Prosthetic joint infection

Background

Microbiology

• Hip and knee
  • Early (<3 months): Staphylococcus aureus (38%), aerobic Gram-negative bacilli (24%), coagulase-negative staphylococci (22%), Enterococcus species (10%), and Streptococcus species (4%), anaerobes including Cutibacterium acnes (3%), culture-negative (10%); 31% are polymicrobial
  • Overall: Staphylococcus aureus (27%), coagulase-negative staphylococci (27%), aerobic Gram-negative bacilli (9%), Streptococcus species (8%), anaerobes including Cutibacterium acnes (4%), Enterococcus species (3%), culture-negative (14%); 15% are polymicrobial
• Shoulder: coagulase-negative staphylococci (42%), Cutibacterium acnes (24%), Staphylococcus aureus (18%), aerobic Gram-negative bacilli (10%), others, culture-negative (15%); polymicrobial in 16%
• Elbow: Staphylococcus aureus (42%), coagulase-negative staphylococci (41%), others, culture-negative (5%); polymicrobial in 3%

Epidemiology

• Complicates about 2% of arthroplasty

Pathophysiology

• Bacteria grown on the prosthesis in a biofilm, making it resistant to medical management

Management

Surgical Therapy

• Ultimately the decision of whether and how to treat surgically rests with the orthopedic surgeon

Antimicrobial Therapy

Surgical Management	Species	Location	Duration IV	Total Duration	Adjunctive Rifampin	Chronic Suppressive Thearpy
debridement and retention	Staphylococcus species	knee	2-6 weeks	6 months	yes; 4-6 weeks IV if not given	±
debridement and retention	Staphylococcus species	hip	2-6 weeks	3 months	yes; 4-6 weeks IV if not given	±
debridement and retention	Staphylococcus species	elbow	2-6 weeks	3 months	yes; 4-6 weeks IV if not given	±
debridement and retention	Staphylococcus species	shoulder	2-6 weeks	3 months	yes; 4-6 weeks IV if not given	±
debridement and retention	Staphylococcus species	ankle	2-6 weeks	3 months	yes; 4-6 weeks IV if not given	±
debridement and retention	species other than staphylococci	—	4-6 weeks			±
resection ± reimplantation	—	—	4-6 weeks
1-stage exchange	Staphylococcus species	—	2-6 weeks	3 months	yes; 4-6 weeks IV if not given	±
1-stage exchange	species other than staphylococci	—	4-6 weeks	3 months		±
amputation with source control	—	—	24-48 hours
amputation without source control	—	—	4-6 weeks

• IV therapy includes highly bioavailable oral therapy

Intravenous and Highly Bioavailable Oral Therapy

Choice of Antimicrobial

Species	Preferred Antimicrobials	Alternative Antimicrobials
Staphylococcus species (oxacillin-susceptible)	nafcillin or cefazolin or ceftriaxone	vancomycin or daptomycin or linezolid
Staphylococcus species (oxacillin-resistant)	vancomycin	daptomycin
Enterococcus species (penicillin-susceptible)	penicillin G or ampicillin	vancomycin or daptomycin or linezolid
Pseudomonas aeruginosa	cefepime or meropenem	ciprofloxacin or ceftazidime
Enterobacter species	cefepime	ciprofloxacin
Enterobacteriaceae	ampicillin or ceftriaxone or ciprofloxacin
β-hemolytic streptococci	penicillin G or ceftriaxone	vancomycin
Cutibacterium acnes	penicillin G or ceftriaxone	clindamycin or vancomycin

Dosing

Antimicrobial	Dose
ampicillin	12 g IV q24h continuously or split q4h
cefazolin	1-2 g IV q8h
cefepime	2 g IV q12h
ceftazidime	2 g IV q8h
ceftriaxone	2 g IV q24h
ciprofloxacin	750 mg PO bid
ciprofloxacin	400 mg IV q12h
clindamycin	300-450 mg PO qid
clindamycin	600-900 mg IV q8h
daptomycin	6 mg/kg IV q24h
ertapenem	1 g IV q24h
linezolid	600 mg PO/IV q12h
meropenem	1 g IV q8h
nafcillin	1.5-2 g IV q4-6h
penicillin G	20-24 MU IV q24h continuously or split q4h
vancomycin	15 mg/kg IV q12h

Chronic Suppressive Therapy

Microorganism	Preferred treatment	Alternative treatment
Staphylococcus species (oxacillin-susceptible)	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
Staphylococcus species (oxacillin-resistant)	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 species (penicillin-susceptible)	Penicillin V 500 mg PO bid to qid; Amoxicillin 500 mg PO tid
Pseudomonas aeruginosa	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

Further Reading

• Prosthetic Joint Infection. Clin Micro Rev. 2014;27(2):302-345. doi: 10.1128/CMR.00111-13
• Diagnosis and Management of Prosthetic Joint Infection: Clinical Practice Guidelines by the IDSA. Clin Infect Dis. 2013;56(1):e1-25. doi: 10.1093/cid/cis803