Postoperative Joint Infections Research Articles

Evaluation of KLIC and CRIME80 scores for analysis of the risk of failure of the debridement, antibiotics and implant retention procedure in acute postoperative periprosthetic joint infections of the knee

Objectives The primary objective of the study was to evaluate the efficiency of KLIC and CRIME80 scores in assessing the risk of failure of the Debridement, Antibiotics and Implant Retention (DAIR) procedure for the treatment of acute postoperative periprosthetic joint infection after total knee arthroplasty (TKA). Secondary objectives included determining the failure rate of DAIR and identifying factors related to DAIR treatment failure. Methods A retrospective study was conducted with patients undergoing DAIR within 30 days post-TKA or TKA revision at a specialized SUS hospital for high-complexity orthopedic surgeries. Patient records were evaluated to collect the necessary information for score assessment. Procedure failures were considered if re-intervention was required within 60 days, death occurred within 60 days, or if suppressive antibiotic therapy was needed. Results The study included 17 patients undergoing the DAIR procedure. 52% of infections were caused by Staphylococcus aureus, and 29% occurred after revision surgery. Six (35%) patients experienced DAIR failure, and the mortality rate was 11%. Patients who failed had a higher score on the KLIC score (p<0.0001). Regarding the CRIME80 score, only 33% of those with a score of less than 3 experienced procedure failure. Results also showed that for patients with a KLIC score between 2,5 and 5, the presence of a comorbidity or risk factor resulted in DAIR failure. Additionally, 100% of patients with chronic kidney disease experienced treatment failure, with 66% of them progressing to death. Conclusion Our results demonstrated that the KLIC and CRIME80 scores proved to be effective methods in predicting the likelihood of failure in the treatment of acute postoperative periprosthetic joint infection with DARI and patients in intermediate KLIC groups with comorbidities are subject to a higher chance of failure.

Relationship between soft tissue envelope thickness of the lower extremity and acute periprosthetic joint infection of the knee.

The prevalence of obesity is increasing worldwide and it is known to be associated with many postoperative complications, including infection. Patients' body fat distribution may vary and body mass index (BMI) does not provide sufficient information about adipose tissue thickness of the lower extremities. The aim of this study is to investigate the relationship between thigh diameters and early postoperative prosthesis-related joint infections (PJI) in patients who underwent arthroplasty. The study included 76 patients and 114 knees who were operated on by a single surgeon and underwent total knee arthroplasty (TKA) due to primary knee osteoarthritis between May 2022 and September 2023 in a tertiary reference hospital. Circumference of the thickest part of the operated thigh (cm), preoperative erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, height, weight, BMI and the presence of early postoperative prosthesis-related joint infections were evaluated. The mean BMI was 32.6 ± 4.2 (kg/m2). Two (2.6%) were normal weight, 14 (18.5%) were overweight, 58 (76.3%) were obese and 2 (2.6%) were morbidly obese. The mean circumference of the thickest part of the thigh was 57.56 ± 6.38 (cm). 6 patients were diagnosed with PJI in the acute phase. The mean circumference of the thickest part of the thigh was statistically significantly greater in the group with acute PJI compared to the group without PJI (p = 0.048). The incidence of acute PJI was found to be significantly higher in patients with larger thigh diameters, whereas no such relationship was observed for BMI. The incorporation of preoperative soft tissue envelope measurements into routine clinical examination may prove beneficial in reducing the risk of PJI.

A Proposal for a Multidisciplinary Integrated Oral Health Network for Patients Undergoing Major Orthopaedic Surgery (IOHN-OS).

The passing of the years of life physiologically leads to the accumulation of changes in tissues in the oral cavity, influencing dentition, chewing and swallowing mechanisms, and the oral microbiota. Some diseases and medications can aggravate oral symptoms and negatively influence eating behaviours, increasing the likelihood of becoming malnourished. This could make older individuals more vulnerable to complications when undergoing major orthopaedic surgery. Hidden infection foci in the oral cavity are a recognised cause of post-operative periprosthetic joint infections. Dysfunctional oral problems might also compromise feeding after surgery when good nutrition represents a fundamental aspect of a proper recovery. To manage these shortcomings, in this article, the authors hypothesise a multidisciplinary path of care named the Integrated Oral Health Network applied to major Orthopaedic Surgery (IOHN-OS). This peri-operative initiative would include pre-operative oral health screening and risk management by a dental team, patient education programmes before and after surgery, and bedside gerodontology actions like oral care and meal and eating support for fragile individuals. The IOHN-OS has the potential to reshape the concept of suitability for major orthopaedic surgery and generate momentum for designing community-based surveillance programmes that can keep the mouths of older subjects healthy for a long time.

Semaglutide Use Prior to Total Hip Arthroplasty Results in Fewer Postoperative Prosthetic Joint Infections and Readmissions

BackgroundSemaglutide, a novel diabetes management medication, is known for its efficacy in inducing weight loss. Despite this, its impact on outcomes after total hip arthroplasty (THA) remains unclear. The aim of this study was to evaluate if THA patients on semaglutide demonstrate: (1) fewer medical complications; (2) fewer implant-related complications; (3) fewer readmissions; and (4) lower costs. MethodsUsing a national claims database from 2010 to 2021, we retrospectively examined diabetic patients prescribed semaglutide who underwent primary THA. This yielded 9,465 patients (Semaglutide = 1,653; Control = 7,812). Multivariable logistic regression was used to evaluate the following outcomes: 90-day postoperative medical complications, 2-year implant-related complications, 90-day readmissions, in-hospital lengths of stay, and day-of-surgery and 90-day episode of care costs. ResultsSemaglutide users exhibited lower 90-day readmission rates (6.2 versus 8.8%; odds ratio 0.68; P < .01) and reduced prosthetic joint infections (1.6 versus 2.9%; odds ratio 0.56; P < .01). However, medical complication rates, hospital stays, same-day surgical costs, and 90-day episode costs showed no significant differences. ConclusionsThis study highlights semaglutide users undergoing THA with fewer 90-day readmissions and 2-year prosthetic joint infections. Although no variance appeared in medical complications, hospital stays, or costs, the medication's notable glycemic control and weight loss benefits could prompt pre-surgery consideration. Further research is essential for a comprehensive understanding of semaglutide's impact on post-THA outcomes.

The Impact of Perioperative Use of Nonbiologic Disease-Modifying Anti-rheumatic Drugs on Perioperative Blood Loss and Complications in Patients Who Have Rheumatoid Arthritis Undergoing Total Knee Arthroplasty

BackgroundThe use of disease-modifying antirheumatic drugs (DMARDs) before total knee arthroplasty (TKA) was associated with increased risk of postoperative periprosthetic joint and wound infections as well as worse platelet function in patients who have knee rheumatoid arthritis (RA). This study investigated the effects of DMARDS on perioperative blood loss, complications, and blood transfusion in patients undergoing TKA for knee RA. MethodsWe retrospectively enrolled patients undergoing TKA for knee RA at our hospital between 2017 and 2021 who received DMARDs (n = 73) or not (n = 84). Every RA patient was matched with patients who had osteoarthritis (OA) in a ratio of 1:1 or 1:2. Primary outcomes were intraoperative and perioperative blood losses, while secondary outcomes were complications and allogeneic transfusions. ResultsThe mean total (804 versus 728 mL (mL), P = .114), mean intraoperative (113 versus 101 mL, P = .488), or hidden blood losses (705 versus 640 mL, P = .340) did not differ statistically between RA patients who received DMARDs versus those who did not. RA patients who received DMARDs showed significantly greater mean total (804 versus 654 mL, P = .001), intraoperative (113 versus 75 mL, P = .002), and hidden blood losses (705 versus 560 mL, P = .016) than OA patients. No statistical differences were found in complications or allogeneic transfusions. ConclusionAlthough RA patients experienced greater perioperative blood loss than OA patients, there was no statistical difference in perioperative blood loss, complications, or allogeneic transfusions between RA patients who received DMARDs and those who did not.

VANCOMYCIN SOAKING IS HIGHLY COST-EFFECTIVE IN PRIMARY ACLR INFECTION PREVENTION: A COST-EFFECTIVENESS STUDY

While pre-soaking grafts in vancomycin has demonstrated to be effective in observational studies for anterior cruciate ligament reconstruction (ACLR) infection prevention, the economic benefit of the technique is uncertain. The primary aim of this study was to determine the cost-effectiveness of vancomycin pre-soaking during primary ACLR to prevent post-operative joint infections. The secondary aims of the study were to establish the breakeven cost-effectiveness threshold of the technique.A Markov model was used to determine cost effectiveness and the incremental cost effectiveness ratio of additional vancomycin pre-soaking compared to intravenous antibiotic prophylaxis alone. A repeated meta-analysis of nine cohort studies (Level III evidence) was completed to determine the odds ratio of infection with vancomycin pre-soaking compared to intravenous antibiotics alone. Estimated costs and transitional probabilities for further surgery were obtained from the literature. Breakeven threshold analysis was performed.The vancomycin soaking technique provides an expected cost saving of $600AUD per patient. There was an improvement in the quality-adjusted life years of 0.007 compared to intravenous antibiotic prophylaxis alone (4.297 versus 4.290). If the infection rate is below 0.023% with intravenous antibiotics alone or the additional intervention cost more than $1000AUD, the vancomycin wrap would no longer be cost-effective.For $30AUD, the vancomycin soaking technique provides a $600AUD cost saving by both reducing the risk of ACLR related infection and economic burden of infection. Treating septic arthritis represents a mean cost per patient of 6 times compared to that of the primary surgery. There has been no previous cost-effectiveness study of the vancomycin wrap technique.The vancomycin pre-soaking technique is a highly cost-effective method to prevent post-operative septic arthritis following primary ACLR.

Novel reconstruction method by mega-prosthesis wrapped with vancomycin-containing cement after resection of malignancies.

To introduce wrapping vancomycin-containing cement around a mega-prosthesis (MP) as a novel method to prevent prosthetic joint infection after reconstruction surgery for malignant bone and soft tissue tumors. Five patients with malignant bone and soft tissue tumors treated at our hospital from April 2009 to December 2019 were included. The average age was 71.4 years. Four males and one female were included. Three patients had a bone tumor, and two had a soft tissue tumor. Three right thighs and two left femurs were affected. These tumors were identified histologically as undifferentiated pleomorphic sarcoma, spindle cell sarcoma, diffuse large cell B-cell lymphoma, metastasis of renal cancer, and metastasis of lung cancer. All patients underwent tumor resection and reconstruction with a MP. In all cases, vancomycin-containing cement (2 g/40 g) was wrapped around the implant at the extension. The average follow-up period was 30.4 months. We surveyed whether infection occurred after surgical treatment. We also investigated the Musculoskeletal Tumor Society score and clinical outcome. We observed no postoperative infection. One case of local recurrence was observed, and a hip dissection was performed. The Musculoskeletal Tumor Society score was 79.26 ± 1.26 (mean ± standard deviation) (range: 76-80.3). Three patients remained disease-free, one survived but with disease, and one died of disease. Wrapping vancomycin-containing cement around the MP may be a useful method of preventing postoperative joint infections.

Bariatric surgery prior to total hip arthroplasty: does timing or type matter?

Morbid obesity is a known risk-factor for increased complications following total hip arthroplasty (THA). Thus, many orthopaedic surgeons recommend bariatric surgery (BS). However, there is no consensus on the type (commonly either a Roux-en-Y gastric bypass [RYGB] or sleeve gastrectomy [SG]) and timing of BS prior to THA. Therefore, the purpose of this study is to compare BS recipients prior to THA to assess differences in 90-day to 2-year medical/surgical complications as well as revisions for: (1) type of BS (RYGB and SG); and (2) timing of BS. Additionally, we aim to assess risk factors for postoperative prosthetic joint infections (PJIs), dislocations, and revisions. We queried a national, all-payer database to identify patients undergoing primary THA from January 2010 to October 2020 (n = 715,100). Patients were then divided into 6 cohorts: 2 cohorts without history of BS (body mass index [BMI] kg/m2 20-35 [n = 59,995]) and BMI > 40 [n = 36,799]); 2 cohorts with previous RYGB (n = 1278) or SG (n = 1051); and 2 cohorts that underwent BS either 6-12 months (n = 412) and >12 months (n = 1655) prior to the THA. Bivariate chi-square analyses of medical and surgical outcomes at 90 days-2 years were conducted. Multivariate logistic regressions identified independent risk factors for PJIs, dislocations, and revisions. At 90 days-2 years, no differences in postoperative medical/surgical complications or revisions were seen among timing or type of BS. The BMI > 40 kg/m2 cohort had the highest complication profile among all other cohorts. Timing and type of BS has similar odds of PJIs, dislocations, and revisions. Patients undergoing RYGB or SG 6-12 months and >1 year prior to THA showed similar complications profiles. These results suggest, bariatric patients do not need to wait 1 year before undergoing a THA.

Vancomycin Soaking Is Highly Cost-Effective in Primary ACLR Infection Prevention: A Cost-Effectiveness Study

Background: Although presoaking grafts in vancomycin has been demonstrated to be effective in observational studies for anterior cruciate ligament reconstruction (ACLR) infection prevention, the economic benefit of the technique is uncertain. Purpose: To 1) determine the cost-effectiveness of vancomycin presoaking during primary ACLR to prevent postoperative joint infections and 2) to establish the break-even cost-effectiveness threshold of the technique and determine its cost-effectiveness across various international health care settings. Study Design: Economic and decision analysis; Level of evidence, 2. Methods: A Markov model was used to determine cost-effectiveness and the incremental cost-effectiveness ratio of additional vancomycin presoaking compared with intravenous antibiotic prophylaxis alone. A repeated search of the PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials databases, using the same criteria as a recent meta-analysis, was completed. A repeated meta-analysis of 9 cohort studies (level 3 evidence) was completed to determine the odds ratio of infection with vancomycin presoaking compared with intravenous antibiotics alone. Estimated costs of the vancomycin technique, treatment of infection, and further surgery were sourced from local hospitals and literature. Transitional probabilities for further surgery, including revision reconstruction and primary arthroplasty, were obtained from the literature. Probabilistic sensitivity analyses and a 1-way sensitivity analysis were performed to evaluate the ACLR infection rate break-even threshold for which the vancomycin technique would be no longer cost-effective. Results: The vancomycin soaking technique provides expected cost savings of $660 (USA), A$581 (Australia), and €226 (Spain) per patient. There was an improvement in the quality-adjusted life-years of 0.007 compared with intravenous antibiotic prophylaxis alone (4.297 vs 4.290). If the infection rate is below 0.014% with intravenous antibiotics alone, the vancomycin wrap would no longer be cost-effective. Conclusion: The vancomycin presoaking technique is a highly cost-effective method to prevent postoperative septic arthritis after primary ACLR.

Truth or DAIR? A review of debridement, antibiotics and implant retention

Debridement, antibiotics and implant retention (DAIR) is a viable treatment option in early postoperative and acute haematogenous periprosthetic joint infections (PJIs) with a stable implant. Despite lower success rates compared to one- and two-stage revisions, DAIR maintains satisfactory outcomes in selected patient groups and, if successful, has similar functional outcomes to primary arthroplasty. DAIR remains an attractive treatment option, providing satisfactory outcomes with decreased healthcare costs, reduced surgical burden on the patient and shorter hospital stays. With success rates of 37-90%, various factors need to be considered when deciding on DAIR as the appropriate treatment option for PJI. The risk of DAIR failure needs to be weighed against the potential benefits of DAIR success. Factors that increase success rates include an open DAIR procedure performed for a low-virulence, antibiotic-sensitive organism, within a short duration between symptom onset and/or index surgery and DAIR. The procedure involves intraoperative exchange of mobile components and copious wound irrigation, followed by an appropriate antibiotic regimen for a minimum of six weeks that can be administered either intravenously or orally in a well-optimised host, without significant soft tissue defects or contraindications to surgery. Factors increasing the risk for DAIR failure include chronic/late PJIs with resistant organisms, especially methicillin-resistant Staphylococcus aureus (MRSA) in poor hosts with significant comorbidities, such as chronic obstructive pulmonary disease (COPD), liver cirrhosis, rheumatoid arthritis, advanced age &gt; 80 years, patients with fracture indications for arthroplasty and those who cannot tolerate rifampicin- and fluoroquinolone-based antibiotic regimens. Unfortunately, there is no definitive factor to serve as an indication of whether DAIR will be successful, but with recent data showing that a failed DAIR procedure does not lower success in future staged revisions, then even in the face of a 50% success rate, DAIR can maintain its role as an initial treatment option in the management of PJIs

111. Duration of Antibiotic Therapy after Debridement and Implant Retention in Patients with Periprosthetic Joint Infections

BackgroundDebridement, antibiotics, and implant retention (DAIR) is appropriate for select acute postoperative and hematogenous periprosthetic joint infections (PJIs). However, the optimal duration of antimicrobial therapy in patients treated with DAIR has not been defined. Therefore, we aimed to identify the ideal duration of parenteral and oral antibiotics after DAIR. MethodsWe performed a retrospective study of patients >18 years of age with hip or knee PJI managed with DAIR between January 1, 2008, and December 31, 2018, at Mayo Clinic. PJI was defined using criteria adapted from the International Consensus Meeting on PJI. The outcome was defined as either PJI recurrence or unplanned reoperation due to infection. Joint-stratified Cox proportional hazards regression models with time-dependent covariates were used to assess nonlinear effects of antibiotic duration. Hazard ratios were computed based on prespecified time points for comparison, whereas p-values represented the overall effect across the entire range of durations.ResultsThere were 247 unique episodes of PJI in 237 patients during the study period. Parenteral antibiotics were given in 99.2% of cases (n=245). This was followed by chronic oral antibiotic suppression in 92.2% (n=226) with a median duration of 2.2 years (1.0-4.1).DAIR failed in 65 cases over a median follow-up of 4.4 years, with a 5-year cumulative incidence of 28.1%. After adjustment for risk factors, there was no significant association between duration of parenteral antibiotics and treatment failure (p=0.203), with no difference between four versus six weeks (HR 1.11; 95% CI 0.71-1.75) (Figure 1). However, both use and longer duration of oral antibiotic therapy was associated with a lower risk of failure (p=0.006). To account for the possibility that this association was driven by results during early follow-up, conditional analyses at one- and two-year follow-up were performed. Both showed a significantly lower risk for a longer duration of antibiotics (Figure 2). Figure 1. Time-Dependent Analysis of Parenteral Antibiotic Duration Figure 2. Time-Dependent Analysis of Oral Antibiotic Suppression Duration ConclusionAfter DAIR, efficacy from four weeks of parenteral antibiotics was no different from six weeks when followed by chronic oral antibiotic suppression. Our results could not establish an optimal duration but suggested that continuing suppression portends a lower risk of failure of DAIR. Disclosures Elie Berbari, MD, Uptodate.com (Other Financial or Material Support, Honorary unrelated to this work) Matthew P. Abdel, MD, Stryker and AAOS Board of Directors (Board Member, Other Financial or Material Support, Royalties) Aaron J. Tande, MD, UpToDate.com (Other Financial or Material Support, Honoraria for medical writing)

One-year infection control rates of a DAIR (debridement, antibiotics and implant retention) procedure after primary and prosthetic-joint-infection-related revision arthroplasty - a retrospective cohort study.

Introduction: Debridement, antibiotics and implant retention (DAIR) procedures are effective treatments for acute postoperative or acute hematogenous periprosthetic joint infections. However, literature reporting on the effectiveness of DAIR procedures performed after a one- or two-stage revision because of a prosthetic joint infection (PJI) (PJI-related revision arthroplasty) is scarce. The aim of this study is to retrospectively evaluate the infection control after 1 year of a DAIR procedure in the case of an early postoperative infection either after primary arthroplasty or after PJI-related revision arthroplasty. Materials and methods: All patients treated with a DAIR procedure within 3 months after onset of PJI between 2009 and 2017 were retrospectively included. Data were collected on patient and infection characteristics. All infections were confirmed by applying the Musculoskeletal Infection Society (MSIS) 2014 criteria. The primary outcome was successful control of infection at 1 year after a DAIR procedure, which was defined as the absence of clinical signs, such as pain, swelling, and erythema; radiological signs, such as protheses loosening; or laboratory signs, such as C-reactive protein (CRP) () with no use of antibiotic therapy. Results: Sixty-seven patients were treated with a DAIR procedure (41 hips and 26 knees). Successful infection control rates of a DAIR procedure after primary arthroplasty () and after prior PJI-related revision arthroplasty () were 69 % and 56 %, respectively (). The successful infection control rates of a DAIR procedure after an early acute infection () and after a hematogenous infection () following primary arthroplasty were both 69 % (). Conclusion: In this limited study population, no statistically significant difference is found in infection control after 1 year between DAIR procedures after primary arthroplasty and PJI-related revision arthroplasty.

The incidence and incubation period of false-positive culture results in shoulder surgery

Postoperative shoulder infection is a significant complication requiring timely identification and treatment. Indolent infections such as those involving Cutibacterium acnes (formerly Propionibacterium acnes) provide a diagnostic dilemma as they present differently, without the acute symptoms associated with most postoperative bone and joint infections. Furthermore, Cacnes is thought to be a common contaminant isolated from intraoperative cultures. With no consensus algorithm, long-held cultures play a major role in guiding management decisions in potential postoperative shoulder infection. Our study sought to determine the incidence of positive culture results in both open and arthroscopic procedures in noninfected patients, as well as to clarify whether an increase in the incubation time frame leads to an increased rate of culture growth. One hundred patients were prospectively enrolled into either the open or arthroscopic procedure group. Patients with abnormal inflammatory laboratory findings, a history of shoulder surgery, or corticosteroid injection within 6 months of surgery were excluded from the study. Three cultures were obtained for each patient: superficial tissue culture, tissue culture, and "sterile" control swab. Cultures were held for 28 days and checked at regular intervals. All patients were followed up clinically for 6 months to ensure no signs of postoperative infection occurred. Ultimately, 95 patients were included in the final analysis. The false-positive rate was 17.0% in those who underwent open shoulder surgery and 10.4% in those who underwent arthroscopic shoulder surgery. The incidence of positive Cacnes culture results was 6.4% in the open group, whereas Cacnes was not isolated in the arthroscopic group. All positive bacterial culture results were reported within 7 days of collection. One culture result was positive for moldat 26 days. A relatively high false-positive culture rate occurred in both open and arthroscopic shoulder surgery. Cacnes was the most commonly identified bacterium in cultures in the open surgery group. Knowledge of one's institutional false-positive culture rate could be important in avoiding potentially inappropriate treatment. Additionally, we found that holding cultures longer than 14 days did not lead to an increased rate of false-positive culture results.

3D printed bioceramic for phage therapy against bone nosocomial infections.

This study provides a new therapeutic response to postoperative joint and bone infections. Alone or in combination with antibiotics, phage therapy has many advantages, including accurate targeting of pathogenic bacteria. In addition, a decrease in harmful side effects can improve the healing process. Integrating the bacteriophage directly into the graft product will improve the antibacterial spread over the site of the surgery. The phage cocktail-filled ceramics are an innovative device for localized and curative phage therapy (in prosthetic replacement surgery, for example) in bone and joint surgery. Calcium phosphate-based ceramics were synthesized and shaped by stereolithography (3D) before loading by a phage cocktail to lyse a heterospecific bacterial population. In addition, the device makes possible the protection of osteoblastic cells against Staphylococcus aureus infection during their colonization on the ceramic material and prevents the formation of biofilm on the surface of biomaterials.

Selective Laser Melting of Integrated Ti6Al4V ELI Permeable Walls for Controlled Drug Delivery of Vancomycin.

Bacteria colonizing the surface of orthopedic implants are responsible for most postoperative periprosthetic joint infections. A possible alternative route for drug delivery is described in this study by utilizing the bulk of the implant itself as a reservoir. Drug release is enabled by manufacturing of integrated permeable structures possessing high porosity through application of selective laser melting technology. The concept was evaluated in two paths, with 400 μm permeable thin walls and with dense reservoirs containing an integrated 950 μm permeable wall. Components were designed and preprocessed as separate parts, allowing for allocation of different settings of laser power and scanning speed. Lowering the energy input into the selective laser melting process to induce intermittent melting of the Ti6Al4V ELI powder produced porous components through which vancomycin was released with differing profiles. Static water contact angle measurements demonstrated a significant effect on the hydrophilicity by permeable wall thickness. Relative porosities of the 400 μm structures were determined with microcomputed tomography analyses. A transition zone of 21.17% porosity was identified where release profiles change from porosity-dependent to near free diffusion. Antimicrobial activity of released vancomycin was confirmed through evaluation against Staphylococcus aureus Xen 36 in two separate agar diffusion assays. The approach is promising for incorporation into the design and manufacturing of next-generation prosthetic implants with controlled release of antibiotics in situ and the subsequent prevention of periprosthetic joint infections.

Research progress of asymptomatic bacteriuria before arthroplasty: A systematic review.

A high prevalence of asymptomatic bacteriuria exists in patients prior to arthroplasty, and urinary tract infection is considered to be a source of postoperative superficial wound and prosthetic joint infections. There is no consensus whether to screen for and treat asymptomatic bacteriuria before arthroplasty. To summarize the association between asymptomatic bacteriuria and complications after arthroplasty and to evaluate the clinical benefits of treating asymptomatic bacteriuria prior to arthroplasty. We systematically searched PubMed, Embase, and the Cochrane Library to retrieve potentially eligible articles. By screening the titles and abstracts of retrieved records and then reading the full texts of the remaining papers, we finally included 8 English-language articles in this systematic review. Asymptomatic bacteriuria prior to arthroplasty is significantly associated with an increased occurrence of postoperative prosthetic joint and superficial wound infections. However, there is little evidence for direct or hematogenous seeding of urinary infections, and treating asymptomatic bacteriuria before arthroplasty did not decrease the incidence of postoperative infectious complications. Asymptomatic bacteriuria is not a contraindication for arthroplasty, and the practice of routine preoperative screening for and treatment of asymptomatic bacteriuria should not be continued.

Moderating effects of immunosuppressive medications and risk factors for post-operative joint infection following total joint arthroplasty in patients with rheumatoid arthritis or osteoarthritis.

Inconclusive findings about infection risks, importantly the use of immunosuppressive medications in patients who have undergone large-joint total joint arthroplasty, challenge efforts to provide evidence-based perioperative total joint arthroplasty recommendations to improve surgical outcomes. Thus, the aim of this study was to describe risk factors for developing a post-operative infection in patients undergoing TJA of a large joint (total hip arthroplasty, total knee arthroplasty, or total shoulder arthroplasty) by identifying clinical and demographic factors, including the use of high-risk medications (i.e., prednisone and immunosuppressive medications) and diagnoses [i.e., rheumatoid arthritis (RA), osteoarthritis (OA), gout, obesity, and diabetes mellitus] that are linked to infection status, controlling for length of follow-up. A retrospective, case-control study (N = 2212) using de-identified patient health claims information from a commercially insured, U.S. dataset representing 15 million patients annually (from January 1, 2007 to December 31, 2009) was conducted. Descriptive statistics, t-test, chi-square test, Fisher's exact test, and multivariate logistic regression were used. Male gender (OR = 1.42, p < 0.001), diagnosis of RA (OR = 1.47, p = 0.031), diabetes mellitus (OR = 1.38, p = 0.001), obesity (OR = 1.66, p < 0.001) or gout (OR = 1.95, p = 0.001), and a prescription for prednisone (OR = 1.59, p < 0.001) predicted a post-operative infection following total joint arthroplasty. Persons with post-operative joint infections were significantly more likely to be prescribed allopurinol (p = 0.002) and colchicine (p = 0.006); no significant difference was found for the use of specific disease-modifying anti-rheumatic drugs and TNF-α inhibitors. High-risk, post-operative joint infection groups were identified allowing for precautionary clinical measures to be taken.

Iron Status Evaluation as a Marker and Postoperative Joint Infection: A Pilot Study

We evaluated the effect of different inflammatory conditions on iron status and, as a consequence, the possible use of iron markers as indicators of infection in the diagnosis of postoperative prosthetic orthopaedic joint infections. The study population was consisted of 26 patients undergoing revision of total hip or total knee joint arthroplasty and subdivided into three groups according to the cause of prosthesis implant failure: 10 as having had previous infection (Group A), 10 patients were categorized as having infection (Group B); and the remaining 6 (Group C) as not having infection. These patients were assayed for mean corpuscular haemoglobin concentration (MCHC) and serum values of iron (Fe), ferritin (Fer), transferrin (Tf), soluble transferrin receptor (sTfR), and transferrin saturation (sat Tf). Septic patients display statistically significant lower serum iron concentration, higher sTfR and ferritin levels, lower, but not statistically significant, MCHC compared to non septic ones. Little differences were observed for Tf, sat Tf, tibc, TfR index, among the three groups of patients. Our study suggests that iron status parameters, in particular serum iron, ferritin, sTfR and TfR index, could be useful tools for the early detection and the diagnosis of orthopaedic prosthetic joint infections.

A Surgical Technique Using Presoaked Vancomycin Hamstring Grafts to Decrease the Risk of Infection After Anterior Cruciate Ligament Reconstruction

The purpose of this study was to investigate whether presoaking hamstring graft with a dilute antibiotic solution provides a potential new tool to improve measures to prevent joint infection. This is a retrospective analysis of data that were prospectively collected for 1,135 consecutive patients who underwent anterior cruciate ligament reconstruction (ACLR) during a 7-year period. In the initial 3-year period, 285 patients (group 1) underwent ACLR with a hamstring autograft with preoperative intravenous (IV) antibiotics. In the subsequent 4-year period, 870 patients underwent ACLR with a vancomycin-presoaked hamstring autograft (group 2) with preoperative IV antibiotics. Presoaking involved wrapping hamstring tendon autografts in a sterile gauze swab, which had been previously saturated with 5-mg/mL vancomycin solution. In group 1 a total of 4 postoperative joint infections were documented (1.4%). Each case showed increasing pain and effusion, as well as a high intra-articular white blood cell count and increased C-reactive protein level. Of the 4 infected cases, 3 cultured coagulase-negative Staphylococcus (Staphylococcus epidermidis). The fourth case was treated as a postoperative infection despite a negative culture and responded to arthroscopic washout and IV antibiotics. In group 2 no infections (0%) were recorded, and no investigatory washouts occurred. The difference was statistically significant. Known failures were similar in each group. Prophylactic vancomycin presoaking of hamstring autografts statistically reduced the infection rate in this series compared with IV antibiotics alone. Level IV, therapeutic case series.

Prosthetic joint infections: what to do if the C-reactive protein level remains elevated

As the number of implanted joint prostheses of various joints increases, so does the number of episodes of postoperative prosthetic joint infections. The management of such infections is difficult and usually requires a combined approach involving surgical debridement and long-term antibiotic therapy. With this approach, it is possible to retain the prosthesis in many cases, especially in those patients with early diagnosis of the infection [1, 2]. If all goes well, antibiotic treatment can be stopped after 3 months for hip prostheses and 6 months for knee prostheses [1]. The C-reactive protein (CRP) level is routinely measured to assess the response to treatment in addition to clinical assessment. Typically, CRP values return to normal levels during antibiotic treatment. However, in some patients, CRP values may remain elevated. Such a situation usually raises concerns regarding the effectiveness of the chosen antibiotic treatment among treating clinicians. Concerns may even be large enough to result in either an exhaustive diagnostic investigation, at times involving several imaging methods, or the use of surgical exploration to rule out the persistence of infection. Whether or not an elevated CRP should result in an aggressive diagnostic workup is a matter of debate. Undoubtedly, elevated CRP values need a good clinical assessment of the patient, including good medical history and physical examination. In this issue of Infection, Piso and Elke publish their experience of 14 patients with prosthetic joint infections and persistently elevated CRP [3]. The authors adhered to the treatment protocol mentioned above, using surgical debridement and retention of the prosthesis in 11 patients, single-staged reimplantation in one patient, and two-staged reimplantation in two patients. They stopped the antibiotic treatment after the time points mentioned above, even if the CRP levels remained above the upper limit of normal. The patients were followed up for 2 years. Interestingly, in most patients, the CRP value was lower after 2 years than during the treatment phase, but it did not reach normal levels in some patients. In one patient, there was a relapse of infection 5 months after stopping antibiotic treatment. In this case, the second pathogen was not identical to the first isolate. In all other patients, no recurrence of infection occurred within 24 months. While this is a small study, the findings are, nevertheless, interesting. The study highlights that it is not justified launching a diagnostic workup in each patient with a persistently elevated CRP after an adequate duration of antimicrobial therapy if there are no other clinical signs for infection. Of course, this study does not provide the argument for abandoning CRP measurements or ignoring the results of such measurements. It just reminds us that CRP elevation may have a variety of causes, infection being only one of them.