Abstract
Introduction: Orthopedic implant-associated infections caused by multidrug-resistant Enterobacteriaceae are a growing challenge for healthcare providers due to their increasing incidence and the difficulties of medical and surgical treatment. Material and Methods: A retrospective observational study of all cases of multidrug resistant Enterobacteriaceae orthopedic implant-associated infection diagnosed in a tertiary European hospital from December 2011 to November 2017 was carried out. Clinical records were reviewed using a previously designed protocol. Data analysis was performed with IBM® SPSS®, version 22. Results: 25 patients met inclusion criteria. The infected implants included 10 prosthetic joints, seven osteosyntheses, six combinations of prosthetic joint and osteosynthesis material, and two spacers. Of the multidrug resistant Enterobacteriaceae obtained on culture, 12 were extended-spectrum beta-lactamase-producing Escherichia coli, three OXA-48-producing Klebsiella pneumoniae, nine extended-spectrum beta-lactamase-producing Klebsiella pneumoniae, and one extended-spectrum beta-lactamase-producing Proteus mirabilis. Combination antimicrobial therapy was employed in all cases but two. Overall, 16 (64%) patients underwent implant removal. The rate of infection control in the overall implant removal group was 100% compared to 33% in the implant retention group. A strong relationship between implant removal and infection control was observed (p = 0.001). Discussion: Implant removal is strongly associated with infection control. However, in some cases, patient age and comorbidity contraindicate hardware extraction. Potential objectives for future studies should be geared towards targeting the population in which debridement, antibiotic therapy, and implant retention can be used as a first-line therapeutic strategy with a reasonable probability of achieving infection control.
Highlights
Orthopedic implant-associated infections caused by multidrug-resistant Enterobacteriaceae are a growing challenge for healthcare providers due to their increasing incidence and the difficulties of medical and surgical treatment
Ten patients (40%) had suffered a previous episode of orthopedic implant-associated infection by another microorganism, and 15 of infected hardware (60%) had been implanted during a revision surgery
This patient was admitted to our Center for a one-step hardware exchange, with bacteremia by Extended-Spectrum Beta-LactamaseESBL producing Escherichia coli (Migula 1895) and infection of the new hardware ensuing.) All cases of previous hardware infection took place in the same joint as that infected by MDREB
Summary
Orthopedic implant-associated infections caused by multidrug-resistant Enterobacteriaceae are a growing challenge for healthcare providers due to their increasing incidence and the difficulties of medical and surgical treatment. The most frequent sites of infection are the urinary tract, respiratory system, and surgical wounds [4] Within this last category, orthopedic device-related infections by MDREB have been described [5], and seem to be gaining importance with an increasing prevalence, as shown from data gathered in recent studies [6]. The treatment of bone and joint implant-associated infections by MDREB is a challenge both for clinicians and microbiologists The complexity of this type of infection stems, from the difficulties of designing an effective antimicrobial treatment, which in cases of hardware retention requires combination therapy [7,8], and from the presence of the implant itself, which favors the formation of biofilms, conditioning difficulty for bacterial eradication [9]. New drugs have been included in the therapeutic arsenal for the treatment of MDREB infection [10,11], but as of yet, there are no large randomized clinical trials focused on the performance of these drugs in cases of orthopedic implant-associated infection
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