1
|
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.
Collapse
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
| |
Collapse
|
2
|
Olearo F, Zanichelli V, Exarchakou A, Both A, Uςkay I, Aepfelbacher M, Rohde H. The Impact of Antimicrobial Therapy Duration in the Treatment of Prosthetic Joint Infections Depending on Surgical Strategies: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2023; 10:ofad246. [PMID: 37265666 PMCID: PMC10230567 DOI: 10.1093/ofid/ofad246] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/05/2023] [Indexed: 06/03/2023] Open
Abstract
The aim of this systematic review was to address the question if short antibiotic treatment (SAT; at least 4 but <12 weeks) versus long antibiotic treatment (LAT) affects outcomes in prosthetic joint infections (PJIs). Database research (Medline, Embase, Web of Science, Scopus, Cochrane) retrieved 3740 articles, of which 10 studies were included in the analysis. Compared to LAT, 11% lower odds of treatment failure in the SAT group were found, although the difference was not statistically significant (pooled odds ratio, 0.89 [95% confidence interval, .53-1.50]). No difference in treatment failure was found between SAT and LAT once stratified by type of surgery, studies conducted in the United States versus Europe, study design, and follow-up. There is still no conclusive evidence that antibiotic treatment of PJIs for 12 weeks or longer is associated with better outcomes, irrespective of the type of surgical procedure. Most recent, high-quality studies tend to favor longer antibiotic courses, making them preferable in most situations.
Collapse
Affiliation(s)
- Flaminia Olearo
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Veronica Zanichelli
- Departement of Infectious Diseases, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Aimilia Exarchakou
- Department of Noncommunicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anna Both
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ilker Uςkay
- Infectiology, Balgrist University Hospital and Faculty of Medicine, Zurich, Switzerland
| | - Martin Aepfelbacher
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Holger Rohde
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
3
|
Uçkay I, Wirth S, Zörner B, Fucentese S, Wieser K, Schweizer A, Müller D, Zingg P, Farshad M. Study protocol: short against long antibiotic therapy for infected orthopedic sites - the randomized-controlled SALATIO trials. Trials 2023; 24:117. [PMID: 36803837 PMCID: PMC9938993 DOI: 10.1186/s13063-023-07141-2] [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: 10/01/2022] [Accepted: 02/07/2023] [Indexed: 02/20/2023] Open
Abstract
BACKGROUND Few studies address the appropriate duration of post-surgical antibiotic therapy for orthopedic infections; with or without infected residual implants. We perform two similar randomized-clinical trials (RCT) to reduce the antibiotic use and associated adverse events. METHODS Two unblinded RCTs in adult patients (non-inferiority with a margin of 10%, a power of 80%) with the primary outcomes "remission" and "microbiologically-identical recurrences" after a combined surgical and antibiotic therapy. The main secondary outcome is antibiotic-related adverse events. The RCTs allocate the participants between 3 vs. 6 weeks of post-surgical systemic antibiotic therapy for implant-free infections and between 6 vs. 12 weeks for residual implant-related infections. We need a total of 280 episodes (randomization schemes 1:1) with a minimal follow-up of 12 months. We perform two interim analyses starting approximately after 1 and 2 years. The study approximatively lasts 3 years. DISCUSSION Both parallel RCTs will enable to prescribe less antibiotics for future orthopedic infections in adult patients. TRIAL REGISTRATION ClinicalTrial.gov NCT05499481. Registered on 12 August 2022. PROTOCOL VERSION 2 (19 May 2022).
Collapse
Affiliation(s)
- Ilker Uçkay
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland. .,Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Zurich, Switzerland. .,Infectiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
| | - Stephan Wirth
- grid.7400.30000 0004 1937 0650Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Björn Zörner
- grid.7400.30000 0004 1937 0650Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Sandro Fucentese
- grid.7400.30000 0004 1937 0650Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Karl Wieser
- grid.7400.30000 0004 1937 0650Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Andreas Schweizer
- grid.7400.30000 0004 1937 0650Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland ,grid.7400.30000 0004 1937 0650Hand Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Daniel Müller
- grid.7400.30000 0004 1937 0650Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Patrick Zingg
- grid.7400.30000 0004 1937 0650Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- grid.7400.30000 0004 1937 0650Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland ,grid.7400.30000 0004 1937 0650Medical Direction, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| |
Collapse
|
4
|
Staphylococcus lugdunensis prosthetic joint infection: A multicentric cohort study. J Infect 2022; 85:652-659. [DOI: 10.1016/j.jinf.2022.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 09/28/2022] [Accepted: 10/15/2022] [Indexed: 11/30/2022]
|
5
|
Ismail A, Leal J, Au F, Puloski S, Mponponsuo K, Smith S, Rennert-May E. Retrospective analysis of the management strategies for surgical site infections post total hip and knee arthroplasty from tertiary care centres in Edmonton, Alberta. J Hosp Infect 2022; 129:1-7. [PMID: 35926666 DOI: 10.1016/j.jhin.2022.07.015] [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: 05/17/2022] [Revised: 07/06/2022] [Accepted: 07/13/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Surgical site infection (SSI) following hip and knee arthroplasty poses serious health and economic burden. AIM To evaluate SSI management strategies and outcomes to help address this problem. METHODS We performed a retrospective cohort study of adults undergoing primary total hip or knee arthroplasty who were identified to have a complex SSI by infection prevention and control surveillance audit. Audits identified SSI within 90 days of arthroplasty. Patients at two tertiary referral centres in Edmonton, Alberta, Canada from 2012 to 2019 were included and SSI cases were followed for two years. FINDINGS We identified 240 SSIs and found that 202 (84%) were managed with debridement with antibiotics and implant retention (DAIR), of which 71% achieved cure. The use of any topical intra-operative antibiotic in DAIR was not associated with improved outcome (OR = 1.68, 95% CI 0.91 - 3.10, p-value = 0.097). DAIR performed at 31-90 days from arthroplasty had lower chance of cure compared to DAIR performed within 30 days, however this was not statistically significant (60 vs 73%, p-value = 0.123). Initial treatment failures requiring additional surgery had 51% cure. The majority (78%) of treatment failures initially managed with DAIR ultimately required two-stage revision. CONCLUSIONS We provide insight from a population-based perspective on the surgical management of SSIs after primary total hip and knee arthroplasty in a large cohort. Additionally, we follow SSIs that had initial management failure. This data can inform future studies such as the economic burden associated with these infections, and plan interventions to optimize SSI management.
Collapse
Affiliation(s)
- Arif Ismail
- Division of Infectious Diseases, University of Alberta, Edmonton, AB, Canada.
| | - Jenine Leal
- Alberta Health Services, Infection Prevention and Control, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada; Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Flora Au
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shannon Puloski
- Division of Orthopedic Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Kwadwo Mponponsuo
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephanie Smith
- Division of Infectious Diseases, University of Alberta, Edmonton, AB, Canada; Alberta Health Services, Infection Prevention and Control, Alberta, Canada
| | - Elissa Rennert-May
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada; Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
6
|
Is Negative Pressure Wound Therapy with Instillation Suitable for the Treatment of Acute Periprosthetic Hip Joint Infection? J Clin Med 2021; 10:jcm10153246. [PMID: 34362030 PMCID: PMC8347389 DOI: 10.3390/jcm10153246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 12/27/2022] Open
Abstract
Background: Periprosthetic joint infection (PJI) can be devastating for the patient and demanding for the surgeon. In acute PJI, attempts are made to retain the prosthesis by debridement of the infected tissue, targeted antibiotic therapy and an exchange of modular components with implant retention (DAIR). There has been sparse research with adjunctive negative pressure wound treatment with wound irrigation (NPWTI) on the treatment outcome. Questions/purposes: The goal was to assess the efficacy of our protocol of DAIR with adjunctive NPWTI in acute PJI and to reduce the need for later additional DAIR and Irrigation and Debridement (I and D). Patients and Methods: Our cohort of 30 patients (31 hips) with acute PJI was divided into two groups based on symptom presentation up to 6 weeks or >6 weeks from prior (index) surgery (acute early or acute late groups, respectively). All received DAIR with an exchange of modular components and NPWTI with polyhexanide instillation, with the goal of bacterial elimination and biofilm elimination. Postoperatively, the patients were followed up clinically and radiographically for a mean of 4.3 years. Results: Of the 31 PJI hips, 19 were early acute and 12 were late acute. In total, 21 hips had no evidence of residual infection, 10 required further surgical revision: 1 due to dislocation and 9 due to infection. Of these nine, seven had a removal of all the components and two were treated with irrigation and debridement (I and D), with the demise of one patient from pneumonia shortly after the procedure. The Kaplan–Meier 60-month revision free implant survival from infection was 73.2% (CI: 58.9–91.0%) and at the final follow up, the mean Harris Hip Score (HHS) was 81.1 ± 11.8 and the mean WOMAC score was 33.3 ± 20.1. Conclusions: Our results are in line with those reported in prior studies. However, the utility of our protocol is inconclusive and needs further evaluation based on our small cohort and the lack of a control group. Level of Evidence: IV.
Collapse
|
7
|
Renz N, Trampuz A, Zimmerli W. Controversy about the Role of Rifampin in Biofilm Infections: Is It Justified? Antibiotics (Basel) 2021; 10:antibiotics10020165. [PMID: 33562821 PMCID: PMC7916064 DOI: 10.3390/antibiotics10020165] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 01/29/2021] [Accepted: 02/03/2021] [Indexed: 01/04/2023] Open
Abstract
Rifampin is a potent antibiotic against staphylococcal implant-associated infections. In the absence of implants, current data suggest against the use of rifampin combinations. In the past decades, abundant preclinical and clinical evidence has accumulated supporting its role in biofilm-related infections.In the present article, experimental data from animal models of foreign-body infections and clinical trials are reviewed. The risk for emergence of rifampin resistance and multiple drug interactions are emphasized. A recent randomized controlled trial (RCT) showing no beneficial effect of rifampin in patients with acute staphylococcal periprosthetic joint infection treated with prosthesis retention is critically reviewed and data interpreted. Given the existing strong evidence demonstrating the benefit of rifampin, the conduction of an adequately powered RCT with appropriate definitions and interventions would probably not comply with ethical standards.
Collapse
Affiliation(s)
- Nora Renz
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany;
- Department of Infectious Diseases, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany;
- Correspondence:
| | - Werner Zimmerli
- Interdisciplinary Unit of Orthopaedic Infections, Kantonsspital Baselland, 4410 Liestal, Switzerland;
| |
Collapse
|
8
|
Xu Y, Wang L, Xu W. Risk factors affect success rate of debridement, antibiotics and implant retention (DAIR) in periprosthetic joint infection. ARTHROPLASTY 2020; 2:37. [PMID: 35236454 PMCID: PMC8796582 DOI: 10.1186/s42836-020-00056-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/27/2020] [Indexed: 12/23/2022] Open
Abstract
Background Periprosthetic joint infection (PJI) is the most devastating complication of joint replacement that seriously affects the quality of life and causes a heavy burden to the families and society. Due to shorter hospital stays, lower costs, improved joint function and less morbidity, a process of debridement, antibiotics and implant retention (DAIR) is recommended as the preferred treatment for acute periprosthetic joint infection. However, the factors that impact the success rate of DAIR remain controversial. This article evaluates the influential factors of DAIR and provides insights for orthopaedics surgeons to make optimal decisions to improve the success rate of DAIR. Conclusion The poor general condition of patients, high preoperative C-reactive protein (CRP) level, repeated joint surgeries, and Methicillin-resistant Staphylococcus aureus (MRSA) infections may be associated with lower DAIR success rate. To the contrary, early surgery, radical debridement, exchange of removable components, washing with iodine and vacuum sealing drainage (VSD) may improve the success rate of DAIR. A sinus tract may not be absolutely contraindicated, but surgeons should treat it with caution. As there is no consensus on many issues, more high-quality research is required.
Collapse
|
9
|
Complications in Total Joint Arthroplasties. J Clin Med 2019; 8:jcm8111891. [PMID: 31698808 PMCID: PMC6912594 DOI: 10.3390/jcm8111891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 11/04/2019] [Indexed: 01/16/2023] Open
|