Long-term Antibiotic Suppression Research Articles

Atypical Mycobacterial Infections of the Spine: Evaluation and Management.

Atypical mycobacterial infections of the spine can be difficult to treat and represent a subset of the vertebral osteomyelitis and diskitis spectrum often requiring early and aggressive surgical intervention. The purpose of this review is to improve the understanding of and approach to disease management from the perspective of the spine surgeon. Debridement or excision of the affected levels may be necessary to decrease mycobacterial loads and restore biomechanics. A close relationship with the patient's internal medicine and infectious disease specialists should be maintained to ensure disease eradication or remission. Long-term suppressive antibiotic therapy may be required for infection control. Atypical mycobacterial spine infections are rare, complex, and difficult to eradicate. Our institution proposes a collaborative effort among the spine surgeon, infectious disease specialists, and internal medicine specialists to best approach the work-up, diagnosis, and treatment of these infections. [Orthopedics. 2024;47(2):e61-e66.].

KLIC Score Does Not Predict Failure After Early Prosthetic Joint Infection: An External Validation With 153 Knees and 130 Hips

BackgroundA preoperative risk score, the KLIC score (chronic renal failure [K], liver cirrhosis [L], indication of the index surgery [I], cemented prosthesis [C], and C-reactive protein >115 mg/L), has been developed to predict the risk of treatment failure after early prosthetic joint infection (PJI). This study aimed to validate the KLIC score for the debridement, antibiotics, and implant retention (DAIR) procedure and one-stage revisions in a Northern European cohort. MethodsRevisions due to early PJI of the hip or knee between January 1, 2008, and September 12, 2021, were identified retrospectively. The primary outcome was early failure, which was considered when the patient needed an unscheduled surgery, the patient died, or the patient was prescribed long-term suppressive antibiotics. To examine the association between KLIC score and failure risk, univariable logistic regression with area under the curve (AUC) was used. In addition, models were calibrated to assess prognostic ability and clinical utility was examined with decision-curve analyses. ResultsAn increase in KLIC score had a moderate predictive value for early failure after DAIR (odds ratio [OR] 1.45; confidence interval [CI] 1.13 to 1.90). For one-stage revision, it was only slightly predictive of failure (OR 1.20; CI 0.93 to 1.56). After 60 days, the AUC for DAIR was 0.63 (CI 0.55 to 0.72) and 0.56 (CI 0.46 to 0.66) for one-stage revisions, indicating poor discriminative ability. The decision-curve analyses revealed that the model did not offer a remarkable net benefit across a range of threshold probabilities. ConclusionsWe demonstrated that the KLIC score is not a reliable predictor of early failure after early PJI in a Northern European cohort. Using the model to guide treatment decisions does not provide any additional clinical utility beyond the baseline strategies.

2763. Evaluating the Safety and Effectiveness of Long-term Antibiotic Suppression in Patients with Left Ventricular Assist Devices

Abstract Background The utilization of left ventricular assist devices (LVADs) as a bridge to transplantation or destination therapy for non-transplant candidates continues to rise. Unfortunately, infection remains one of the most common complication and lack of definitive source control often leads to the decision to initiate long-term antibiotic suppression. The purpose of this retrospective cohort study is to evaluate the long-term safety and effectiveness of antibiotic suppression following an LVAD-related or LVAD-specific infection. Methods Adults who underwent LVAD placement between August 2018 and September 2022 at Prisma Health Midlands and received antibiotic suppression for an LVAD-related or LVAD-specific infection were evaluated. Safety was evaluated as a composite endpoint of treatment emergent adverse events, and discontinuation of or decrease in dose due to tolerability concerns. Effectiveness was evaluated as the proportion of patients without a suppression emergent infection (SEI) within six months of antibiotic suppression initiation. Patients experiencing a SEI (failure) were compared to those without an SEI (success) at six months. Secondary outcomes included the proportion of patients experiencing early SEI within 90 days of antibiotic suppression initiation and evaluation of factors associated with success of antibiotic suppression at six months. Results Fifty-one patients received antibiotic suppressive therapy following an LVAD-related or LVAD-specific index infection. Patients were followed for a minimum of 6 months and an average 2.8 years. Treatment emergent adverse events occurred in 4 (7.8%) patients, with 2 events leading to antibiotic discontinuation. SEI occurred in 9 (17.6%) of patients at 6 months with the most common organisms being P. aeruginosa, S. aureus, and S. epidermidis. Early SEI was observed in 4 (7.8%) patients. Overall, SEI occurred in 28 patients (55%) at a median 341 days (IQR 157-502). Documented resistance to suppressive antibiotic was observed in 13 (25.4%) patients. Index infections with a gram-negative organism was significantly more common in those experiencing SEI (80% vs. 47%, p=0.031). Conclusion Antibiotic suppression following LVAD-associated infections is well-tolerated and successful in 82% of patients at 6 months. Disclosures Julie Ann Justo, PharmD, MS, FIDSA, BCPS, Gilead Sciences: Advisor/Consultant|Shionogi: Advisor/Consultant|Vaxart: Stocks/Bonds

MANAGEMENT OF PERIPROSTHETIC JOINT INFECTION FOLLOWING TOTAL JOINT ARTHROPLASTY: EXPERIENCE FROM A RURAL CENTRE

Prosthetic joint infection (PJI) remains one of the most challenging complications to manage following total joint arthroplasty (TJA). There is a paucity of published data on the management of PJI in smaller, rural hospital settings. In this study, we investigate [1] the success rate of surgical management for PJI following TJA and [2] the microbiology of infecting organisms in this unique geographical environment.We performed a retrospective single-centre study at a rural hospital (Southland Hospital, Invercargill, New Zealand) over a 3-year period (2019 to 2022). All patients presenting with a first episode of PJI fulfilling Musculoskeletal Infection Society criteria after hip or knee arthroplasty were included. All patients had a minimum follow up of 6 months. Treatment success was defined eradication of infection.Twenty-one cases (14 hips and 7 knees) were identified. These were managed with Debridement, antibiotics, and implant retention (DAIR) procedure (n=14, 67%), single-stage revision (n=6, 29%), or long-term suppressive antibiotics (n=1, 4%). Of the DAIR patients, infection recurred in 50% and underwent subsequent revision. Of the single-stage revision patients, 17% failed and underwent subsequent revision. The overall success rate was 90%. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most isolated pathogen (57%,) with no methicillin-resistance Staphylococcus aureus (MRSA) identified. Overall, 90% of infecting organisms were cefazolin sensitive.These results suggest that management of PJI is a safe and viable treatment option when performed in a rural hospital setting, with comparable treatment success rates to urban centres. The incidence of MRSA is low in this setting. Rates of antibiotic resistance were relatively low and most organisms were sensitive to cefazolin, the routine antibiotic used in prophylaxis.

Risk of Cardiovascular Implantable Electronic Device Infection in Patients Presenting With Gram-Negative Bacteremia

BackgroundGram-negative bacteremia (GNB) as a manifestation of cardiovascular implantable electronic device (CIED) infection is uncommon. Moreover, echocardiography may be nonspecific in its ability to differentiate whether CIED lead masses are infected. We aimed to determine the rate of CIED infection in the setting of GNB.MethodsAll patients with CIED who were hospitalized with GNB during 2012–2019 at Mayo Clinic were investigated. The definition of CIED infection was based on criteria recommended by the 2019 European Heart Rhythm Association document.ResultsA total of 126 patients with CIED developed GNB. None of them had signs of pocket infection. Twenty (15.9%) patients underwent transesophageal echocardiography. Overall, 4 (3%) patients had definite CIED infection. None of them underwent CIED extraction; 3 died within 12 weeks and 1 received long-term antibiotic suppression. Ten (8%) patients had possible CIED infection; despite no CIED extraction, no patient had relapsing GNB. We observed a higher rate of CIED infection in patients with Serratia marcescens bacteremia as compared to that in patients with other GNB.ConclusionsThe rate of CIED infection following GNB was relatively low. However, accurate classification of CIED infection among patients presenting with GNB remains challenging, in part, due to a case definition of CIED infection that is characterized by a low pretest probability in the setting of GNB. Prospective, multicenter studies are needed to determine accurate identification of CIED infection among GNB, so that only patients with true infection undergo device removal.

Clinical outcome of postoperative surgical site infections in patients with posterior thoracolumbar and lumbar instrumentation

Postoperative surgical site infection (SSI) is associated with high rates of disability, especially following instrumented spinal surgeries. The management of implant-associated SSI is challenging. This study analysed data from hospital databases to assess the incidence and characteristics related to postoperative SSI after posterior thoracolumbar and lumbar instrumentation. Patient demographics, infection characteristics, details of treatment and perioperative factors were reviewed (January 2010-December 2020). Oswestry Disability Index (ODI), Patient Health Questionnaire-9 (PHQ-9) and Visual Analogue Scale (VAS) scores for back and leg pain were analysed preoperatively and postoperatively until final follow-up. Of the 27,881 procedures collected from the databases, 521 (1.8%) patients were diagnosed with SSI. Of these, 191 (36.7%) patients underwent at least one revision surgery for SSI. The infection rate was significantly higher in patients with lumbar spinal stenosis than in patients with scoliosis or kyphosis (P<0.01). The most commonly isolated pathogen was meticillin-susceptible Staphylococcus aureus (43.4%). The rate of complications secondary to antibiotic treatment was 7.8%, and long-term antibiotic suppression was reported in 15.2% of patients. Instrumentation was retained in 175 (91.6%) patients, and all SSIs were controlled without recurrence during follow-up. Analysis of 27,881 patients showed an average SSI rate of 1.8%. Patients with deep wound SSI can be treated successfully in most cases with retention of instrumentation. Early diagnosis, positive revision surgery with strict irrigation, thorough debridement and a long-term course of antibiotics are critical to eradicate infection, retain implants, decrease morbidity and achieve wound healing.

Medicosurgical management of deep wound infections after thoracolumbar instrumentation: risk factors of poor outcomes.

Surgical site infection (SSI) after thoracolumbar osteosynthesis is a common complication. Its management relies on surgical revision and antibiotic therapy, but treatment failure is not uncommon. The aim of our study was to assess the frequency of SSI management failure and its risk factors. A retrospective study of patients hospitalized from 2011 to 2019 at the University Hospital of Caen was carried out. The infection rate and the time to onset of failure were assessed over a minimum follow-up of 1year. Treatment failure was defined as the occurrence of a new intervention in the spine in the year following the end of antibiotic therapy, the establishment of long-term suppressive antibiotic therapy, or death from any cause within 1year of the end of antibiotic therapy. We compared the treatment failure group with the treatment success group to determine risk factors for treatment failure. A total of 2881 patients underwent surgery during the study period, and 92 developed an SSI, corresponding to an SSI rate of 3.19%. Thirty-six percent of the patients with an SSI presented treatment failure. The median time to failure was 31days. On multivariate analysis, diabetes mellitus was identified as a risk factor for treatment failure, whereas prolonged postoperative drainage for 4 to 5days was a protective factor. The number of failures was significant, and failure occurred mainly during the early phase. To decrease the risk of treatment failure, prolonged duration of postoperative drainage seems to be helpful. Additionally, as diabetes is a risk factor for treatment failure, good control of glycemia in these patients might impact their outcomes.

Local antibiotic treatment with calcium sulfate as carrier material improves the outcome of debridement, antibiotics, and implant retention procedures for periprosthetic joint infections after hip arthroplasty - a retrospective study.

Purpose: Debridement, antibiotics, and implant retention (DAIR) is an established treatment modality in periprosthetic joint infections (PJIs), but success rates vary. This study compared the success of DAIR for PJIs after a total hip arthroplasty (THA), with or without local antibiotic delivery with CaSO as the carrier material. Methods: A retrospective review of DAIR for PJIs after THA performed between 2010 and 2018, including 41 patients is conducted. A total of 27 patients were treated by DAIR with local antibiotics with CaSO as the carrier material, and 14 patients were treated by a standard DAIR. The endpoints were treatment failure, defined as the need for a reoperation, either a second DAIR or a prosthesis removal or exchange due to persistent or recurrent infection, the initiation of a long-term suppressive antibiotic treatment, or death related to infection. Results: Considering any reoperation as an outcome, 11 of 14 cases treated without AB-CaSO (79 %) and 4 of the 27 cases treated with AB-CaSO failed (15 %). Considering revision as an outcome, 9 out of 14 cases treated without AB-CaSO (64 %) and 4 of the 27 cases treated with AB-CaSO (15 %) failed. A Kaplan–Meier survival analysis showed that local antibiotic delivery with CaSO as the carrier material led to a significantly longer infection-free survival, considering any surgical revision (; hazard ratio 8.9 (95 % CI 2.8–28.2)) or revision with component exchange (; hazard ratio 5.6 (95 % CI 1.7–18.2)) as the endpoint. Conclusion: The addition of local antibiotics with CaSO as the carrier material to DAIR for PJIs after THA significantly increases success rates, such as infection-free survival, any reoperation, and revision with component exchange in particular.

Brucella aortitis managed with debridement, extra-anatomical bypass, and long-term antimicrobial therapy.

This report aims to review the management and outcomes of Brucella-associated mycotic aortic aneurysms. This is a retrospective chart review at a tertiary-level healthcare system. IRB approval was waived per policy. We describe a case of Brucella aortitis acquired from habitual contact with wild hogs. Clinical presentation included lower back pain and elevated white blood cell count. Diagnosis was confirmed with imaging showing an infrarenal abdominal aortic aneurysm and serology revealing elevated Brucella antibodies titers. The patient was initially managed with endovascular aortic repair and combined oral and intravenous antibiotics therapy. He then underwent explanation and extra-anatomical bypass due to symptomatic periaortic infection and interval development of type I endoleak. The patient was asymptomatic after his final operation at 24months of follow-up and remained on suppressive oral antibiotic therapy. An aortic aneurysm secondary to Brucella is a rare entity. A detailed history of long-term exposure to animals may be a clue to obtain serologic testing. Operative debridement and re-establishing of reliable blood flow combined with long-term antibiotic suppression are the mainstay of treatment.

Long-term antibiotic therapy in patients with surgery-indicated not undergoing surgery infective endocarditis.

To date, there is little information regarding management of patients with infective endocarditis (IE) that did not undergo an indicated surgery. Therefore, we aimed to evaluate prognosis of these patients treated with a long-term antibiotic treatment strategy, including oral long term suppressive antibiotic treatment in five referral centres with a multidisciplinary endocarditis team. This retrospective, multicenter study retrieved individual patient-level data from five referral centres in Spain. Among a total of 1797, 32 consecutive patients with IE were examined (median age 72 years; 78% males) who had not undergone an indicated surgery, but received long-term antibiotic treatment (LTAT) and were followed by a multidisciplinary endocarditis team, between 2011 and 2019. Primary outcomes were infection relapse and mortality during follow-up. Among 32 patients, 21 had IE associated with prostheses. Of the latter, 8 had an ascending aorta prosthetic graft. In 24 patients, a switch to long-term oral suppressive antibiotic treatment (LOSAT) was considered. The median duration of LOSAT was 277 days. Four patients experienced a relapse during follow-up. One patient died within 60 days, and 12 patients died between 60 days and 3 years. However, only 4 deaths were related to IE. The present study results suggest that a LTAT strategy, including LOSAT, might be considered for patients with IE that cannot undergo an indicated surgery. After hospitalization, they should be followed by a multidisciplinary endocarditis team.

Association between Continuous Flow Left Ventricular Assist Device Infections Requiring Long-Term Antibiotic Use and Post Heart Transplant Morbidity and Mortality

PurposeInfections in patients with a left ventricular assist device (LVAD) for bridge to heart transplant (HTx) do not appear to impact post-HTx survival. We evaluated the association between LVAD-related infections requiring long-term suppressive antibiotics and non-recent infections of any kind on the risk of early and late infection, rejection and mortality post-HTx in comparison to LVAD recipients without infection.MethodsThis is a single-center retrospective observational cohort study of consecutive adults with a durable continuous flow LVAD undergoing HTx between 2006-2019. Patients were grouped into: 1) LVAD-related infection requiring long-term antibiotic use until time of HTx; 2) any type of infection after LVAD implant in whom antibiotics were stopped at least 1 month prior to HTx; and 3) no infections between LVAD implant and HTx. LVAD-related infections included bacteremia, driveline or pocket. We evaluated the association between LVAD infection and post-HTx in-hospital infection, rejection and mortality using logistic regression, and long-term infection, rejection and mortality using Cox PH models.ResultsWe included 75 LVAD recipients; 16 (21%) patients had an LVAD-related infection on suppressive antibiotics, 30 (40%) had a non-recent infection, and 29 (39%) had no infections. During a median post-HTx follow-up time of 4 (2-7) years, we observed 65/75 (87%) infections, 43/67 (64%) rejections, and 17/75 (23%) deaths. Both short- and long-term risk of infection, rejection, and mortality did not differ significantly among the groups (Table 1).ConclusionLVAD patients with history of infections did not have higher risk of infection, rejection or mortality at any time point after HTx. Different post-HTx management strategies may have buffered the risk of adverse events in LVAD patients with infections. Infections in patients with a left ventricular assist device (LVAD) for bridge to heart transplant (HTx) do not appear to impact post-HTx survival. We evaluated the association between LVAD-related infections requiring long-term suppressive antibiotics and non-recent infections of any kind on the risk of early and late infection, rejection and mortality post-HTx in comparison to LVAD recipients without infection. This is a single-center retrospective observational cohort study of consecutive adults with a durable continuous flow LVAD undergoing HTx between 2006-2019. Patients were grouped into: 1) LVAD-related infection requiring long-term antibiotic use until time of HTx; 2) any type of infection after LVAD implant in whom antibiotics were stopped at least 1 month prior to HTx; and 3) no infections between LVAD implant and HTx. LVAD-related infections included bacteremia, driveline or pocket. We evaluated the association between LVAD infection and post-HTx in-hospital infection, rejection and mortality using logistic regression, and long-term infection, rejection and mortality using Cox PH models. We included 75 LVAD recipients; 16 (21%) patients had an LVAD-related infection on suppressive antibiotics, 30 (40%) had a non-recent infection, and 29 (39%) had no infections. During a median post-HTx follow-up time of 4 (2-7) years, we observed 65/75 (87%) infections, 43/67 (64%) rejections, and 17/75 (23%) deaths. Both short- and long-term risk of infection, rejection, and mortality did not differ significantly among the groups (Table 1). LVAD patients with history of infections did not have higher risk of infection, rejection or mortality at any time point after HTx. Different post-HTx management strategies may have buffered the risk of adverse events in LVAD patients with infections.

Infective Endocarditis in a Hospital-at-Home Setting: A Retrospective Analysis in a Peripheral Spanish Hospital

Infective endocarditis (IE) is a severe condition with high morbidity and mortality, and it requires long-term suppressive antibiotic therapy. Outpatient parenteral antimicrobial therapy (OPAT) has been used for a range of infectious diseases for more than 30 years, and in Spain it is used in hospital-at-home (HaH) settings. Our objectives were to describe and characterize the demographic, clinical, and microbiological features of patients admitted to an HaH setting and to assess the safety and effectiveness of OPAT. We conducted a retrospective study that included patients diagnosed with IE over a period of 8 years (2011-2018). We collected demographic and clinical features, length of hospital stay, antimicrobial treatment, microbiological profiles, and outcomes. We included 26 patients during the observation period. Their mean age was 66.5 years, and 88.5% were male. The mean hospital stay was 10.5 days, and the mean stay in the HaH setting was 31 days. A total of 6 patients required readmission due to deterioration, of whom 3 had severe mitral insufficiency. The 8 patients had symptoms of heart failure, but they were treated at home and did not require readmission. Ultimately, 12 patients recovered and were referred to a surgical unit for valvular repair and replacement on a scheduled basis. OPAT is a useful and effective tool for the management of patients diagnosed with IE in HaH settings.

The Role of Long-Term Antibiotic Suppression in the Management of Peri-Prosthetic Joint Infections Treated With Debridement, Antibiotics, and Implant Retention: A Systematic Review

BackgroundA number of clinical trials have been conducted, assessing the role of long-term (>1 year) suppressive antibiotic treatment (SAT) combined with Debridement, Antibiotics, and Implant Retention (DAIR) for the management of peri-prosthetic joint infection (PJI). However, no systematic review of the literature has been published to date to evaluate complications associated with long-term antibiotic treatment and overall survivorship free from re-operation and revision for infection after DAIR for total hip and total knee PJI. MethodsThe US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried for publications from January 1980 to December 2018 utilizing keywords pertinent to total knee arthroplasty, total hip arthroplasty, PJI, and antibiotic suppression. ResultsOverall, 7 articles of low quality (level III or IV) were included in this analysis. The studies included in this systematic review included 437 cases of PJI treated surgically with DAIR and then with SAT. The overall mean infection-free rate of SAT following DAIR was 75% (318/424 patients), while the all-cause re-operation rate was 6.7%. Overall, the mean rate of adverse effects associated with long-term antibiotic use was 15.4% and the mean rate of adverse effects leading to discontinuation of SAT was 4.3%. There was no study to show significant differences between acute (either post-operative or hematogenous, with onset of symptoms ≤4 weeks) and chronic (onset of symptoms >4 weeks) infections and failure rates of DAIR with SAT. The literature is inconclusive on the influence of anatomic location (hip vs knee) as well as microorganism on the success rate of DAIR with SAT. ConclusionThe results of this systematic review demonstrate that there is still only low-quality evidence regarding the therapeutic effect of DAIR combined with SAT, which is not enough to draw definitive conclusions. Furthermore, high-quality prospective studies are needed to better understand SAT’s efficacy and safety in a controlled fashion. Although discontinuation of antibiotic treatment due to side effects was found to be low, the high rates of adverse effects noted after DAIR with SAT demonstrate the underlying frailty and complexity of many patients with PJI, and the imperfect therapies available. Although Staphylococcus aureus appears to be a risk factor for increased risk of SAT failure, there are not enough data to establish which patients would benefit most from DAIR with post-operative SAT.

849. Reduced CIED Infections with an Antibacterial Envelope: Microbiologic Analysis of the WRAP-IT Study

BackgroundCardiovascular implantable electronic device (CIED) infections are associated with significant morbidity, mortality, and cost. There is limited evidence on antibiotic prophylactic strategies to prevent CIED infection. Recently, the TYRX Envelope, which elutes a combination of rifampin and minocycline for a minimum of 7 days, was shown to significantly reduce major CIED infections in the WRAP-IT trial. We sought to characterize the pathogens among patients who experienced an infection in the current era.MethodsAll patients undergoing CIED replacement, upgrade, revision, or de novo cardiac resynchronization therapy (CRT-D) received standard of care antibiotic prophylaxis and were randomized 1:1 to receive TYRX or not. The primary endpoint was major CIED infection within 12 months of the procedure. Major infection was defined as an infection resulting in (1) system extraction or revision, (2) long-term suppressive antibiotic therapy, or (3) death. Data were analyzed using the Cox proportional hazards regression model.ResultsA total of 6,983 patients were randomized worldwide with 3,495 randomized to receive an envelope and 3,488 randomized to the control. At 12 months, 25 major infections (0.7%) were observed in the envelope group and 42 major infections (1.2%) in the control group, resulting in a 40% reduction of major infections (HR: 0.60, 95% CI: 0.36–0.98, P = 0.04). Of 63 infections assayed, causative pathogens were identified in 36 infections whereas cultures were negative in 27 cases. Staphylococcus species (n = 22) were the predominate pathogens and a 53% reduction was observed with the use of TYRX (Figure 1). Moreover, there was only 1 CIED pocket infection with Staphylococcus species in the envelope group compared with 14 pocket infections in the control group. A comparison of timing of infection in the envelope group showed the presence of 11 endocarditis/bacteremia infections at 103 ± 84 days compared with 14 pocket infections presenting at 70 ± 78 days from the procedure.ConclusionIn this large randomized trial, the use of the TYRX Envelope containing rifampin and minocycline resulted in a significant reduction of major CIED infections and was effective against staphylococcal species, which are the predominant cause of pocket infections. Disclosures All Authors: No reported Disclosures.

Results of Using a "2-in-1" Single-Stage Revision Total Knee Arthroplasty for Infection with Associated Bone Loss: Prospective 2-Year Follow-Up.

Prosthetic joint infections provide a complex challenge for management, owing to their often difficult diagnoses, need for multiple surgeries, and increased technical and financial requirements. The '2 in 1' single-stage approaches have been recently advocated in the field of arthroplasty on account of their reduction in risks, costs, and complications. The aim of our study was to investigate the outcomes of this variant of single-stage revision, which is used in the setting of infection following primary total knee replacement (TKR) and associated bone loss. Prospective data were collected from all patients presenting with an infection following primary TKR over an 8-year period (2009-2017). We examined revision procedures that were undertaken as a single-stage procedure and had bone loss present. Patients were followed-up for evidence of recurrent infection. Functional assessments were conducted using range of motion, Oxford Knee Score (OKS), American Knee Society Score (AKSS), and Short Form-12 (SF-12) survey. Twenty-six patients were included in the analysis, two of whom had previously failed 2 stage revision; another three among them had failed debridement, antibiotics, irrigation, and implant retention procedures. The mean age was 72.5 years, mean body mass index was 33.4, and median American Society of Anesthesiologists (ASA) physical status classification was 2. The mean time to revision was 3.5 years (3 months to 12 years). Six patients had actively been discharging sinuses at the time of surgery. Only 4/26 patients possessed no positive microbiological cultures from deep tissue samples or joint aspirates. One patient was afflicted with a recurrence of infection. This patient did not require further surgery and was successfully treated with the help of long-term antibiotic suppression. There were statistically significant improvements in both the pain component of AKSS scores (preoperative 4.3 to postoperative 32.4) and the functional component of AKSS scores (preoperative 10.7 to postoperative 15.7). There was no significant improvement in flexion; however, mean extension (increased from 18.5 to 6.9 postoperative) and total range of motion (increased from 69.2 preoperative to 90.3 postoperative) both showed statistically significant improvements. The use of "2-in-1" single-stage revision can be considered as an effective option for treating infection following TKR and associated bone loss.

Debridement, Antibiotics, and Implant Retention Is a Viable Treatment Option for Early Periprosthetic Joint Infection Presenting More Than 4 Weeks After Index Arthroplasty.

The success of debridement, antibiotics, and implant retention (DAIR) in early periprosthetic joint infection (PJI) largely depends on the presence of a mature biofilm. At what time point DAIR should be disrecommended is unknown. This multicenter study evaluated the outcome of DAIR in relation to the time after index arthroplasty. We retrospectively evaluated PJIs occurring within 90 days after surgery and treated with DAIR. Patients with bacteremia, arthroscopic debridements, and a follow-up <1 year were excluded. Treatment failure was defined as (1) any further surgical procedure related to infection; (2) PJI-related death; or (3) use of long-term suppressive antibiotics. We included 769 patients. Treatment failure occurred in 294 patients (38%) and was similar between time intervals from index arthroplasty to DAIR: the failure rate for Week 1-2 was 42% (95/226), the rate for Week 3-4 was 38% (143/378), the rate for Week 5-6 was 29% (29/100), and the rate for Week 7-12 was 42% (27/65). An exchange of modular components was performed to a lesser extent in the early post-surgical course compared with the late course (41% vs 63%, respectively; P < .001). The causative microorganisms, comorbidities, and durations of symptoms were comparable between time intervals. DAIR is a viable option in patients with early PJI presenting more than 4 weeks after index surgery, as long as DAIR is performed within at least 1 week after the onset of symptoms and modular components can be exchanged.

Failed Debridement and Implant Retention Does Not Compromise the Success of Subsequent Staged Revision in Infected Total Knee Arthroplasty

BackgroundPeriprosthetic joint infection (PJI) is the leading cause of early revisions after total knee arthroplasty. Debridement, antibiotics, and implant retention (DAIR) procedures are often the initial treatment for PJI. However, there is concern that failed DAIR undermines the future success of revision procedures. This study aims to investigate the impact of DAIR on the success of subsequent staged revisions for PJI. MethodsA multicenter retrospective review was performed over a 15-year period. Treatment success was defined as implant retention without the use of long-term suppressive antibiotics. This was compared between patients who underwent a staged revision as the first procedure for PJI (staged-only) and patients who failed DAIR before staged revision (F-DAIR). Competing risk survival analysis was performed to compare the 2 groups and considered for patient demographics, American Society of Anesthesiologists score, organism type, body mass index, age of prosthesis, and duration of symptoms. ResultsOf 291 eligible patients, 63 underwent staged revision and 228 underwent DAIR as the first procedure for PJI. Of the 228 DAIR patients, 75 failed DAIR and underwent subsequent staged revision (F-DAIR). At mean follow-up of 6.2 years, the success rate was 72% in the F-DAIR group and 81% in the staged-only group. On survival analysis, there was no significant difference in subdistribution hazard ratio comparing the probability of failure (implant retention) in the 2 treatments groups (subdistribution hazard ratio = 0.72; 95% confidence interval 0.32-1.61; P = .42). ConclusionThis study suggested that a previously failed DAIR does not compromise the success rate of a subsequent staged revision.

Postoperative Surgical Site Infection After Spine Surgery: An Update From the Scoliosis Research Society (SRS) Morbidity and Mortality Database*

Retrospective review of prospectively collected data. Analyze the Scoliosis Research Society (SRS) Morbidity & Mortality (M&M) database to assess the incidence and characteristics related to postoperative surgical site infection (SSI) after spinal deformity surgery. Infections involving spinal instrumentation are associated with greater rates of disability. Rates of postoperative SSI after spinal deformity surgery range from 1.9% to 4.4%. Postoperative SSI rates of 4.2% for adult kyphosis, 2.1% for adult spondylolisthesis, and 3.7% for adult scoliosis have been reported. The SRS M&M database was evaluated to define patient demographics, perioperative factors, and infection characteristics of spinal deformity patients with postoperative spine infections after deformity surgery in2012. Of the 47,755 procedures reported to the SRS in 2012, there were 578 (1.2%) diagnosed SSIs. Infection rates for patients with kyphosis were significantly higher compared with patients with scoliosis (2.4% vs. 1.1%, p < .0001) or spondylolisthesis (2.4% vs. 1.1%, p < .0001). Spinal fusions were performed in 86.3% of patients, 75.1% of which were performed posteriorly. Osteotomies were performed in 30.1% of patients. Deep infections below the fascia accounted for 68.0% of infections. Methicillin-sensitive (41.9%) and methicillin-resistant (17.0%) Staphylococcus aureus were the most commonly isolated pathogens, whereas gram-negative bacteria accounted for 25.4% of cases. Long-term antibiotic suppression was required in 18.9% of patients, and overall complications from antibiotics occurred in 4.5% of patients. Operative treatment was required in 81.8% of SSI cases. SSIs occur in 1.2% of spine deformity patients, with a rate significantly higher in patients with kyphosis. Approximately 25% of these infections are secondary to gram-negative species. Antibiotic complications occur in 4.5% of patients being treated for SSI. Despite advancements in surgical technique and infection prophylaxis, postoperative SSI remains one of the most common complications in spinal deformity surgery. Level III.

Repair of Thoracic and Thoracoabdominal Mycotic Aneurysms and Infected Aortic Grafts Using Allograft

Mycotic aneurysm of the thoracic or thoracoabdominal aorta and infection of thoracic or thoracoabdominal aortic grafts are challenging problems with high mortality. In situ reconstruction with cryopreserved allograft (CPA) avoids placement of prosthetic material in an infected field and avoids suppressive antibiotics or autologous tissue coverage. Fifty consecutive patients with infection of a thoracic or thoracoabdominal aortic graft or mycotic aneurysm underwent resection and replacement with CPA from 2006 to 2016. Intravenous antibiotics were continued postoperatively for 6 weeks. Long-term suppressive antibiotics were uncommonly used (8 patients). Follow-up imaging occurred at 6, 18, and 42 months postoperatively. Initial follow-up was 93% complete. Men comprised 64% of the cohort. The mean age was 63 ± 14 years. The procedures performed included reoperations in 37 patients; replacement of the aortic root, ascending aorta, or transverse arch in 19; replacement of the descending or thoracoabdominal aorta in 27; and extensive replacement of the ascending, arch, and descending or thoracoabdominal aorta in 4. Intraoperative cultures revealed most commonly Staphylococcus (24%), Enterococcus (12%), Candida (6%), and gram-negative rods (14%). Operative mortality was 8%, stroke was 4%, paralysis was 2%, hemodialysis was 6%, and respiratory failure requiring tracheostomy was 6%. Early reoperation for pseudoaneurysm of the CPA was necessary in 4 patients. One-, 2-, and 5-year survival was 84%, 76%, and 64%, respectively. Radical resection and in situ reconstruction with CPA avoids placing prosthetic material in an infected field and provides good early and midterm outcomes. However, early postoperative imaging is necessary given the risk of pseudoaneurysm formation.

Prognostic Factors for Success After Irrigation and Debridement With Modular Component Exchange for Infected Total Knee Arthroplasty

BackgroundIrrigation and debridement with modular component exchange (IDMCE) can treat prosthetic joint infection (PJI) after total knee arthroplasty (TKA). Compared to 2-stage revision, IDMCE is associated with lower morbidity but may carry higher infection recurrence rates. We aimed to identify prognostic factors associated with successful IDMCE in patients with PJI. MethodsWe identified 99 consecutive patients who underwent IDMCE following TKA PJI at a tertiary academic medical center from November 2009 through January 2016. Examined variables included age, gender, symptom duration, body mass index, Charlson comorbidity index, total protein, albumin, hemoglobin A1c, erythrocyte sedimentation rate (ESR), C-reactive protein, white blood cell count, gram stain results, final cultures, and use of long-term antibiotic suppression. Success was defined as no further operation on the ipsilateral knee. We used t tests and chi-square analyses to determine whether each preoperative factor was associated with IDMCE reoperation. ResultsAt mean follow-up of 2.6 years, 64 patients who underwent IDMCE were defined as successful. Thirty-five patients required one or more additional procedures for recurrent infection; of these, 20 patients underwent 2-stage revision. Patients with symptom duration of less than 2 days avoided additional surgery in 88% of cases. Elevated ESR >47 mm/h was the only variable associated with reoperation (P = .005). There were no associations among the other examined variables. ConclusionUsing IDMCE for PJI after TKA required reoperation in 35% of cases. Elevated preoperative ESR laboratory values and duration of symptoms >2 days were associated with reoperation.