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
- History and physical
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 |
- may subsitute minocycline for doxycycline