View source for Prosthetic joint infections (PJI) (IDSA 2013)

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: [https://doi.org/10.1093/cid/cis803 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 ==

{| class="wikitable"
! Microorganism
! Preferred treatment
! Alternative treatment
|-
| [[MSSA]]
| [[Cephalexin]] 500 mg PO tid to qid; <br/>[[Cefadroxil]] 500 mg PO bid
| [[Dicloxacillin]] 500 mg PO tid to qid; <br />[[Clindamycin]] 300 mg PO qid; <br />[[Amoxicillin-clavulanic acid]] 500mg PO tid
|-
| [[MRSA]]
| [[TMP-SMX]] DS 1 tab PO bid; <br />[[Doxycycline]] 100 mg PO bid
|
|-
| [[β-hemolytic streptococci]]
| [[Penicillin V]] 500 mg PO bid to qid; <br />[[Amoxicillin]] 500 mg PO tid
| [[Cephalexin]] 500 mg PO tid to qid
|-
| [[Enterococcus]] (sensitive)
| [[Penicillin V]] 500 mg PO bid to qid; <br />[[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; <br />[[Amoxicillin]] 500 mg PO tid
| [[Cephalexin]] 500 mg PO tid to qid; <br />[[Doxycycline]] 100 mg PO bid
|}

* may subsitute [[minocycline]] for [[doxycycline]]

[[Category:Bone and joint infections]]
[[Category:IDSA guidelines]]