Prosthetic joint infection
From IDWiki
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 of Highly Bioavailable Oral Therapy
| 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 |
| 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
