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: 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 suppresive 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; Amox/clav 500mg PO tid
MRSA	Septra DS 1 tab PO bid; Doxycycline 100 mg PO bid
Beta-heme Strep	Pen V 500 mg PO bid to qid; Amoxicillin 500 mg PO tid	Cephalexin 500 mg PO tid to qid
Enterococcus (sensitive)	Pen V 500 mg PO bid to qid; Amoxicillin 500 mg PO tid
Pseudomonas	Ciprofloxacin 250-500 mg PO bid
Enterobacteriaceae	Septra DS 1 tab PO bid	Beta-lactam, if susceptible
Cutibacterium	Pen 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