Acute renal failure after antibiotic-impregnated bone cement treatment of an infected total knee arthroplasty

A Case of Severe Acute Kidney Injury Due to an Antibiotic-Loaded Cement Spacer for Infected Knee Arthroplasty

The treatment for periprosthetic joint infection frequently involves the placement of a high-dose antibiotic-loaded bone cement spacer (ALCS) into the debrided joint. Typical antibiotics in the spacer include aminoglycosides and vancomycin. It has been believed that systemic absorption of intraarticular antibiotics would be low, and early experience suggested that the risk of acute kidney injury (AKI) from ALCS was minimal. However, recent case reports and case series have suggested a risk of AKI owing to antibiotic absorption, though confounding factors are common. We report a case of severe AKI requiring hemodialysis with extremely high systemic tobramycin levels after the placement of an ALCS with increased dosing of antibiotics after previous failure to resolve a periprosthetic joint infection with a prior ALCS. There was no concomitant use of intravenous nephrotoxic antibiotics, nor were there other confounding factors. Despite dialysis, the patient needed urgent removal of the ALCS to control tobramycin levels, with subsequent resolution of the AKI. This case highlights the potentially serious nephrotoxicity of ALCSs, the importance of antibiotic type and dosing, and the value of close monitoring after ALCS placement, especially in a patient with chronic kidney disease.

Evaluation and testing of polymethylmetacrylic (PMMA) bone cements with admixed Amphotericin B

BACKGROUND

Amphotericin is admixed to Polymethylmethacrylic (PMMA) spacers for fungal periprosthetic joint infections (PJI) during two-stage exchanges. We aimed to analyse the mechanical properties of PMMA cement with admixed Amphotericin B.

MATERIALS AND METHODS

We tested Amphotericin in PMMA cement mechanically, its elution properties in vitro and present two cases of fungal PJI treated with Amphotericin B powder in Copal cement in vivo.

RESULTS

Sterile Amphotericin B is not available as a pure substance but only as powder for infusions. PMMA mixed with such pharmaceutical Amphotericin B formulations colored the cement orange. Compression strength was slightly decreased, bending and impact strength significantly decreased whereas bending modulus was increased. Drug elution was high within the first 24 h and decreased over time until day 5. Amphotericin B in combination with Copal was successfully used in two cases with Candida ssp.

INFECTIONS

No negative side effects, especially no nephrotoxic effects, were observed. Sterile Amphotericin B powder for preparing an infusion solution contains only small amounts of pure drug. In vivo polymicrobial Candida-infections with bacterial co-infection were successfully treated using the combination of Copal cements with added Amphotericin B without systemic nephrotoxic impact.

CONCLUSIONS

The addition of Amphotericin B to PMMA cement affects the cement's properties in vitro whereas in vivo the combination with Copal is clinically successful in treating complex cases of fungal PJI.

LEVEL OF EVIDENCE

Level IV.

Antibiotic-loaded cement in total joint arthroplasty: a comprehensive review

This review evaluates the decision-making framework for using antibiotic-loaded cement (ALC) in the management of prosthetic joint infection (PJI). Drawing on available literature, we offer orthopaedic surgeons a guided discussion on several critical considerations. First, we explore the impact of antibiotic-loading on the mechanical properties of polymethylmethacrylate (PMMA) cement, assessing both strength and durability. We then explore the optimal antibiotic dosage to load into cement, aiming to achieve effective local concentrations for infection control without compromising mechanical stability. Furthermore, we explore how cement and antibiotic properties affect the overall antibiotic elution characteristics of ALC. Finally, we discuss risks of systemic toxicity, particularly acute kidney injury, when using ALC. The principal goal in this review is to provide a balanced approach based on best available evidence that optimises antibiotic elution from ALC whilst minimising potential harms associated with its use.

Locally Delivered Antibiotics in Fracture-Related Infection

The prevention and treatment of fracture-related infections (FRIs) pose significant challenges in orthopaedic trauma care, with current practices predominantly relying on systemic antibiotic administration. However, locally delivered antibiotics achieve substantially higher tissue concentrations and minimise systemic side effects. Whilst extensively researched in periprosthetic joint infections (PJIs), the use of local delivery methods is increasingly prevalent in FRI prevention and treatment. Various local delivery methods such as powders, aqueous injections and carriers such as cement, bone graft, bioceramics, polymers and hydrogels have been explored. Biodegradable antibiotic carriers offer a promising alternative to non-absorbable carriers (i.e., cement), which necessitate surgical removal. There is good evidence for the use of local antibiotics in preventing and treating FRI, particularly in high-risk fractures or in treating more severe, resistant infections. Despite theoretical concerns, reports of adverse events in human studies are rare. To enhance our understanding of the safety and efficacy of these methods across various fracture patterns, further prospective randomised controlled trials are warranted. This article describes the current strategies and methodologies for FRI prevention and treatment and reviews the existing evidence base.

Bone Cement in Adult Hip and Knee Reconstruction: A Review of Commercially Available Options and Clinical Outcomes

Polymethyl-methacrylate (PMMA) bone cement is used extensively in hip and knee arthroplasty. A thorough understanding of the basic chemistry underlying PMMA is important for orthopaedic surgeons because this underscores the specific way bone cement is used during surgery. Recently, clinical research has shed light on the various types of PMMA regarding the viscosity of the mixture and the effect of cement additives. These variations in composition may alter the clinical efficacy of implanted bone cement in hip and knee arthroplasty. Understanding these key differences will allow the surgeon to tailor the PMMA composition as needed to maximize outcomes of hip and knee arthroplasty. This review will summarize the preclinical feature of PMMA, evaluate current and past commercially available bone cement options, analyze preclinical results and clinical outcomes of various bone cement types, and highlight future areas of research.

High and Low Dosage of Vancomycin in Polymethylmethacrylate Cements: Efficacy and Mechanical Properties

INTRODUCTION

Prosthetic joint infections (PJIs) are difficult to treat and represent a significant burden to the healthcare system. Two-stage revision surgery with placement of an antibiotic-loaded cement spacer is currently the gold standard for treatment in the United States for late-onset infections. We evaluate the efficacy of varying doses of vancomycin added to antibiotic-containing acrylic cement spacers and discuss the biomechanical and antimicrobial properties of using high versus low doses of vancomycin in cement spacers in the hip and knee.

MATERIALS AND METHODS

Commercially available Copal cement containing either gentamicin and clindamycin (G + C) or gentamicin and vancomycin (G + V) was prepared with the manual addition of low (2 g) and high (6 g) doses of vancomycin. In vitro mechanical testing was then carried out according to ISO 5833 and DIN 53435, as well as inhibition zone assays against common PJI pathogens. Additionally, inhibition zone assays were conducted on two commercially available prefabricated spacers containing gentamicin: Copal Exchange G and Cemex Spacer-K.

RESULTS

In biomechanical testing, Copal G + V with the addition of 6 g of vancomycin failed to meet the ISO standard. Copal G + C and Copal G + V with low and high dosages of vancomycin were all effective against the tested pathogens and displayed constant efficacy for a duration of 42 days. High doses of vancomycin showed significantly lower mechanical stability. Moreover, Copal Exchange G showed significantly larger inhibition zones across 42 days.

DISCUSSION

While higher concentrations of vancomycin appear to improve the antimicrobial efficacy of cement, they also reduce its mechanical stability. Despite its smoother surface, the Copal Exchange G spacer exhibits large inhibition zones after 1 day and maintains consistently large inhibition zones over 6 weeks. Thus, it may be preferred for use in two-stage revision surgery.

CONCLUSION

Copal Exchange G is more effective than Cemex Spacer K against S. aureus and E. coli. The manual addition of vancomycin to cement containing double antibiotics is very effective. The influence on ISO compression is low, the ISO bending modulus is increased, and ISO bending, DIN bending, and DIN impact, are reduced.

High-dose vancomycin spacers provided early recovery without nephrotoxicity compared with standard-dose in MRSA-induced periprosthetic joint infection model of rats

BACKGROUND

Periprosthetic joint infections (PJIs) are commonly treated with two-stage revision surgery utilising antibiotic-loaded spacers; however, antibiotic release from spacers is limited and usually drops below effective levels a few days after placement. This study compared high-dose and standard-dose vancomycin-loaded spacers in terms of efficacy, safety, and overall treatment duration in a rat periprosthetic joint infection model.

METHODS

Thirty male Wistar albino rats (8-10 weeks old, 300-320 g) were housed individually at standard conditions. A periprosthetic infection model was established in the right knee of the rats using methicillin-resistant Staphylococcus aureus (MRSA) -contaminated Kirschner wires. Two weeks later, the infection was verified, and the Kirschner wires were removed. Rats were randomly divided into three groups (n = 10): standard-dose (SVanc) and high-dose (HVanc) vancomycin groups had 2.5 and 7.5% vancomycin in their spacers, respectively, while the control group had no spacers. All groups received intramuscular (IM) vancomycin and gentamicin for 4 weeks after spacer implantation. Microbiological counts and vancomycin levels in the blood and joint flush samples were measured, and histopathological assessments were conducted on the femur and kidneys.

RESULTS

After spacer implantation, MRSA was eliminated in the HVanc group with 4 weeks of treatment, while the SVanc group required 6 weeks of treatment (P < 0.001). Histopathological findings of the femoral medulla and cortical samples were better in the HVanc group compared with other groups (P = 0.007). Vancomycin levels in serum remained within safe limits in all groups, and kidney damage was not observed.

CONCLUSION

The use of high-dose vancomycin spacers might accelerate the transition period, which in turn reduces the duration of systemic antibiotic use and mitigates the risk of nephrotoxicity. Thus, this method may decrease the medical costs associated with PJI treatment.

Low dose vancomycin-loaded spacers for two-stage revision knee arthroplasty: High success, low toxicity

BACKGROUND

Two-stage revision arthroplasty is a widely used treatment method for infected knee arthroplasty. Loading high doses of antibiotics to spacer during the first stage is standard practice. However, there are reported systemic side effects attributed to antibiotic-loaded spacers. The aim of our study is to investigate the success rate and systemic toxicity following the first stage revision knee arthroplasty with low-dose vancomycin-loaded spacers.

METHOD

We included patients with infected knee arthroplasty eligible for two-stage revision arthroplasty from 2001 to 2020. One gram of vancomycin is added per pack of bone cement. Spacers were handmade in the operating theatre. Following the first stage, pre-operative and postoperative culture results, infection parameters, kidney and liver function tests, and functional scores were analyzed. Kaplan-Meier survival analysis was done to determine the success rate.

RESULTS

Fifty patients with a mean follow-up of 48 months (24-108) were included in the study. A five-year survival analysis showed an 88.5% success rate. Fourteen percent of the patients had acute kidney injury with creatinine levels between 1.12-2.80 mg/dl, and 8% had a mild drug-induced liver injury with elevated serum ALT levels between 223-540 U/L and total bilirubin levels between 0.59-1.23 mg/dl. None of the patients required dialysis. All of the systemic side effects were reversible.

CONCLUSION

Our results have suggested that low dose antibiotic-loaded spacers are comparable to the studies with high dose antibiotic loaded spacers regarding infection eradication and survival rates. They are less likely to cause severe systemic side effects. Therefore we suggest low dose antibiotic-loaded spacers should be considered when treating patients with vancomycin sensitive Staphylococcal species and culture negative infected knee arthroplasty.

Evidence for Local Antibiotics in the Prevention of Infection in Orthopaedic Trauma

Prevention of fracture-related infection (FRI) remains a substantial challenge in orthopaedic trauma care. There is evolving evidence to support the use of local antibiotics for both the prevention and treatment of musculoskeletal infection. Local antibiotics can achieve higher local tissue concentrations with a lower risk of systemic complications compared to intravenously administered antibiotics. These antibiotics may be administered in powder or liquid form without carrier, or if sustained release is desired, using a carrier. Polymethylmethacrylate (PMMA), ceramics, and hydrogels are examples of antibiotic carriers. Unlike PMMA, ceramics and hydrogels have the advantage of not requiring a second surgery for removal. The VANCO trial supported the use of powdered vancomycin in high-risk fracture cases for the reduction of Gram-positive infections; although, data is limited. Future studies will evaluate the use of aminoglycoside antibiotics to address Gram-negative infection prevention. While theoretical concerns exist with the use of local antibiotics, available studies suggest local antibiotics are safe with a low-risk of adverse effects.

Timely explantation of tobramycin-impregnated beads and bone cement to avoid haemodialysis in a patient with worsening renal failure

A male patient with right total knee arthroplasty complicated by prosthetic joint infection on intravenous antimicrobials developed an acute kidney injury (AKI) with creatinine up to 7.3 mg/dL ('normal' range (0.5-1.2 mg/dL)) after hardware removal and tobramycin loaded polymethylmethacrylate beads and spacer placement. The AKI was initially attributed to intravenous vancomycin. Despite discontinuing vancomycin, the AKI worsened. A tobramycin level was collected and resulted at 5.5 µg/mL. Due to high suspicion for aminoglycoside-induced renal toxicity and to prevent haemodialysis, the antibiotic cement spacer with tobramycin-impregnated beads was removed. After the removal, tobramycin level rapidly decreased and renal functions improved. AKI is an increasingly recognised complication related to antibiotic-loaded bone cement (ALBC) due to the systemic absorption of antibiotics. With this case we highlight the early recognition of ALBC-induced renal toxicity necessitating explantation of ALBC and beads in order to prevent haemodialysis and emphasise monitoring aminoglycoside levels in the early postoperative period.

Intra-articular administration of vancomycin and tobramycin during primary cementless total knee arthroplasty : determination of intra-articular and serum elution profiles

AIMS

Intra-articular administration of antibiotics during primary total knee arthroplasty (TKA) may represent a safe, cost-effective strategy to reduce the risk of acute periprosthetic joint infection (PJI). Vancomycin with an aminoglycoside provides antimicrobial cover for most organisms isolated from acute PJI after TKA. However, the intra-articular doses required to achieve sustained therapeutic intra-articular levels while remaining below toxic serum levels is unknown. The purpose of this study is to determine the intra-articular and serum levels of vancomycin and tobramycin over the first 24 hours postoperatively after intra-articular administration in primary cementless TKA.

METHODS

A prospective cohort study was performed. Patients were excluded if they had poor renal function, known allergic reaction to vancomycin or tobramycin, received intravenous vancomycin, or were scheduled for same-day discharge. All patients received 600 mg tobramycin and 1 g of vancomycin powder suspended in 25 cc of normal saline and injected into the joint after closure of the arthrotomy. Serum from peripheral venous blood and drain fluid samples were collected at one, four, and 24 hours postoperatively. All concentrations are reported in µg per ml.

RESULTS

A total of 22 patients were included in final analysis. At one, four, and 24 hours postoperatively, mean (95% confidence interval (CI)) serum concentrations were 2.4 (0.7 to 4.1), 5.0 (3.1 to 6.9), and 4.8 (2.8 to 6.9) for vancomycin and 4.9 (3.4 to 6.3), 7.0 (5.8 to 8.2), and 1.3 (0.8 to 1.8) for tobramycin; intra-articular concentrations were 1,900.6 (1,492.5 to 2,308.8), 717.9 (485.5 to 950.3), and 162.2 (20.5 to 304.0) for vancomycin and 2,105.3 (1,389.9 to 2,820.6), 403.2 (266.6 to 539.7), and 98.8 (0 to 206.5) for tobramycin.

CONCLUSION

Intra-articular administration of 1 g of vancomycin and 600 mg of tobramycin as a solution after closure of the arthrotomy in primary cementless TKA achieves therapeutic intra-articular concentrations over the first 24 hours postoperatively and does not reach sustained toxic levels in peripheral blood. Cite this article: Bone Joint J 2021;103-B(11):1702-1708.

Is Use of Topical Vancomycin in Pediatric Spine Surgeries a Safe Option in the Prevention of Surgical Site Infections? A Meta-analysis and Systematic Review of the Literature

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To systematically review the available articles on topical vancomycin powder (TVP) use in pediatric spine surgeries exploring the usefulness and safety of such practice.

METHODS

We conducted an independent and duplicate electronic database search in PubMed, EMBASE, and Cochrane Library till March 2020 to identify all relevant literature on the use of TVP for pediatric spine surgeries. Surgical site infection (SSI) rate, specific reported complications, reoperation rate, microbial flora pattern in reported SSIs, and safety profile were the outcomes analyzed. Analysis was performed with the R platform using OpenMeta[Analyst] software.

RESULTS

No prospective studies were available to evaluate the use of TVP in pediatric spine surgeries for the prevention of SSIs. Neither standardized protocol, nor drug dosage, nor safety profile was established for pediatric use. Three retrospective cohort studies including 824 patients (TVP/control: 400/424) were included in the meta-analysis. There was low-quality evidence suggesting no significant difference between the 2 groups in SSI rate (RR = 0.474; 95% CI = [0.106,2.112]; P = .327) with significant heterogeneity (I2 = 70.14; P = .035). The TVP group showed a significant benefit on cost analysis in one of the included studies. However, TVP did not prevent gram-negative coinfection on SSI in the TVP group.

CONCLUSION

From the literature available at present, TVP does not qualify to be recommended as a safe and useful option to prevent SSI following pediatric spine surgeries. High-quality prospective interventional studies are needed to arrive at a consensus on its use along with appropriate dosage and method of application.

Low-dose vancomycin-loaded cement spacer for two-stage revision of infected total hip arthroplasty

OBJECTIVES

This study aims to evaluate the success rate in terms of eradication of infection and long-term outcomes of two- stage revision arthroplasty with spacers loaded with low-dose vancomycin alone for the treatment of an infected hip arthroplasty.

PATIENTS AND METHODS

The records of 42 two-stage exchange arthroplasty patients (16 males, 26 females; mean age 61 years; range, 30 to 80 years) treated between January 1999 and January 2009 were included in this retrospective study. In the first stage, following removal of the prosthesis and debridement, a spacer consisting of 1 g of vancomycin per 40 g of cement was placed in the infected joint space. Patients received six weeks of intravenous antibiotics according to intraoperative cultures. After cessation of systemic antibiotic treatment, with normal C-reactive protein and erythrocyte sedimentation rate levels, second stage surgery with cementless components was performed.

RESULTS

The mean follow-up duration was seven (range, 3 to 13) years. Two patients (4.7%) developed re-infection after two-stage reimplantation and one patient underwent a resection arthroplasty after repeated debridements. Five years of survival was 92.9% with Kaplan-Meier survival analysis.

CONCLUSION

For chronic infected total hip revisions, two-stage revision arthroplasty with low-dose vancomycin impregnated cement spacers have comparable re-infection and success rates. Low-dose vancomycin promotes effective infection control and reduces antibiotic toxicity.

Antibiotic-Loaded Bone Cement in Prevention of Periprosthetic Joint Infections in Primary Total Knee Arthroplasty: A Register-based Multicentre Randomised Controlled Non-inferiority Trial (ALBA trial)

INTRODUCTION

The current evidence on the efficacy of antibiotic-loaded bone cement (ALBC) in reducing the risk of periprosthetic joint infections (PJI) after primary joint reconstruction is insufficient. In several European countries, the use of ALBC is routine practice unlike in the USA where ALBC use is not approved in low-risk patients. Therefore, we designed a double-blinded pragmatic multicentre register-based randomised controlled non-inferiority trial to investigate the effects of ALBC compared with plain bone cement in primary total knee arthroplasty (TKA).

METHODS AND ANALYSIS

A minimum of 9,172 patients undergoing full-cemented primary TKA will be recruited and equally randomised into the ALBC group and the plain bone cement group. This trial will be conducted in Norwegian hospitals that routinely perform cemented primary TKA. The primary outcome will be risk of revision surgery due to PJI at 1-year of follow-up. Secondary outcomes will be: risk of revision due to any reason including aseptic loosening at 1, 6, 10 and 20 years of follow-up; patient-related outcome measures like function, pain, satisfaction and health-related quality of life at 1, 6 and 10 years of follow-up; risk of changes in the microbial pattern and resistance profiles of organisms cultured in subsequent revisions at 1, 6, 10 and 20 years of follow-up; cost-effectiveness of routine ALBC versus plain bone cement use in primary TKA. We will use 1:1 randomisation with random permuted blocks and stratify by participating hospitals to randomise patients to receive ALBC or plain bone cement. Inclusion, randomisation and follow-up will be through the Norwegian Arthroplasty Register.

ETHICS AND DISSEMINATION

The trial was approved by the Western Norway Regional Committees on Medical and Health Research Ethics (reference number: 2019/751/REK vest) on 21 June 2019. The findings of this trial will be disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04135170.

Antibiotics and cement: what I need to know?

We conducted a systematic review about antibiotic-loaded bone cement (ALBC) with a focus on clinical evidence about ALBC in general, concerns about ALBC and ALBC cost.

The cost-effectiveness of antibiotic-loaded bone cement versus plain bone cement following total and partial knee and hip arthroplasty

Background

Postoperative infection is one of the most prevalent complications following total joint arthroplasty (TJA). As such procedures become more prevalent, it is imperative that we develop new prophylactic methods to prevent the need for revision procedures. In recent years, surgeons have opted to use antibiotic-loaded bone cement (ALBC) rather than plain bone cement (PBC) in primary hip and knee replacements due to its theoretical potential of lowering infection rates. However, the cost-effectiveness of this intervention remains in question.Questions/Purposes: To determine the rate of infection and cost-effectiveness of antibiotic-loaded bone cement as compared to plain bone cement in hip and knee arthroplasty.

Patients and methods

We reviewed 4116 primary hip and knee arthroplasty cases performed between 2016 and 2018 at Morristown Medical Center in New Jersey. Data regarding demographics, complications, and any readmissions due to deep infection were collected retrospectively. During that time period there were a total of 4016 knee cases (423 ALBC, 3593 PBC) and 123 hip cases (63 ALBC, 60 PBC). The average cost for one bag of antibiotic-loaded bone cement and plain bone cement for hip and knee arthroplasty was $336.42 and $72.14, respectively. A statistical analysis was performed using Fisher's exact test; the National Healthcare Safety Network (NHSN) surgical site infection guidelines were used to distinguish between superficial and deep infections.

Results

Ten patients were readmitted due to deep infection, all of whom had undergone total knee arthroplasty. Of those cases, plain bone cement was used for the index procedure in seven instances and antibiotic-loaded cement was used in three. This resulted in an infection rate of 0.19% and 0.62%, respectively, p = 0.103. There was no statistically significant difference in infection rates between the two groups. A total of 778 bags of ALBC were used in 423 knee surgeries, and 98 bags of ALBC were used in 63 hip cases. The total cost for ALBC in TKA and THA procedures was $261,734.76 (778*336.42) and $32,969.16 (98*336.42), respectively. If PBC had been used during all index procedures, it would have resulted in a total savings of $231,509.28.

Conclusions

Antibiotic-loaded cement did not significantly reduce the rate of infection for either knee or hip arthroplasty. Thus, the routine use of antibiotic-loaded cement in primary hip and knee arthroplasty may be an unnecessary financial burden to the healthcare system. A larger sample size and a randomized controlled trial would help confirm our findings and would provide further information on the cost-effectiveness of ALBC cement versus PBC.Significance/Clinical Relevance: In this review of cases performed from 2016 to 2018 there was no statistically significant difference between the rate of infection and the need for revision surgeries for patients treated with ALBC versus PBC. As hospital systems continue to transition towards a bundled payment model, it becomes imperative for providers to reduce any unnecessary costs in order to increase quality and efficiency. We estimate that our hospital system could save nearly $120,000/year by using plain bone cement instead of antibiotic-loaded cement.

Evidence-Based Recommendations for Local Antimicrobial Strategies and Dead Space Management in Fracture-Related Infection

Fracture-related infection (FRI) remains a challenging complication that imposes a heavy burden on orthopaedic trauma patients. The surgical management eradicates the local infectious focus and if necessary facilitates bone healing. Treatment success is associated with debridement of all dead and poorly vascularized tissue. However, debridement is often associated with the formation of a dead space, which provides an ideal environment for bacteria and is a potential site for recurrent infection. Dead space management is therefore of critical importance. For this reason, the use of locally delivered antimicrobials has gained attention not only for local antimicrobial activity but also for dead space management. Local antimicrobial therapy has been widely studied in periprosthetic joint infection, without addressing the specific problems of FRI. Furthermore, the literature presents a wide array of methods and guidelines with respect to the use of local antimicrobials. The present review describes the scientific evidence related to dead space management with a focus on the currently available local antimicrobial strategies in the management of FRI. LEVEL OF EVIDENCE:: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Vancomycin-Gentamicin Prefabricated Spacers in 2-Stage Revision Arthroplasty for Chronic Hip and Knee Periprosthetic Joint Infection: Insights Into Reimplantation Microbiology and Outcomes

BACKGROUND

Second-stage positive cultures in 2-stage revision arthroplasty are a matter of concern, as their influence in outcomes is not clearly defined. We sought to study reimplantation microbiology when using vancomycin-gentamicin prefabricated cement spacers in hip and knee periprosthetic joint infection. The associations of second-stage positive cultures with treatment failures and patient-associated factors were analyzed.

METHODS

We conducted a retrospective cohort study, examining patients managed with 2-stage revision arthroplasty due to knee or hip chronic periprosthetic joint infection between 2010 and 2017. Prefabricated vancomycin-gentamicin cement spacers were used during the spacer stage. Intraoperative microbiological culture results after the first and second stages were evaluated. The primary end point was infection eradication or relapse.

RESULTS

A total of 108 cases were included (61 hips and 47 knees). And 22.2% of patients had ≥1 second-stage positive culture, while 9.3% had ≥2 positive samples. Overall success, at an average follow-up of 46.4 months, was 77.8%. Treatment failure was higher among cases with positive cultures (15.5% vs 45.8%, P < .01) regardless of the number of positive samples. Diabetes was identified as a risk factor for second-stage positive cultures (P = .03); use of cement loaded with extra antibiotics for spacer fixation showed a protective effect (P < .01).

CONCLUSION

Second-stage positive cultures were related to a higher failure rate when using vancomycin-gentamicin cement spacers. Diabetes increased the likelihood of second-stage positive cultures. The use of extra-antibiotic-loaded cement for spacer fixation during the first stage showed a protective effect.

Antibiotic-loaded bone cement is associated with a lower risk of revision following primary cemented total knee arthroplasty: an analysis of 731,214 cases using National Joint Registry data

AIMS

Antibiotic-loaded bone cements (ALBCs) may offer early protection against the formation of bacterial biofilm after joint arthroplasty. Use in hip arthroplasty is widely accepted, but there is a lack of evidence in total knee arthroplasty (TKA). The objective of this study was to evaluate the use of ALBC in a large population of TKA patients.

MATERIALS AND METHODS

Data from the National Joint Registry (NJR) of England and Wales were obtained for all primary cemented TKAs between March 2003 and July 2016. Patient, implant, and surgical variables were analyzed. Cox proportional hazards models were used to assess the influence of ALBC on risk of revision. Body mass index (BMI) data were available in a subset of patients.

RESULTS

Of 731 214 TKAs, 15 295 (2.1%) were implanted with plain cement and 715 919 (97.9%) with ALBC. There were 13 391 revisions; 2391 were performed for infection. After adjusting for other variables, ALBC had a significantly lower risk of revision for any cause (hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.77 to 0.93; p < 0.001). ALBC was associated with a lower risk of revision for all aseptic causes (HR 0.85, 95% CI 0.77 to 0.95; p < 0.001) and revisions for infection (HR 0.84, 95% CI 0.67 to 1.01; p = 0.06). The results were similar when BMI was added into the model, and in a subanalysis where surgeons using only ALBC over the entire study period were excluded. Prosthesis survival at ten years for TKAs implanted with ALBC was 96.3% (95% CI 96.3 to 96.4) compared with 95.5% (95% CI 95.0 to 95.9) in those implanted with plain cement. On a population level, where 100 000 TKAs are performed annually, this difference represents 870 fewer revisions at ten years in the ALBC group.

CONCLUSION

After adjusting for a range of variables, ALBC was associated with a significantly lower risk of revision in this registry-based study of an entire nation of primary cemented knee arthroplasties. Using ALBC does not appear to increase midterm implant failure rates. Cite this article: Bone Joint J 2019;101-B:1331-1347.

CLINICAL EVALUATION OF PATIENTS WITH VANCOMYCIN SPACER RETAINED FOR MORE THAN 12 MONTHS

Objective:

There is no consensus in the literature regarding the time taken to remove antibiotic spacers in the treatment of bone infections. The aim of this study is to evaluate the clinical results of patients with prolonged retention of the same.

Methods:

Patients selected were diagnosed with post-osteosynthesis infection and/or osteomyelitis and were submitted to treatment using an orthopedic cement spacer (polymethylmethacrylate) with vancomycin, retaining it for a period of more than 12 months. They were clinically evaluated to determine the presence of local or systemic infectious signs via hemogram, investigations of inflammatory markers, liver, renal and, with radiographic control.

Results:

Eighteen patients were included in the study. The mean retention time of the spacer was 30.4 months (15 – 61 months). No patient had clinical signs of local or systemic infectious relapse at the time of evaluation. Seven patients (39%) presented non-disabling pain in the operated limb. Seventeen patients (94%) presented a reduction in C-reactive protein values compared to the preoperative period. Radiographically, no migration, no spacer failure, or bone sequestration occurred.

Conclusion:

In this retrospective case series, cement spacer retention with vancomycin for more than 12 months was associated with good clinical results, without relapse of the infectious condition. Nível de Evidência IV. Estudos Terapêuticos - Investigação dos Resultados do Tratamento.

Acute Renal Failure due to a Tobramycin and Vancomycin Spacer in Revision Two-Staged Knee Arthroplasty

Two-stage revision total knee arthroplasty (TKA) is the standard of care for prosthetic joint infections. The first stage involves removal of the infected prosthesis and placement of an antibiotic impregnated cement spacer; following a period ranging from 4 weeks to 6 months, the spacer is then removed and replaced with a permanent prosthesis. The advantage to this approach is that antibiotic impregnated spacers provide supratherapeutic levels in the joint without toxic accumulation in serum. However, it remains important for physicians and pharmacists to be aware of antibiotic associated complications in knee revisions. We present a case of a two-stage revision total knee arthroplasty in which a cement antibiotic spacer caused acute renal failure and ultimately resulted in persistent chronic kidney disease without hemodialysis at 2 months' follow-up. Our case reports the third highest serum tobramycin (13.7 mcg/ml) and second highest serum creatinine (8.62 mg/dl) for patients experiencing ARF due to an antibiotic spacer in two-stage revision TKA.

In-Hospital Acute Kidney Injury After TKA Revision With Placement of an Antibiotic Cement Spacer

BACKGROUND

There is mounting evidence that treatment of periprosthetic joint infection of the knee with an antibiotic cement spacer (ACS) may increase risk for acute kidney injury (AKI). We sought to determine the incidence, as well as potential risk factors, of in-hospital AKI in this cohort.

METHODS

We retrospectively identified 75 patients that received either a static or articulating ACS at a single institution. In-hospital AKI was defined by a more than 50% rise in serum creatinine from preoperative baseline to at least 1.4 mg/dL. Our secondary outcome was percent change in creatinine from preoperative to peak postoperative value. Variables were analyzed for the outcome of AKI with univariate logistic regression. A final multivariate model for percent change in creatinine was formed while controlling for age, gender, body mass index, and baseline creatinine.

RESULTS

The incidence of AKI was 14.6%, occurring at a mean of 6.3 days (2-8 days). A lower preoperative hemoglobin (odds ratio = 1.82, P = .015) significantly increased risk for AKI on univariate analysis. Diagnosis of either hypertension or diabetes also showed a strong statistical trend (P = .056). On multivariate regression, lower preoperative hemoglobin significantly correlated with a greater percent rise in creatinine postoperatively (β = 0.30, P = .015).

CONCLUSION

The incidence of AKI in patients who receive ACS is relatively high, raising clinical concern in the care of periprosthetic joint infection patients. Our results suggest that a lower baseline hemoglobin may be involved in the etiology of AKI in this population. Therefore, it may be clinically appropriate to monitor anemic patients for AKI when implanting an ACS.

Acute Kidney Injury After First-Stage Joint Revision for Infection: Risk Factors and the Impact of Antibiotic Dosing

BACKGROUND

Scarce literature exists regarding risk factors associated with postoperative acute kidney injury (AKI) after first-stage revision procedures. The purpose of this study was to determine risk factors for AKI and the efficacy of intra-articular antibiotics in infection eradication.

METHODS

We retrospectively identified 247 patients who underwent a 2-stage revision procedure for the treatment of hip or knee periprosthetic joint infection. We applied previously published diagnostic criteria for AKI to determine its incidence and risk factors for its development.

RESULTS

A 26% incidence of AKI was found after first-stage joint revision for infection. Higher body mass index (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.01-1.13; P = .02), lower baseline hemoglobin level (OR, 0.70; 95% CI, 0.51-0.96; P = .03), and existence of a comorbid condition (OR, 2.67; 95% CI, 1.26-5.64; P = .01) were significant risk factors for AKI. Neither a higher dose of vancomycin (OR, 0.99; 95% CI, 0.88-1.11; P = .83) nor tobramycin (OR, 0.89; 95% CI, 0.77-1.04; P = .15) used in the cement spacer increased the risk of AKI. Each unit increase in vancomycin dose in the cement spacer decreased the odds of failing to clear the infection at 1 and 2 years by a factor of 0.82 (95% CI, 0.70-0.95; P = .01).

CONCLUSION

AKI after first-stage revision procedures for periprosthetic joint infection occurs more commonly than previously reported. Patients with identified risk factors should be managed carefully with attention paid to hemoglobin levels, to avoid AKI after this procedure. Further research is needed to determine the optimal local antibiotic type and dosing to maximize infection clearance and minimize potential side effects.

Antibiotic impregnated total femur spacers: a technical tip

Simultaneous prosthetic joint infection of ipsilateral hip and knee arthroplasties is often accompanied by significant bone loss and presents a challenging reconstructive problem. Two-stage reconstruction is favored and requires the placement of a total femur spacer, which is not a commercially available device. We describe a surgical technique, reporting on 2 cases in which a customized total femur antibiotic impregnated spacer was created by combining an articulating knee spacer and an articulating hip spacer with a reinforced cement dowel construct connecting the 2 spacers. Custom total femoral spacers are useful in the management of infected femoral megaprostheses and cases with ipsilateral injected hip and knee arthroplasties and severe femoral bone loss.

Renal failure after placement of an articulating, antibiotic impregnated polymethylmethacrlyate hip spacer

A 58-year-old male presented with native joint septic arthritis of the hip and osteomyelitis. After treatment with an articulating antibiotic spacer, he developed acute renal failure requiring dialysis. He continued to have elevated serum tobramycin levels exclusively from the antibiotic spacer elution as no intravenous tobramycin was used. Subsequent explantation was required to correct his renal failure. Although renal failure after antibiotic impregnated cement placement is rare, the risk of this potential complication should be considered preoperatively and in the postoperative management of these patients.

One-stage Revision With Catheter Infusion of Intraarticular Antibiotics Successfully Treats Infected THA

BACKGROUND

Two-stage revision surgery for infected total hip arthroplasty (THA) is commonly advocated, but substantial morbidity and expense are associated with this technique. In certain cases of infected THA, treatment with one-stage revision surgery and intraarticular infusion of antibiotics may offer a reasonable alternative with the distinct advantage of providing a means of delivering the drug in high concentrations.

QUESTIONS/PURPOSES

We describe a protocol for intraarticular delivery of antibiotics to the hip through an indwelling catheter combined with one-stage revision surgery and examine (1) the success as judged by eradication of infection at 1 year when treating chronically infected cemented stems; (2) success in treating late-onset acute infections in well-ingrown cementless stems; and (3) what complications were associated with this approach in a small case series.

METHODS

Between January 2002 and July 2013, 30 patients (30 hips) presented to the senior author for treatment of infected THA. Of those, 21 patients (21 hips) with infected cemented THAs underwent débridement and single-stage revision to cementless total hip implants followed by catheter infusion of intraarticular antibiotics. Nine patients (nine hips) with late-onset acute infections in cementless THA had bone-ingrown implants. These patients were all more than 2 years from their original surgery and had acute symptoms of infection for 4 to 9 days. Seven had their original THA elsewhere, and two were the author's patients. All were symptom-free until the onset of their infection, and none had postoperative wound complications, fever, or prolonged pain suggestive of a more chronic process. They were treated with débridement and head and liner exchange, again followed by catheter infusion of intraarticular antibiotics. During this time period, this represented all infected THAs treated by the senior author, and all were treated with this protocol; no patient underwent two-stage exchange during this time, and no patients were lost to followup. At the time of the surgery, two Hickman catheters were placed in each hip to begin intraarticular delivery of antibiotics in the early postoperative period. Antibiotics were infused daily into the hip for 6 weeks with the tubes used for infusion only. Eleven of the single-stage revisions and four of the hips treated with débridement had methicillin-resistant Staphylococcus aureus. Patients were considered free of infection if they had no clinical signs of infection and had a normal C-reactive protein and erythrocyte sedimentation rate at 1 year. Complications were ascertained by chart review.

RESULTS

Twenty of 21 (95%) infections in patients who had single-stage revision for chronically infected cemented THA were apparently free from infection and remained so at a mean followup of 63 months (range, 25-157 months). One case grew Candida albicans in the operative cultures and remained free of signs of infection after rerevision followed by infusion of fluconazole. The nine cementless THAs treated with débridement and head/liner exchange all remained free of signs of infection at a mean followup of 74 months (range, 62-121 months). Few complications were associated with the technique. Four patients had elevated serum levels of vancomycin without renal function changes and two patients had transient blood urea nitrogen/creatinine elevations with normal vancomycin levels that resolved with dosage adjustments. No patient had evidence of permanent renal damage. None of the patients in this study developed a chronic fistula or had significant drainage from the catheter site.

CONCLUSIONS

Single-stage revision for chronically infected cemented THA and débridement of bone-ingrown cementless THA with late-onset acute infection followed with indwelling catheter antibiotic infusion can result in infection eradication even when resistant organisms are involved. Larger study groups would better assess this technique and prospective comparisons to more traditional one- and two-stage revision techniques for infected THA will likely require multi-institutional approaches.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Therapeutic Use of Antibiotic-loaded Bone Cement in the Treatment of Hip and Knee Joint Infections

The use of antibiotic-loaded cement spacers is an established method in the management of periprosthetic hip and knee joint infections. Despite inconsistencies among published studies, data shows that infection control rates exceed 90% with two-stage exchange arthroplasty. The present work reviews the current literature about antibiotic-loaded cement spacers and concentrates on the indications for spacer implantation, spacer production details, antibiotic impregnation, pharmacokinetic properties, clinical success, mechanical complications, and systemic safety.

The results of two-stage revision TKA using Ceftazidime-Vancomycin-impregnated cement articulating spacers in Tsukayama Type II periprosthetic joint infections

PURPOSE

This study examined the success and factors associated with failure, of using cement spacers impregnated with high-dose Ceftazidime and Vancomycin when performing two-stage revision for infected total knee arthroplasty (TKA).

METHODS

A retrospective analysis was performed using a prospectively collected database of 82 patients (median age 68 years, range 39-87) with a confirmed deep TKA infection treated with a two-stage revision. All cement spacers were impregnated with high-dose Ceftazidime and Vancomycin. The rate of success was recorded-an association between failure of treatment, and patient factors, previous surgical treatment, and microbial characteristics was sought.

RESULTS

The mean time to infection from index arthroplasty was 45 months (range 3-240). The initial two-stage revision was successful in 70/82 patients (85.4 %), who remained free of infection at average follow-up of 36.2 months (range 24-85). A second two-stage revision for infection was required in 12/82 patients (14.6 %), which was successful in 4/12 (33 %). A third two-stage revision was performed in three patients, all of whom had a polymicrobial infection of which only one patient had successful eradication of infection. Recurrent infection was correlated with irrigation and debridement with implant retention prior to initial two-stage revision (p < 0.01), polymicrobial infections (p = 0.035), and infections presenting <6 months after index surgery (p = 0.031). No correlation was seen with age, BMI, type of organism, diabetes mellitus, or Charlson Comorbidity Index.

CONCLUSION

The findings of this study suggest that the combination of Ceftazidime and Vancomycin in cement spacers is as efficacious as other published single or combined antibiotic mixtures, which is clinically relevant to clinicians treating this difficult problem in the setting of patients with compromised renal function.

Successful treatment of chronic osteomyelitis in children with debridement, antibiotic-laden cement spacer and bone graft substitute

PURPOSE

Chronic osteomyelitis and infected nonunion are relatively rare conditions in pediatric patients and are more frequently seen in developing countries. Although relatively rare, they are medically and surgically challenging. Here we report a novel surgical technique used to manage five patients with chronic osteomyelitis of long bones.

METHODS

Five skeletally immature patients with chronic osteomyelitis and infected nonunion of the long bones were treated surgically between 2010 and 2014 by a combination of resection of necrotic infected bone, debridement of surrounding soft tissue, and application of antibiotic-laden cement spacer inducing periosteal membrane before final bone reconstruction. Once inflammatory markers normalized, all the patients were re-operated for cement removal, bone graft substitution, and concomitant osteosynthesis of the affected bone, if needed. All patients underwent MRI, CT scan, and laboratory evaluation prior to surgery. The antibiotic regimen was started empirically and then adjusted according to culture and sensitivity results.

RESULTS

Mean patient age at the time of diagnosis was 11 years (range 4-14), and all patients had at least 2-year follow-up (range 2-5). At last follow-up, clinical and laboratory evaluation had normalized, the bone had healed, and all patients had resumed daily living and sports activities.

CONCLUSION

Surgical debridement is the standard approach to chronic osteomyelitis. Use of antibiotic-laden cement is recommended to penetrate local infection, with antibiotic therapy playing an adjunctive role. The cement also induces membrane formation that aids bone reconstruction.

LEVEL OF EVIDENCE

IV.

Salvage of Infected Prosthetic Breast Reconstructions

Periprosthetic infection is a major complication in breast reconstruction, leading to implant loss and delayed and sometimes abandoned reconstruction. Traditional management of persistent infections requires explantation followed by secondary reconstruction after 6 months of delay. Although effective in treating the infection, this approach often leads to distortion and/or loss of tissue envelope, making secondary reconstruction very difficult. As a result, there is significant interest in salvaging infected prosthetic breast reconstructions. Recent studies reported variable success through systemic antibiotic therapy and surgical interventions. The aim of this article is to review the management of periprosthetic infection and to provide a potential salvage algorithm.

Custom-Made Antibiotic Cement Nails in Orthopaedic Trauma: Review of Outcomes, New Approaches, and Perspectives

Since the first description in 2002 by Paley and Herzenberg, antibiotic bone cement nails (ACNs) have become an effective tool in the orthopaedic trauma surgeons' hands. They simultaneously elute high amounts of antibiotics into medullary canal dead space and provide limited stability to the debrided long bone. In this paper, we perform a systematic review of current evidence on ACNs in orthopaedic trauma and provide an up-to-date review of the indications, operative technique, failure mechanisms, complications, outcomes, and outlooks for the ACNs use in long bone infection.

Acute Kidney Injury With Tobramycin-Impregnated Bone Cement Spacers in Prosthetic Joint Infections

BACKGROUND

Antibiotic-impregnated bone cement spacer (ACS) with tobramycin ± vancomycin is commonly used in a 2-stage replacement of infected prosthetic joints. This procedure has been associated with development of acute kidney injury (AKI).

OBJECTIVE

To determine the incidence and risk factors for AKI after implantation of tobramycin-impregnated ACS.

METHODS

This prospective, observational study evaluated 50 consecutive patients who received tobramycin ACS for first-stage revision of an infected hip or knee arthroplasty from August 2011 to February 2013. AKI was defined as 50% or greater rise in serum creatinine (SCr) from baseline within the first 7 postoperative days (PODs).

RESULTS

The incidence of AKI was 20%, with median onset occurring at POD 2 (interquartile range [IQR] = 1-3); patients with AKI had a longer median duration of hospital stay (16 days, IQR = 12-17, vs 10 days, IQR = 8-10; P = 0.03). Serum tobramycin concentrations were significantly higher in the AKI group, peaking on POD 1 (median 1.9 vs 0.9 µg/mL, P = 0.01). Risk factors for nephrotoxicity identified by multivariate analysis were use of bone cement premanufactured with gentamicin (OR = 8.2; 95% CI = 1.1-60; P = 0.04), administration of blood transfusions intraoperatively (OR = 32.5; 95% CI = 2.3-454.3; P = 0.01) and nonsteroidal anti-inflammatory drugs postoperatively (OR = 23.0; 95% CI = 1.3-397.7; P = 0.03).

CONCLUSIONS

Tobramycin ACS is associated with a high risk of AKI. Measures to minimize AKI risk in the perioperative period include early detection through close monitoring of SCr, avoiding use of premanufactured bone cement containing gentamicin, and avoiding potential nephrotoxins within the first 72 hours postoperatively.

Local antibiotic therapy strategies in orthopaedic trauma: Practical tips and tricks and review of the literature

The use of local antibiotics for the prevention of infection in the setting of open fractures and as part of the treatment of osteomyelitis is well established. Antibiotics are most commonly incorporated into polymethylmethacrylate (PMMA) cement, which can then be formed into beads, moulded to fit a bone defect or used to coat a guide wire or IM nail. Newer delivery vehicles and techniques are being evaluated to improve upon these methods. Many factors influence how local antibiotics are applied. Treatment strategies are challenging to standardise due to the variability of clinical presentations. The presence of hardware, upper versus lower extremity, healed versus non-healed fracture and quality of soft tissues overlying the affected bone, as well as patients' comorbidities all need to be considered. Despite the accepted use of local antibiotic therapy in orthopaedic trauma, high-quality evidence regarding the use of local antibiotics is lacking. Indications, techniques, dosages, types of antibiotics, elution properties and pharmacokinetics are poorly defined in the clinical setting. The purpose of our manuscript is to review current strategies and provide practical tips for local application of antibiotics in orthopaedic trauma. We focus on delivery vehicles, types of antibiotics, dosage recommendations when mixed with PMMA and indications.

Two cases with HSS/DRESS syndrome developing after prosthetic joint surgery: does vancomycin-laden bone cement play a role in this syndrome?

We report two cases of hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (HSS/DRESS) syndrome following systemic and local (via antibiotic laden bone cement (ALBC)) exposures to vancomycin. Both cases developed symptoms 2-4 weeks after the initiation of treatment. They responded to systemic corticosteroid treatment and were cured completely. Various drug groups may cause HSS/DRESS syndrome, and vancomycin-related cases do not exceed 2-5% of the reported cases. Almost all of these cases developed the syndrome following systemic exposure to vancomycin. ALBC seems to be the safer antibiotic administration method, as systemic antibiotic levels did not reach a toxic threshold level. However, local administration may not always be sufficient for bone-related/joint-related infections; these infections may require systemic antibiotics as well. As HSS/DRESS syndrome can mimic infectious diseases, it must be considered during differential diagnosis before suspecting failure of treatment and initiation of a different antibiotic course.

Peri-operative renal morbidity secondary to gentamicin and flucloxacillin chemoprophylaxis for hip and knee arthroplasty

INTRODUCTION

This retrospective cohort study uses serum creatinine levels to assess the effect of gentamicin and flucloxacillin on renal function in hip and knee arthroplasty patients.

METHODS

Serum creatinine levels were recorded pre-operatively and at two points post-operatively (sample 1 and sample 2) for all patients undergoing hip and knee arthroplasty. Either cefuroxime, or gentamicin and flucloxacillin were used for chemoprophylaxis. The Risk, Injury, Failure, Loss, End Stage classification was used to assess renal injury.

RESULTS

The differences in mean percentage change between the two groups were 5.86% (p = 0.077) and 11.34% (p = 0.030) at sample 1 and sample 2, respectively. Two patients (1.62%) receiving cefuroxime were exposed to renal risk or worse at some point. A total of nine patients (6.04%) receiving flucloxacillin and gentamicin were exposed to renal risk. Of these, three (2.01%) sustained renal injury and two (1.34%) sustained renal failure. The risk of being exposed to renal risk was 3.75 times greater for the gentamicin and flucloxacillin group. The risks of sustaining a significant deterioration of renal function were 1.9 and 17 times greater for the gentamicin and flucloxacillin group at the first and second post-operative samples, respectively.

DISCUSSION

Flucloxacillin and gentamicin significantly worsens renal function post-operatively compared with cefuroxime.

Nephrotoxicity Risk Factors and Intravenous Vancomycin Dosing in the Immediate Postoperative Period Following Antibiotic-Impregnated Cement Spacer Placement

BACKGROUND

Several case reports have documented acute kidney injury (AKI) attributable to antibiotic-impregnated cement (AIC) spacers.

OBJECTIVES

To identify AKI risk factors among patients who underwent AIC placement and determine whether vancomycin-AIC placement affects systemic vancomycin dosing.

METHODS

Phase 1 was a case-control study to identify AKI risk factors among patients who underwent AIC placement. Cases experienced AKI; controls had unchanged renal function. Phase 2 was a retrospective cohort study. Patients who received ≥72 hours of intravenous (IV) vancomycin were divided into 2 groups according to whether they underwent vancomycin-AIC placement. Primary outcome was number of vancomycin dosing changes.

RESULTS

Phase 1: Among 26 cases and 74 controls AKI risk factors on univariate and multivariable analysis included exposure to angiotensin-converting-enzyme (ACE) inhibitor exposure within 7 days of AIC placement (42% vs 20%, P = 0.03) and piperacillin-tazobactam within 7 days following AIC placement (31% vs 12%, P = 0.03). Phase 2: Among 53 patients who underwent vancomycin-AIC placement and 104 who underwent another surgery type, vancomycin was adjusted more frequently in patients who underwent vancomycin-AIC placement (28% vs 15%, P = 0.06).

CONCLUSIONS

Among patients who undergo AIC placement with vancomycin and/or tobramycin, exposure to ACE inhibitors and piperacillin-tazobactam are associated with increased risk of AKI in the immediate postoperative period. No empirical adjustments to IV vancomycin dosing are necessary in patients undergoing vancomycin-AIC placement.

Diffuse Desquamating Rash Following Exposure to Vancomycin-Impregnated Bone Cement

OBJECTIVE

To describe a case of systemic desquamating dermatitis following implantation of vancomycin antibiotic-laden cement (ABLC) in a patient with prior history of Stevens-Johnson (SJS) reaction to vancomycin.

CASE SUMMARY

A 59-year-old man with a history of SJS reaction to systemic vancomycin and recurrent methicillin-susceptible Staphylococcus aureus prosthetic knee infection developed a painful, blistering rash after implantation of bone cement that had been mixed with 2 g of vancomycin. He was started empirically on steroids by his primary care provider and had desquamation about 1 week later.

DISCUSSION

Systemic absorption of antibiotics from ABLC has been well documented in the literature. Reports of systemic toxicity are rare, and none have described systemic allergic reactions to vancomycin. This patient's prior episode of SJS was diagnosed at another academic medical center 6 years ago, and records are unavailable. Following low-level reexposure to vancomycin, he developed a diffuse painful desquamating rash. Application of the Naranjo nomogram yielded a score of 8 (probable adverse reaction). Although he did not experience fever, sore throat, or mucous membrane involvement to fulfill classic features of SJS, we believe that his severe rash represented a less-severe form of a systemic hypersensitivity reaction to vancomycin.

CONCLUSION

Antibiotics contained in ABLC are systemically absorbed, though at low levels, and have been associated with systemic toxicities. Antibiotics to which a patient has had a potentially life-threatening reaction should not be used in ABLC. Particular attention should be paid to an individual's antibiotic allergy history prior to implantation of any ABLC.

Two-stage arthroplasty for prosthetic joint infection: a systematic review of acute kidney injury, systemic toxicity and infection control

Periprosthetic infections of hip and knee joints are now treated by two-stage revision arthroplasty with an infection control rate of 91%. The present systematic review studied the reported incidence of acute kidney injury (AKI) and infection recurrence from January 1989 to June 2012 to assess the risk-benefit ratio of antibiotic spacer use. Ten observational studies (n=544 patients) with clinical outcomes showed an average incidence of AKI of 4.8%. The average reported persistence or recurrence rate of infection was 11% during a follow-up period that ranged from 13 to 108 months. The risk-benefit ratio presently favors treatment although there appears to be higher complication rates and incidence of AKI than previously reported. Marked heterogeneity in practice and lack of detail in reporting precluded more robust quantitative synthesis. Clinicians need to be aware of the potential risk of AKI, particularly in high-risk patients; practice patterns for the use of antibiotic spacers need to be standardized.

Success after treatment of periprosthetic joint infection: a Delphi-based international multidisciplinary consensus

BACKGROUND

The lack of agreement regarding what constitutes successful treatment for periprosthetic joint infections (PJI) makes it difficult to compare the different strategies of management that are used in clinical practice and in research studies.

QUESTIONS/PURPOSES

The aims of this study were to create a consensus definition for success after PJI treatment, and to provide a universal, multidimensional framework for reporting of studies regarding PJI treatment.

METHODS

A two-round basic Delphi method was used to reach a consensus definition. We invited 159 international experts (orthopaedic surgeons, infectious disease specialists, and clinical researchers) from 17 countries to participate; 59 participated in the first round, and 42 participated in the second round. The final definition consisted of all statements that achieved strong agreement (80% or greater of participants considering a criterion relevant for defining success).

RESULTS

The consensus definition of a successfully treated PJI is: (1) infection eradication, characterized by a healed wound without fistula, drainage, or pain, and no infection recurrence caused by the same organism strain; (2) no subsequent surgical intervention for infection after reimplantation surgery; and (3) no occurrence of PJI-related mortality (by causes such as sepsis, necrotizing fasciitis). The Delphi panel agreed to defining midterm results as those reported 5 or more years after the definitive PJI surgery, and long-term results as those reported 10 or more years after surgery. Although no consensus was reached on the definition of short-term results, 71% of the participants agreed that 2 years after the definitive PJI surgery is acceptable to define it.

CONCLUSIONS

This multidimensional definition of success after PJI treatment may be used to report and compare results of treatment of this catastrophic complication.

LEVEL OF EVIDENCE

Level V, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.