

LEVEL OF EVIDENCE

Level III.

Gastrointestinal Endoscopy and the Risk of Prosthetic Joint Infection: A Nationwide Database Analysis

BACKGROUND

Current guidelines suggest antibiotics prophylaxis is not necessary for patients with orthopedic prosthetics undergoing gastrointestinal endoscopy. Clinical evidence to support this recommendation is lacking.

AIMS

To analyze the association between inpatient gastrointestinal endoscopy and prosthetic joint infection (PJI) in patients with a recent arthroplasty.

METHODS

We included patients admitted from July to October of each calendar year (index admissions) who had an arthroplasty in the same calendar year prior to the index admission. We followed the occurrence of PJI for 60 days after the index admission. Only admissions from July to October were chosen as index admissions, and the follow-up period was limited to 60 days because the database structure prohibits the analysis of events in different calendar years. We compared the rate of 60-day PJI between those who had gastrointestinal endoscopy on index admissions to those who had not. We excluded patients aged less than 18 years, who died on index admission, or had any infection in the same calendar year before or during the index admission.

RESULTS

Of 1,831,218 patients with arthroplasty, 88,345 met the inclusion criteria, out of which 5,855 had gastrointestinal endoscopy. The rate of 60-day PJI in those who had endoscopy was 0.23%, and in those who had not was 0.52% (P < 0.001). EGD without excision (adjusted odds ratio [95% confidence interval]: 0.20 [0.03-1.42], P = 0.107), EGD with excision (0.58 [0.21-1.60], P = 0.295), colonoscopy without excision (0.43 [0.11-1.72], P = 0.233), colonoscopy with excision (0.31 [0.04-2.21], P = 0.241), and PEG/PEJ (0.38 [0.05-2.71], P = 0.337) were not associated with risk of 60-day PJI. We found no PJI cases in patients underwent esophageal dilation, ERCP, and EUS with FNA.

CONCLUSIONS

Gastrointestinal endoscopy in hospitalized patients with a recent previous arthroplasty is not associated with an increased risk of 60-day prosthetic joint infection.

Antibiotic Prophylaxis for Prosthetic Joint Patients Undergoing Invasive Dental Procedures: Time for a Rethink?

BACKGROUND

In the United States, it has been common practice to recommend that dentists provide antibiotic prophylaxis (AP) before invasive dental procedures (IDPs) to prevent late periprosthetic joint infections (LPJIs) in patients who have prosthetic arthroplasties despite lack of evidence for a causal relationship between IDP and LPJI and a lack of evidence for AP efficacy.

METHODS

A recent study quantified the IDP incidence over the 15-month period prior to LPJI hospital admissions in the United Kingdom for which dental records were available. A case-crossover analysis compared IDP incidence in the 3 months before LPJI admission with the preceding 12 months. The English population was used because guidelines do not recommend AP and any relationship between IDPs and LPJI should be fully exposed.

RESULTS

No significant positive association was identified between IDPs and LPJI. Indeed, the incidence of IDPs was lower in the 3 months before LPJI hospital admission than that in the preceding 12 months.

CONCLUSION

In the absence of a significant positive association between IDPs and LPJI, there is no rationale to administer AP before IDPs in patients with prosthetic joints, particularly given the cost and inconvenience of AP, the risk of adverse drug reactions, and the potential for unnecessary AP use that promotes antibiotic resistance. These results should reassure orthopedic surgeons and their patients that dental care of patients who have prosthetic joints should focus on maintaining good oral hygiene rather than on recommending AP for IDPs. Moreover, it should also reassure those in other countries where AP is not recommended that such guidance is sufficient.

Risk of Periprosthetic Joint Infection in Patients With Total Knee Arthroplasty Undergoing Colonoscopy: A Nationwide Propensity Score Matched Study

BACKGROUND

The post-colonoscopy periprosthetic joint infection (PJI) risk in patients with total prosthetic knee joints has limited research. The present study investigated the PJI risk and determined the risk factors for post-colonoscopy PJI in total knee arthroplasty (TKA) recipients. The hypothesis was that colonoscopy is associated with an increased PJI risk in patients with total prosthetic knee joints. This study can potentially help guide the decision making for prophylactic antibiotic use for colonoscopy.

METHODS

This nationwide matched cohort study used claims data from the Health Insurance Review and Assessment Service database and enrolled patients who underwent unilateral TKA between 2008 and 2016. The history of diagnostic colonoscopy was investigated at least 1 year postoperatively. The propensity score was matched between colonoscopy and non-colonoscopy cohorts, and the post-colonoscopy PJI risk was compared. The PJI risk following invasive colonoscopic procedures, including biopsy, polypectomy, and mucosal or submucosal resection, was investigated, and the risk factors for post-colonoscopy PJI were determined.

RESULTS

In total, 45,612 and 211,841 patients were matched in the colonoscopy and control cohorts, respectively. The colonoscopy cohort had greater 9-month and 1-year PJI risks from the index colonoscopy date than the matched controls (9 months: hazard ratio [HR] 1.836, P = .006; 1 year: HR 1.822, P = .031). Invasive colonoscopic procedures did not increase the PJI risk at any time point post-colonoscopy. The only significant risk factor for PJI was post-traumatic arthritis (adjusted HR 4.034, P = .023).

CONCLUSION

Colonoscopy was associated with an increased PJI risk in TKA recipients, regardless of concomitant invasive colonoscopic procedures.

LEVEL OF EVIDENCE

III, Prognostic.

[Diagnosis of periprosthetic joint infection : Development of an evidence-based algorithm by the work group of implant-associated infection of the AE-(German Society for Arthroplasty)]

Hintergrund

Die Behandlung periprothetischer Infektionen (PPI) ist eine der größten Herausforderungen im Bereich der Endoprothetik. Der möglichst sichere Ausschluss oder die Bestätigung einer periprothetischen Infektion ist die Voraussetzung für jede Revisionsoperation und kann für den behandelnden Orthopäden und Unfallchirurgen eine große Herausforderung darstellen. Eine sichere evidenzbasierte präoperative Diagnostik ist im Sinne des Patienten notwendig, um einerseits eine periprothetische Infektion zu erkennen sowie die entsprechende chirurgische und antibiotische Therapie zu planen und andererseits unnötige zweizeitige Wechsel zu vermeiden.

Ziel der Arbeit

Ziel ist es, ein evidenzbasiertes problem- und prioritätenbasiertes Vorgehen zu entwickeln und dies in einem transparenten und standardisierten Algorithmus zusammenzufassen.

Methode

Durch systematische Literaturrecherche wurden relevante Arbeiten identifiziert und im Rahmen von Expertenrunden bewertet. Nach Extraktion der Daten erfolgte die Berechnung von Sensitivität, Spezifität, positiver und negativer Likelihood-Ratio sowie positiver und negativer prädiktiver Werte. Im Rahmen von 4 Treffen wurden die entsprechenden Studien der Arbeitsgruppe für implantatassoziierte Infektionen präsentiert und analog zu Standard-Delphi-Runden durch die einzelnen Experten bearbeitet und bewertet. Gemäß der Prioritätenliste der Expertenrunde erfolgte die Entwicklung eines zur ISO (International Organization for Standardisation) konformen Algorithmus.

Ergebnisse

Der entwickelte Algorithmus ist eine Abfolge von evidenzbasierten Prozessen gemäß der verwendeten ISO-Norm. Gemäß der durch die Expertenrunde priorisierten Haupt- und Nebenkriterien erfolgte die Entwicklung logisch strukturiert und problemorientiert.

Schlussfolgerung

Der Ausschluss einer periprothetischen Infektion ist von enormer Bedeutung vor einer Revisionsoperation und entscheidet in vielen Fällen über den Erfolg und die Invasivität der Operation. Die Diagnose „periprothetische Infektion“ erfordert eine substanzielle Veränderung der therapeutischen Strategie. Der durch die Arbeitsgruppe entwickelte Algorithmus fasst Positionen aus der aktuellen Literatur und spezielle Expertenmeinungen zusammen, dies ermöglicht einen transparenten diagnostischen Ansatz im Sinne einer Standard Operation Procedure.

An unexpected pathogen causing prosthetic joint infection following screening colonoscopy

A 61-year-old woman with a right total knee arthroplasty presented with 1 week of atraumatic right knee swelling, pain, and fevers 2 weeks following a routine screening colonoscopy. Aspiration was concerning for prosthetic joint infection and she underwent definitive treatment with irrigation and debridement with polyethylene exchange followed by a 6-week course of oral metronidazole. Cultures speciated as Bacteroides fragilis with the presumed source being the colonoscopy causing transient bacteremia and subsequent seeding of the right knee. This case highlights the need for consideration of guidelines regarding prophylactic antibiotics to prevent prosthetic joint infection after endoscopic procedures.

Economic Evaluation of Antibacterial Coatings on Healthcare Costs in First Year Following Total Joint Arthroplasty

BACKGROUND

Antibacterial coatings (ABCs) of implants have proven safe and effective to reduce postsurgical infection, but little is known about their possible economic impact on large-scale use. This study evaluated the point of economic balance, during the first year after surgery, and the potential overall annual healthcare cost savings of 3 different antibacterial technologies applied to joint arthroplasty: a dual-antibiotic-loaded bone cement (COPAL G + C), an antibacterial hydrogel coating (DAC), and a silver coating (Agluna).

METHODS

The variables included in the algorithm were average cost and number of primary joint arthroplasties; average cost per patient of the ABC; incidence of periprosthetic joint infections and expected reduction using the ABCs; average cost of infection treatment and expected number of cases.

RESULTS

The point of economic balance for COPAL G + C, DAC, and Agluna in the first year after surgery was reached in patient populations with an expected postsurgical infection rate of 1.5%, 2.6%, and 19.2%, respectively. If applied on a national scale, in a moderately high-risk population of patients with a 5% expected postsurgical infection rate, COPAL G + C and DAC hydrogel would provide annual direct cost savings of approximately €48,800,000 and €43,200,000 (€1220 and €1080 per patient), respectively, while the silver coating would be associated with an economic loss of approximately €136,000,000.

CONCLUSION

This economic evaluation shows that ABC technologies have the potential to decrease healthcare costs primarily by decreasing the incidence of surgical site infections, provided that the technology is used in the appropriate risk class of patients.

Predicting lower limb periprosthetic joint infections: A review of risk factors and their classification

AIM

To undertook a systematic review to determine factors that increase a patient's risk of developing lower limb periprosthetic joint infections (PJI).

METHODS

This systematic review included full-text studies that reviewed risk factors of developing either a hip or knee PJI following a primary arthroplasty published from January 1998 to November 2016. A variety of keywords were used to identify studies through international databases referencing hip arthroplasty, knee arthroplasty, infection, and risk factors. Studies were only included if they included greater than 20 patients in their study cohort, and there was clear documentation of the statistical parameter used; specifically P-value, hazard ratio, relative risk, or/and odds ratio (OR). Furthermore a quality assessment criteria for the individual studies was undertaken to evaluate the presence of record and reporting bias.

RESULTS

Twenty-seven original studies reviewing risk factors relating to primary total hip and knee arthroplasty infections were included. Four studies (14.8%) reviewed PJI of the hip, 3 (11.21%) of the knee, and 20 (74.1%) reviewed both joints. Nineteen studies (70.4%) were retrospective and 8 (29.6%) prospective. Record bias was identified in the majority of studies (66.7%). The definition of PJI varied amongst the studies but there was a general consensus to define infection by previously validated methods. The most significant risks were the use of preoperative high dose steroids (OR = 21.0, 95%CI: 3.5-127.2, P < 0.001), a BMI above 50 (OR = 18.3, P < 0.001), tobacco use (OR = 12.76, 95%CI: 2.47-66.16, P = 0.017), body mass index below 20 (OR = 6.00, 95%CI: 1.2-30.9, P = 0.033), diabetes (OR = 5.47, 95%CI: 1.77-16.97, P = 0.003), and coronary artery disease (OR = 5.10, 95%CI: 1.3-19.8, P = 0.017).

CONCLUSION

We have highlighted the need for the provider to optimise modifiable risk factors, and develop strategies to limit the impact of non-modifiable factors.

Prevention of Infection in Orthopedic Prosthetic Surgery

Total joint arthroplasty is a generally safe orthopedic procedure; however, infection is a potentially devastating complication. Multiple risk factors have been identified for development of prosthetic joint infections. Identification of patients at risk and preoperative correction of known risk factors, such as smoking, diabetes mellitus, anemia, malnutrition, and decolonization of Staphylococcus carriers, represent well-established actions to decrease the infection risk. Careful operative technique, proper draping and skin preparation, and appropriate selection and dosing of antimicrobials for perioperative prophylaxis are also very important in prevention of infection.

Prosthetic joint infection development of an evidence-based diagnostic algorithm

BACKGROUND

Increasing rates of prosthetic joint infection (PJI) have presented challenges for general practitioners, orthopedic surgeons and the health care system in the recent years. The diagnosis of PJI is complex; multiple diagnostic tools are used in the attempt to correctly diagnose PJI. Evidence-based algorithms can help to identify PJI using standardized diagnostic steps.

METHODS

We reviewed relevant publications between 1990 and 2015 using a systematic literature search in MEDLINE and PUBMED. The selected search results were then classified into levels of evidence. The keywords were prosthetic joint infection, biofilm, diagnosis, sonication, antibiotic treatment, implant-associated infection, Staph. aureus, rifampicin, implant retention, pcr, maldi-tof, serology, synovial fluid, c-reactive protein level, total hip arthroplasty (THA), total knee arthroplasty (TKA) and combinations of these terms.

RESULTS

From an initial 768 publications, 156 publications were stringently reviewed. Publications with class I-III recommendations (EAST) were considered. We developed an algorithm for the diagnostic approach to display the complex diagnosis of PJI in a clear and logically structured process according to ISO 5807.

CONCLUSIONS

The evidence-based standardized algorithm combines modern clinical requirements and evidence-based treatment principles. The algorithm provides a detailed transparent standard operating procedure (SOP) for diagnosing PJI. Thus, consistently high, examiner-independent process quality is assured to meet the demands of modern quality management in PJI diagnosis.

Aggregatibacter aphrophilus Sacroiliitis Following Gastroscopy in a Young Sportsman

We report a case of Aggregatibacter aphrophilus sacroiliitis in a young sportsman, presenting 48 hours after endoscopy and biopsy. Microbiological diagnosis was made only after repeated attempt at joint aspiration. The patient was cured after radiologically guided drainage and a prolonged course of directed antibiotics.

Duodenoscopy related infection risk and duodenoscope cleaning and disinfection

With the development of minimally invasive techniques, duodenoscope, as an instrument for diagnosis and treatment of pancreaticobiliary diseases, has been gradually applied in clinical practice. Iatrogenic infection caused by duodenoscopy is a well-documented complication, which has gained extensive attention especially in duodenoscope cleaning and disinfecting. It has been postulated that the complexity in design of duodenoscope makes cleaning difficult and poses a risk for nosocomial infections. As such, it is of positive practical significance to analyze the factors that affect cleaning and disinfecting and to take effective measures to do them better, in order to prevent nosocomial infection. This paper briefly reviews the cleaning and sterilizing of duodenoscope and the risk of infection associated with duodenoscopy.

Genitourinary Procedures as Risk Factors for Prosthetic Hip or Knee Infection: A Hospital-Based Prospective Case-Control Study

Antibiotic prophylaxis during genitourinary procedures was not associated with a statistically significant reduction in risk for prosthetic joint infection in our study. Current policies for administering antibiotic prophylaxis to patients with prosthetic hip or knee arthroplasty undergoing genitourinary procedures should be reconsidered.

Background. The purpose of this study was to determine the risk of prosthetic joint infection (PJI) as a complication of routine genitourinary (GU) procedures in patients with total hip arthroplasty (THA) or total knee arthroplasty (TKA) and to study the impact of antibiotic prophylaxis administered prior to these procedures.

Methods. We conducted a prospective, single-center, case-control study between December 1, 2001 and May 31, 2006. Case patients were hospitalized with total hip or knee PJI. Control subjects underwent a THA or TKA and were hospitalized during the same period on the same orthopedic floor without a PJI. Data regarding demographic features and potential risk factors were collected. The outcome measure was the odds ratio (OR) of PJI after GU procedures performed within 2 years of admission.

Results. A total of 339 case patients and 339 control subjects were enrolled in the study. Of these, 52 cases (15%) and 55 controls (16%) had undergone a GU procedure in the preceding 2 years. There was no increased risk of PJI for patients undergoing a GU procedure with or without antibiotic prophylaxis (adjusted OR [aOR] = 1.0, 95% confidence interval [CI] = 0.2–4.5, P = .95 and aOR = 1.0, 95% CI = 0.6–1.7, P = .99, respectively). Results were similar in a subset of patients with a joint age less than 6 months, less than 1 year, or greater than 1 year.

Conclusions. Genitourinary procedures were not risk factors for subsequent PJI. The use of antibiotic prophylaxis before GU procedures did not decrease the risk of subsequent PJI in our study.

Prosthetic joint infection

Prosthetic joint infection (PJI) is a tremendous burden for individual patients as well as the global health care industry. While a small minority of joint arthroplasties will become infected, appropriate recognition and management are critical to preserve or restore adequate function and prevent excess morbidity. In this review, we describe the reported risk factors for and clinical manifestations of PJI. We discuss the pathogenesis of PJI and the numerous microorganisms that can cause this devastating infection. The recently proposed consensus definitions of PJI and approaches to accurate diagnosis are reviewed in detail. An overview of the treatment and prevention of this challenging condition is provided.