Prosthetic joint infection: Difference between revisions

From IDWiki
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*Should be suspected when there is a sinus tract, persistent wound drainage, acute onset of pain, or chronic pain after a pain-free interval
  
*Should be suspected when there is a sinus tract, persistent wound drainage, acute onset of pain, or chronic pain after a pain-free interval
   
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== Diagnosis ==
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==Diagnosis==
   
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* Routine investigations should include ESR, CRP, plain film x-ray, diagnostic arthrocentesis, and blood cultures (if fever or other systemic symptom)
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*Routine investigations should include ESR, CRP, plain film x-ray, diagnostic arthrocentesis, and blood cultures (if fever or other systemic symptom)
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** If clinically stable, try to obtain arthrocentesis samples before antibiotics
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**If clinically stable, try to obtain arthrocentesis samples before antibiotics
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** Other imaging should not be used routinely
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**Other imaging should not be used routinely
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* Diagnosis is made most definitively by histopathology of periprosthetic tissue biopsy, and supported by positive intraoperative tissue cultures
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*Diagnosis is made most definitively by histopathology of periprosthetic tissue biopsy, and supported by positive intraoperative tissue cultures
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** Should take 3 to 6 intraoperative samples
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**Should take 3 to 6 intraoperative samples
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** If clinically stable, try to obtain tissue cultures before starting antibiotics
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**If clinically stable, try to obtain tissue cultures before starting antibiotics
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* A definitive diagnosis of PJI requires any of the following:
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*A definitive diagnosis of PJI requires any of the following:
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** Sinus tract that communicates with the prosthesis
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**Sinus tract that communicates with the prosthesis
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** Acute inflammation on histopathology of intraoperatic periprosthetic tissue sample
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**Acute inflammation on histopathology of intraoperatic periprosthetic tissue sample
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** Periprosthetic purulence without other cause
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**Periprosthetic purulence without other cause
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** Two or more intraoperative cultures with identical organism, though a single positive culture may be sufficient in some cases
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**Two or more intraoperative cultures with identical organism, though a single positive culture may be sufficient in some cases
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* A diagnosis of PJI may still be possible if the above criteria are not met but clinical suspicion remains
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*A diagnosis of PJI may still be possible if the above criteria are not met but clinical suspicion remains
   
 
==Management==
  
==Management==
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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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{| class="wikitable"
  
{| class="wikitable"
 
!Microorganism
  
!Microorganism

Revision as of 21:51, 2 February 2021

Background

Microbiology

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

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

  • 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

  1. ^  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.
  2. ^  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.
  3. ^  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.

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