Prosthetic joint infection: Difference between revisions
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==== Adjunctive Rifamycins ==== |
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* Adjunctive [[rifampin]] 300 to 450 mg twice daily is usually added for staphylococcal infection where strong contraindications do not exist[[CiteRef::zimmerli2018ro]] |
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* Alternatively , can potentially use [[rifabutin]] 300 mg PO daily[[CiteRef::doub2020ri]] |
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===Chronic Suppressive Therapy=== |
===Chronic Suppressive Therapy=== |
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*Duration unclear; 3-12 months or lifelong |
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*In people in whom there is recurrence, it tends to recur within 4 months of discontinuing suppressive therapy |
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Revision as of 14:02, 12 March 2021
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
- 2% of hip and knee arthroplasties
- 1% of shoulder arthroplasties
Pathophysiology
- Bacteria grown on the prosthesis in a biofilm, making it resistant to medical management
Clinical Manifestations
- Most commonly occur within the 3 months after arthroplasty (early); 70% within the first two years
- Should be suspected when there is a sinus tract, persistent wound drainage, acute onset of pain, or chronic pain after a pain-free interval
Diagnosis
- Routine investigations should include ESR, CRP, plain film x-ray, diagnostic arthrocentesis, and blood cultures (if fever or other systemic symptom)
- If clinically stable, try to obtain arthrocentesis samples before antibiotics
- Other imaging should not be used routinely
- Diagnosis is made most definitively by histopathology of periprosthetic tissue biopsy, and supported by positive intraoperative tissue cultures
- Should take 3 to 6 intraoperative samples
- If clinically stable, try to obtain tissue cultures before starting antibiotics
- A definitive diagnosis of PJI requires any of the following:
- Sinus tract that communicates with the prosthesis
- Acute inflammation on histopathology of intraoperatic periprosthetic tissue sample
- Periprosthetic purulence without other cause
- Two or more intraoperative cultures with identical organism, though a single positive culture may be sufficient in some cases
- A diagnosis of PJI may still be possible if the above criteria are not met but clinical suspicion remains
Management
Surgical Therapy
- Ultimately the decision of whether and how to treat surgically rests with the orthopedic surgeon
- Options include:
- Debridement and retention
- One-stage replacement
- Two-stage replacement
- Antibiotic-impregnated cement is often used for the spacer
- Usually vancomycin 2 to 8 g per 40 g cement, or an aminoglycoside
- No clear guidelines for dosing
- No clear evidence of effectiveness, but recommended in all revisions for septic arthritis
- Releases over a period of two to three days
- Usually vancomycin 2 to 8 g per 40 g cement, or an aminoglycoside
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 | ± |
| hip | 3 months | ± | ||||
| elbow | ± | |||||
| shoulder | ± | |||||
| ankle | ± | |||||
| 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 | ± |
| 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 |
Adjunctive Rifamycins
- Adjunctive rifampin 300 to 450 mg twice daily is usually added for staphylococcal infection where strong contraindications do not exist1
- Alternatively , can potentially use rifabutin 300 mg PO daily2
Chronic Suppressive Therapy
- Duration unclear; 3-12 months or lifelong
- In people in whom there is recurrence, it tends to recur within 4 months of discontinuing 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 |
Intra-Articular Infusion
- Used in veterinary practice for decades, but only used experimentally in humans
- Intraoperatively insert two Hickman catheters into the intraarticular space
- Two catheters used to ensure that at least one will remain viable for the duration
- Vancomycin
- May precipitate local inflammatory response necessitating holding it for several days
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
References
- ^ Louis Bernard, Cédric Arvieux, Benoit Brunschweiler, Sophie Touchais, Séverine Ansart, Jean-Pierre Bru, Eric Oziol, Cyril Boeri, Guillaume Gras, Jérôme Druon, Philippe Rosset, Eric Senneville, Houcine Bentayeb, Damien Bouhour, Gwenaël Le Moal, Jocelyn Michon, Hugues Aumaître, Emmanuel Forestier, Jean-Michel Laffosse, Thierry Begué, Catherine Chirouze, Fréderic-Antoine Dauchy, Edouard Devaud, Benoît Martha, Denis Burgot, David Boutoille, Eric Stindel, Aurélien Dinh, Pascale Bemer, Bruno Giraudeau, Bertrand Issartel, Agnès Caille. Antibiotic Therapy for 6 or 12 Weeks for Prosthetic Joint Infection. New England Journal of Medicine. 2021;384(21):1991-2001. doi:10.1056/nejmoa2020198.
- ^ Werner Zimmerli, Parham Sendi. Role of Rifampin against Staphylococcal Biofilm InfectionsIn Vitro, in Animal Models, and in Orthopedic-Device-Related Infections. Antimicrobial Agents and Chemotherapy. 2018;63(2):e01746-18. doi:10.1128/aac.01746-18.
- ^ James B. Doub, Emily L. Heil, Afua Ntem-Mensah, Renaldo Neeley, Patrick R. Ching. Rifabutin Use in Staphylococcus Biofilm Infections: A Case Series. Antibiotics. 2020;9(6):326. doi:10.3390/antibiotics9060326.
