Management Of Prosthetic Joint Infection Research Articles

Culture Negative Prosthetic Joint Infection–A Description of Current Treatment and Outcomes

Background: The management of prosthetic joint infections remains a clinical challenge particularly when standard aerobic and anaerobic culture techniques fail to isolate the causative pathogen, so called ‘culture negative prosthetic joint infection’ (CNPJI). There are few studies detailing approaches to management in this cohort of patients. This study reports the treatment and outcomes of 19 patients with CNPJI. Results: The majority of patients (68%) with CNPJI had exposure to antibiotic therapy in the week prior to presentation with CNPJI. Patients with early (10 patients) and haematogenous (3 patients) CNPJI were treated with debridement and retention of the prosthesis. In contrast, patients with delayed and late chronic CNPJI (6 patients) were managed by two-stage exchange. In addition to the surgical management patients were commenced on broadspectrum oral antibiotics combination therapy with rifampicin, fusidic acid +/- ciprofloxacin for a prolonged duration (median 7 months; interquartile range 3-20). Patients were followed up for a median of 19 months (interquartile range 13-29). Two patients experienced treatment failure with a 12 month estimate of infection free survival of 95% (95% confidence interval: 68,99). Of concern, 28% patients receiving oral antibiotics experienced adverse effects necessitating change in treatment. Conclusions: In this cohort, the outcomes for patients with CNPJI were comparable to those reported for culture positive infections, and contrary to previous recommendations, this study demonstrates that debridement and retention of a CNPJI is reasonable for patients with early infections. It also highlights the importance of exclusion of prosthetic joint infection prior to instigation of antibiotic therapy to optimise peri-prosthetic tissue culture yields to avoid this situation in which multiple broad spectrum antibiotics with potential side effects become necessary

Management of prosthetic joint infection treated with two-stage exchange

Management of prosthetic joint infection treated with two-stage exchange

Laboratory Diagnosis of Prosthetic Joint Infection, Part II

Prosthetic joint infection (PJI), although a rare complication of primary or revision arthroplasty, is reported more frequently as the number patients undergoing arthroplasty increases. Accurate diagnosis of PJI is essential for adequate management and outcome. Although multiple tests have been applied, in some cases, differentiation of PJI from aseptic loosening of the prosthesis remains a challenge. Here, we review the current diagnostic laboratory modalities used for the diagnosis PJI. In Part I of this two-part article, components of the preoperative evaluation of the patient and the histology of the intraoperative evaluation were discussed. Part II of the article discusses the remaining components of the intraoperative evaluation, including periprosthetic tissue and sonicate fluid cultures. In addition, recent investigational approaches for the diagnosis of PJI, antimicrobial susceptibility testing, and management of PJIs are reviewed.

Prevention and Management of Prosthetic Joint Infection in Older Adults

Total joint arthroplasty (TJA) is commonly performed on older adults. Prosthetic joint infection (PJI) is a serious complication of TJA that can significantly impact quality of life and physical function. In this review, we discuss the epidemiology and risk factors for PJIs among older adults. We also offer an overview of current diagnostic, treatment and management strategies for PJI. Given the serious nature of PJI, prevention efforts remain essential. Several approaches to infection prevention exist, including antimicrobial prophylaxis and decolonization. Although there are standardized recommendations for antimicrobial prophylaxis, the specific regimens must be individualized based on the patient's drug allergies, potential for drug interactions, renal function and bodyweight. The best approach to pre-operative screening and decolonization programmes remains unclear. Each of these issues is reviewed in detail with a focus on adverse effects and current debates regarding best practice. Given the increased numbers of TJAs performed, additional research on prevention and management is critical.

The diagnosis and management of prosthetic joint infections

A host of technical and operative improvements have seen the rates of infection associated with joint replacement reach historic lows. However, the increasing number of operations being performed means that the absolute number of such infections remains significant. Diagnosis may be challenging and delaying appropriate treatment can lead to reduced joint function and the need for more complex, perhaps multiple, procedures. Individual centres tend to see small numbers of such cases, and in the absence of large clinical trials management varies. Early diagnosis, selection of an appropriate surgical strategy, accurate identification of the responsible microorganisms and construction of an appropriate antibiotic regimen are essential elements of any management strategy. Such packages of care are best delivered by a multidisciplinary team composed of orthopaedic and plastic surgeons, microbiologists, infectious disease physicians, specialist nurses, physiotherapists and occupational therapists. Each treatment plan must be developed in consultation with the patient, taking into account their aims and realistic goals. This review provides an overview of current understanding regarding diagnosis and treatment of prosthetic joint infections and suggests a treatment algorithm.

Consensus document on controversial issues in the diagnosis and treatment of prosthetic joint infections

Joint replacement surgery has been on the increase in recent decades and prosthesis infection remains the most critical complication. Many aspects of the primary prevention and clinical management of such prosthesis infections still need to be clarified. The aim of this GISIG (Gruppo Italiano di Studio sulle Infezioni Gravi) working group - a panel of multidisciplinary experts - was to define recommendations for the following controversial issues: (1) Is a conservative surgical approach for the management of prosthetic joint infections effective? (2) Is the one-stage or the two-stage revision for the management of prosthetic joint infections more effective? (3) What is the most effective treatment for the management of prosthetic joint infections due to methicillin-resistant staphylococci? Results are presented and discussed in detail. A systematic literature search using the MEDLINE database for the period 1988 to 2008 of randomized controlled trials and/or non-randomized studies was performed. A matrix was created to extract evidence from original studies using the CONSORT method to evaluate randomized clinical trials and the Newcastle-Ottawa Quality Assessment Scale for case-control studies, longitudinal cohorts, and retrospective studies. The GRADE method for grading quality of evidence and strength of recommendation was applied.

Irrigation and Debridement in the Management of Prosthetic Joint Infection: Traditional Indications Revisited

Irrigation and debridement (I and D) is a procedure commonly used for the treatment of acute periprosthetic infection. This study retrospectively reviewed clinical records of patients with periprosthetic infection of the hip or knee who underwent I and D with retention of their prostheses between 1997 and 2005 at a single institution. One hundred four patients (44 males and 60 females) were identified. Mean age at time of initial debridement was 65 years. Average follow-up was 5.7 years. Treatment failure was defined as the need for resection arthroplasty or recurrent microbiologically proven infection. According to these criteria, I and D was successful in 46 patients (44%). Patients with staphylococcal infection, elevated American Society of Anesthesiologists score, and purulence around the prosthesis were more likely to fail. The high failure rate of this procedure implies that it should be preferably limited to select healthy patients with low virulence organisms and equivocal intraoperative findings.

Periprosthetic Joint Infection: The Economic Impact of Methicillin Resistant Infections

A worrisome rise in the incidence of prosthetic joint infections (PJI) caused by virulent, antibiotic-resistant organisms has been noted over the past decade. In addition to higher failure rates, management of PJI caused by resistant organism is believed to be associated with a prolonged hospital stay, and need for multiple surgeries. The purpose of this multi-institutional, case-control study was to evaluate the economic impact of antibiotic resistance through studying the cost of treating PJI caused by resistant versus sensitive organisms.

Treatment approaches to prosthetic joint infections: results of an Emerging Infections Network survey

We report the results of an Emerging Infections Network survey of 994 infectious disease consultants (IDCs) regarding their participation in the medical management of prosthetic joint infections and observations of adverse effects associated with antibiotic-impregnated materials (response rate, 54.8%). There was general agreement about when a prosthesis can be retained, but substantial variability in the duration of suppressive antibiotics was recommended, with 36% supporting life-long suppression. For 2-stage procedures, 95% recommended a minimum of 4 weeks of systemic antibiotics after the first stage. However, there was little agreement regarding the duration of an antibiotic-free period before reimplantation. Eleven percent of IDCs reported adverse events related to antibiotic-impregnated materials, ranging from skin reactions to renal failure. Further studies to address the substantial variability in the duration of antibiotic suppressive therapy for retained joints and for the duration of antibiotic-free period before reimplantation are needed.

Static and Mobile Antibiotic-impregnated Cement Spacers for the Management of Prosthetic Joint Infection

Two-stage treatment is currently the most common approach for management of an infected joint prosthesis in the United States. Static antibiotic-impregnated polymethylmethacrylate cement spacers have traditionally been used; increasingly, however, mobile or articulating spacers are being utilized. Advocates of mobile spacers have cited potential advantages, including more effective maintenance of the joint space, allowing for limited weight bearing and facilitating joint motion; possible reduction in bone loss; and local delivery of antibiotics. Because a variety of materials and construction methods is used to make knee and hip spacers, comparisons are difficult. Randomized, prospective studies are needed to determine the best spacers for total knee and total hip arthroplasties.

Update on osteo-articular infections and severe skin and soft tissue infections

The present article is an update on bone, joint, skin and soft-tissue infections. A panel of Spanish clinicians including orthopedic surgeons, infectious diseases specialists and microbiologists with extensive experience in these fields have commented on the most relevant medical articles published during the last two years. In the next section, we review and discuss 10 articles on pathogenesis (1), diagnostic methods (1), epidemiology (1) and general management of prosthetic joint infections (8) and three on severe and necrotizing soft tissue infections. Although the rate of joint arthroplasty infection is about 1-3%, the infection of an orthopedic implant is particularly devastating since it requires several interventions, prolonged hospitalization and antibiotic treatment for weeks or months. Taking into account the increasing number of arthroplasties performed each year, a parallel increase is expected in the number of prosthetic joint infections. In the absence of well-designed prospective, randomized, controlled studies, the diagnosis and treatment of prosthetic joint infections is based mainly on personal experience. For these reasons, the authors consider particularly interesting a critical review of the most important references in this field. Recently, emergent pathogens such as community-acquired methicillin-resistant Staphylococcus aureus have been involved in necrotizing fasciitis. In addition, new tools for the diagnosis and treatment of these infections have been described and are now reviewed in the present article. El artículo presente recoge una actualización de las infecciones óseas, articulares, cutáneas y de los tejidos blandos. Un grupo de clínicos españoles constituido por traumatólogos, especialistas en enfermedades infecciosas y microbiólogos con amplia experiencia en estos campos ha comentado los artículos de mayor relevancia a este respecto publicados durante los 2 últimos años. En la sección siguiente se revisan y comentan 10 artículos sobre patogenia (1), métodos diagnósticos (1), epidemiología (1) y abordaje terapéutico general de las infecciones en las prótesis articulares (8); además, se exponen los resultados obtenidos en tres publicaciones sobre infecciones necrosantes graves de los tejidos blandos. A pesar de que la incidencia de infección de las artroplastias es de aproximadamente el 1-3%, la infección de un implante ortopédico es un cuadro especialmente grave debido a que obliga a la realización de varias intervenciones quirúrgicas, a una hospitalización prolongada y a la administración de tratamiento antibiótico durante semanas o meses. Considerando en conjunto el número creciente de intervenciones de artroplastias que se realizan anualmente, se espera un incremento paralelo en el número de infecciones de las prótesis articulares. En ausencia de estudios prospectivos y realizados con asignación aleatoria y control, el diagnóstico y el tratamiento de las infecciones de las prótesis articulares están fundamentados principalmente en la experiencia personal. Por estas razones, los autores consideran especialmente interesante una revisión crítica de las publicaciones más importantes que se han efectuado en este campo. Recientemente se han observado cuadros de fascitis necrosante de origen extrahospitalario causados por Staphylococcus aureus resistente a meticilina. Además, en el artículo presente se revisan las nuevas herramientas introducidas para el diagnóstico y el tratamiento de estas infecciones.

Fungi, Mycobacteria, Zoonotic and Other Organisms in Prosthetic Joint Infection

A systematic review of the presentation and management of prosthetic joint infection (PJI) due to zoonotic microorganisms, fungi, mycobacteria and other unusual microorganisms is not available. We therefore sought to provide a resource for the practicing orthopaedic surgeon which will serve as a guide for making appropriate decisions in managing such rare, but potentially problematic conditions. We conducted a Medline search of all case reports of PJI due to these unusual microorganisms. Our review of the current literature showed the diagnosis of PJI due to zoonotic microorganisms, fungi, mycobacteria and other unusual microorganisms typically necessitates specialized diagnostic tests. Maintaining a high index of suspicion in diagnosis of such unusual microorganisms and requesting the appropriate laboratory tests at the time of surgical débridement is crucial for determining the microbiologic etiology of these infections. The appropriate medical and surgical management of such infections is complex and often requires the use of special antimicrobials with which the orthopaedist may not be familiar. Collaboration with an infectious disease specialist is advisable when treating these infections.

Management of prosthetic joint infection

Infection is the most severe complication of arthroplasty and in the majority of cases is due to contamination during surgery. The rate is about 1–3% or even higher in revision arthroplasties. The pathogenesis of these infections is related to microorganisms that reach the prosthesis directly during surgery or after surgery by the haematogenous route. The microorganisms grow on the implant surface forming biofilms that make the diagnosis and treatment of these infections difficult. There are two types of prosthetic joint infection according to the duration of symptoms: acute and chronic. The diagnosis of an acute infection is based on clinical manifestations and the treatment consists of open debridement without removal of the implant. A chronic infection is difficult to distinguish from aseptic failure, often presenting only with pain and early radiological signs of loosening. A combination of preoperative and intraoperative tests is usually required for diagnosis. The most successful treatment in these cases is the removal of all inert material, including cement, prosthesis and necrotic tissue. In general, the adequate surgical procedure for each type of infection should be combined with long-term antimicrobial therapy including an active agent against microorganisms growing in biofilms. Since the main characteristic of these microorganisms is their slow growth, the best antibiotics are those with activity against stationary phase bacteria. In this article, pathogenesis, clinical presentation, epidemiology, diagnosis and treatment of prosthetic joint infections are reviewed.

Advances in the laboratory diagnosis of prosthetic joint infection

Prosthetic joint implant surgery (arthroplasty) provides restoration of movement to almost half a million people each year in the USA, with major health and economic benefits. While the majority of recipients experience dramatic relief of preoperative pain at the arthroplasty site, some prostheses fail to achieve this result. This is most commonly the result of aseptic biomechanical failure or prosthetic joint infection (PJI), both of which are associated with significant morbidity. Because the management of PJI differs from that of aseptic failure, it is important to accurately differentiate these two entities. Current laboratory methods for diagnosis of PJI depend on isolation of a pathogen by culture from a clinical specimen (e.g., synovial fluid, periprosthetic tissue). However, as PJI is typically a low organism burden and focal infection caused by commensal micro-organisms, these methods have neither ideal sensitivity nor ideal specificity. Therefore, culture-independent molecular methods have been used to improve the diagnosis of PJI. In the research setting, detection of 16S ribosomal DNA (rDNA) by polymerase chain reaction has been the prime focus of the molecular diagnosis of PJI. In this article, advantages and limitations of conventional and molecular methods for the laboratory diagnosis of PJI are reviewed, as is the use of methods that may improve detection of organisms in the biofilm environment. The diagnosis of PJI remains challenging and a rapid, sensitive and specific method is needed for appropriate surgical and medical treatment decisions in the growing arthroplasty population.

Prosthetic joint infection: when can prosthesis salvage be considered?

Management of prosthetic joint infection (PJI) remains a therapeutic challenge. We retrospectively studied 69 infected total hip or knee arthroplasties managed between 1980 and 1996 in our institution. Treatment failure, defined as relapse of PJI in the first year following the last antimicrobial treatment, occurred for 14 patients (20.3%). None of the potentially contributive parameters analyzed was significantly predictive of treatment failure. Of the subgroup of 34 patients with PJI who initially underwent debridement with retention of the prosthesis, the 13 (38.2%) who did not require further surgical treatment had symptoms for a significantly shorter duration before debridement (4.85 vs. 54.24 days; P < .0001). Because debridement with retention of the prosthesis rarely enables control of PJI, this therapeutic approach should be considered only when the duration of symptoms is very short.