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
- 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 |
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 |
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
- a b c 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.
- ^ Joshua S Davis, Sarah Metcalf, Benjamin Clark, J Owen Robinson, Paul Huggan, Chris Luey, Stephen McBride, Craig Aboltins, Renjy Nelson, David Campbell, L Bogdan Solomon, Kellie Schneider, Mark R Loewenthal, Piers Yates, Eugene Athan, Darcie Cooper, Babak Rad, Tony Allworth, Alistair Reid, Kerry Read, Peter Leung, Archana Sud, Vana Nagendra, Roy Chean, Chris Lemoh, Nora Mutalima, Ton Tran, Kate Grimwade, Marjoree Sehu, Davis Looke, Adrienne Torda, Thi Aung, Steven Graves, David L Paterson, Laurens Manning. Predictors of treatment success following peri-prosthetic joint infection: 24-month follow up from a multi-center prospective observational cohort study of 653 patients. Open Forum Infectious Diseases. 2022. doi:10.1093/ofid/ofac048.
- ^ Javad Parvizi, Timothy L. Tan, Karan Goswami, Carlos Higuera, Craig Della Valle, Antonia F. Chen, Noam Shohat. The 2018 Definition of Periprosthetic Hip and Knee Infection: An Evidence-Based and Validated Criteria. The Journal of Arthroplasty. 2018;33(5):1309-1314.e2. doi:10.1016/j.arth.2018.02.078.
- ^ 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.
