Prosthetic joint infections (PJI) (IDSA 2013)

From IDWiki

Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, Rao N, Hanssen A, Wilson WR; Infectious Diseases Society of America. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013 Jan;56(1):e1-e25. doi: 10.1093/cid/cis803. Epub 2012 Dec 6.

Diagnostic testing

Preoperative testing

  • Presentation
    • Sinus tract or persistent wound drainage
    • Acute onset of pain
    • Chronic pain at any time after implantation
      • After a pain-free interval
      • In the first few years
      • With a history of wound healing problems or site infection
  • Evaluation
    • History and physical
      • Type of prosthesis
      • Date of implantation
      • Past surgeries on the joint
      • History of wound healing problems following implantation
      • Remote infections
      • Current symptoms
      • Drug allergies
      • Comorbid conditions
      • Prior and current microbiology results
      • Prior and current antimicrobial therapy
    • Bloodwork
      • ESR/CRP
      • Blood cultures if fever, acute onset, or suspicion of bloodstream infection
    • Imaging
      • Plain radiograph
      • Do not routinely use bone/WBC scans, MRI, CT, or PET
    • Diagnostic arthrocentesis
      • Should be performed if above investigations suggest infection, unless surgery is planned and antimicrobials can be withheld before surgery
      • If stable, off antibiotics for at least 2 weeks

Intraoperative diagnosis

  • Tissue cultures
    • At least 3, ideally 5 or 6
    • If stable, off antibiotics for at least 2 weeks

Definition of PJI

  • Definite
    • Sinus tract that communicates with the prosthesis
    • Purulence surrounding the prosthesis, without another etiology
    • Two or more intraoperative cultures with the same organism
  • Suggestive
    • Acute inflammation on histopathology
    • A single positive intraoperative cultures for a vierulent organism
  • PJI possible even without the above

Surgical management

  • Debridement and retention
    • Well-fixed prosthesis, no sinus tract, within 30 days of implantation or 3 weeks of symptom onset
    • Not meeting the above criteria but with unacceptable surgical risk
  • 2-stage
    • Not candidates for a 1-stage and are medically able to undergo multiple surgeries
    • Obtain a baseline ESR/CRP
  • 1-stage
    • THA infection, good soft tissue, known susceptible pathogen that can be treated with antibiotics that have good oral bioavailability
  • Permanent resection
    • non-ambulatory patients
    • Limited bone stock, poor soft tissue coverage, or highly resistant organisms
    • Medical condition precluding multiple major surgeries
    • Failed 2-stage with high risk of recurrence
  • Amputation
    • Last-line option for selected, usually life-threatening cases

Management after debridement and rentention

Staphylococcus spp.

  • 2-6 weeks of pathogen-specific IV therapy with rifampin 300-450 mg PO BID, followed by oral therapy with rifampin
    • Recommended oral therapy includes ciprofloxacin and levofloxacin
    • Alternatives include Septra, doxycycline/minocycline, first-generation cephalosporins, or antistaphylococcal penicillins
    • If unable to tolerate rifampin, should treat with 4-6 weeks of IV
  • Duration 6 months for knee
  • Duration 3 months for hip, elbow, shoulder, ankle

Chronic suppressive therapy

  • May follow above regimen
  • Recommended oral therapy includes cephalexin, dicloxacillin, co-trimoxazole, and minocycline
  • Do not use rifampin, either alone or in combination

Other organisms

  • 4-6 weeks of pathogen-specific IV or highly-bioavailable oral therapy
  • May need chronic suppressive therapy

Management after resection with or without reimplantation

  • 4-6 weeks of IV or highly bioavailable oral therapy

Management after 1-stage exchange

Staphylococcus spp.

  • Identical to management with debridement and retention
  • 2-6 weeks of IV therapy plus rifampin 300-450 mg PO bid, followed by oral plus rifampin for total of 3 months
    • Recommended oral therapy includes ciprofloxacin or levofloxacin
    • Alternative oral therapy includes Septra, doxycycline/minocycline, first-generation cephalosporins, or antistaph penicillins
    • If unable to tolerate rifampin, treat for 4-6 weeks of IV therapy
  • May follow with indeifinite chronic oral suppressive therapy, without rifampin

Other organisms

  • 4-6 weeks of IV therapy or highly-bioavailable oral therapy
  • May follow with chronic supressive therapy

Management after amputation

  • If no longer septic and source control has been achieved, treat for 24-48 hours further
  • If unable to achieve source control despite surgery, treat for 4-6 weeks of IV or highly-bioavailable oral therapy

Table 3: Chronic suppressive therapy

Microorganism Preferred treatment Alternative treatment
MSSA Cephalexin 500 mg PO tid to qid;
Cefadroxil 500 mg PO bid
Dicloxacillin 500 mg PO tid to qid;
Clindamycin 300 mg PO qid;
Amoxicillin-clavulanic acid 500mg PO tid
MRSA TMP-SMX DS 1 tab PO bid;
Doxycycline 100 mg PO bid
β-hemolytic streptococci Penicillin V 500 mg PO bid to qid;
Amoxicillin 500 mg PO tid
Cephalexin 500 mg PO tid to qid
Enterococcus (sensitive) Penicillin V 500 mg PO bid to qid;
Amoxicillin 500 mg PO tid
Pseudomonas Ciprofloxacin 250-500 mg PO bid
Enterobacteriaceae TMP-SMX DS 1 tab PO bid Beta-lactam, if susceptible
Cutibacterium Penicillin V 500 mg PO bid to qid;
Amoxicillin 500 mg PO tid
Cephalexin 500 mg PO tid to qid;
Doxycycline 100 mg PO bid