Prosthetic joint infection: Difference between revisions

From IDWiki
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*Hip and knee
  
*Hip and knee
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**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
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**Early (<3 months): [[Staphylococcus aureus]] (38%), aerobic [[Gram-negative bacilli]] (24%), [[coagulase-negative staphylococci]] (22%), [[Enterococcus]] (10%), and [[Streptococcus]] (4%), [[anaerobes]] including [[Cutibacterium acnes]] (3%), culture-negative (10%); 31% are polymicrobial
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**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
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**Overall: [[Staphylococcus aureus]] (27%), [[coagulase-negative staphylococci]] (27%), aerobic [[Gram-negative bacilli]] (9%), [[Streptococcus]] (8%), [[anaerobes]] including [[Cutibacterium acnes]] (4%), [[Enterococcus]] (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%
  
*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%
  
*Elbow: [[Staphylococcus aureus]] (42%), [[coagulase-negative staphylococci]] (41%), others, culture-negative (5%); polymicrobial in 3%
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|-
  
|-
 
| rowspan="6" |debridement and retention
  
| rowspan="6" |debridement and retention
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| rowspan="5" |[[Staphylococcus species]]
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| rowspan="5" |[[Staphylococcus]]
 
|knee
  
|knee
 
| rowspan="5" |2-6 weeks
  
| rowspan="5" |2-6 weeks
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|-
  
|-
 
| rowspan="2" |1-stage exchange
  
| rowspan="2" |1-stage exchange
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|[[Staphylococcus species]]
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|[[Staphylococcus]]
 
|—
  
|—
 
|2-6 weeks
  
|2-6 weeks
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!Alternative Antimicrobials
  
!Alternative Antimicrobials
 
|-
  
|-
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|[[Staphylococcus species]] (oxacillin-susceptible)
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|[[Staphylococcus]] (oxacillin-susceptible)
 
|[[nafcillin]] or [[cefazolin]] or [[ceftriaxone]]
  
|[[nafcillin]] or [[cefazolin]] or [[ceftriaxone]]
 
|[[vancomycin]] or [[daptomycin]] or [[linezolid]]
  
|[[vancomycin]] or [[daptomycin]] or [[linezolid]]
 
|-
  
|-
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|[[Staphylococcus species]] (oxacillin-resistant)
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|[[Staphylococcus]] (oxacillin-resistant)
 
|[[vancomycin]]
  
|[[vancomycin]]
 
|[[daptomycin]]
  
|[[daptomycin]]
 
|-
  
|-
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|[[Enterococcus species]] (penicillin-susceptible)
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|[[Enterococcus]] (penicillin-susceptible)
 
|[[penicillin G]] or [[ampicillin]]
  
|[[penicillin G]] or [[ampicillin]]
 
|[[vancomycin]] or [[daptomycin]] or [[linezolid]]
  
|[[vancomycin]] or [[daptomycin]] or [[linezolid]]
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|[[ciprofloxacin]] or [[ceftazidime]]
  
|[[ciprofloxacin]] or [[ceftazidime]]
 
|-
  
|-
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|[[Enterobacter species]]
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|[[Enterobacter]]
 
|[[cefepime]]
  
|[[cefepime]]
 
|[[ciprofloxacin]]
  
|[[ciprofloxacin]]
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!Alternative treatment
  
!Alternative treatment
 
|-
  
|-
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|[[Staphylococcus species]] (oxacillin-susceptible)
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|[[Staphylococcus]] (oxacillin-susceptible)
 
|[[Cephalexin]] 500 mg PO tid to qid;
 
|[[Cephalexin]] 500 mg PO tid to qid;
 
[[Cefadroxil]] 500 mg PO bid
  
[[Cefadroxil]] 500 mg PO bid
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[[Amoxicillin-clavulanic acid]] 500mg PO tid
  
[[Amoxicillin-clavulanic acid]] 500mg PO tid
 
|-
  
|-
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|[[Staphylococcus species]] (oxacillin-resistant)
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|[[Staphylococcus]] (oxacillin-resistant)
 
|[[TMP-SMX]] DS 1 tab PO bid;
 
|[[TMP-SMX]] DS 1 tab PO bid;
 
[[Doxycycline]] 100 mg PO bid
  
[[Doxycycline]] 100 mg PO bid
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|[[Cephalexin]] 500 mg PO tid to qid
  
|[[Cephalexin]] 500 mg PO tid to qid
 
|-
  
|-
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|[[Enterococcus species]] (penicillin-susceptible)
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|[[Enterococcus]] (penicillin-susceptible)
 
|[[Penicillin V]] 500 mg PO bid to qid;
 
|[[Penicillin V]] 500 mg PO bid to qid;
 
[[Amoxicillin]] 500 mg PO tid
  
[[Amoxicillin]] 500 mg PO tid

Revision as of 15:44, 26 January 2022

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

Prognosis

  • Recurrent rates after DAIR are 9% (with 12 weeks of antibiotics) to 18% (with 6 weeks)1

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 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 — 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 (oxacillin-susceptible) nafcillin or cefazolin or ceftriaxone vancomycin or daptomycin or linezolid
Staphylococcus (oxacillin-resistant) vancomycin daptomycin
Enterococcus (penicillin-susceptible) penicillin G or ampicillin vancomycin or daptomycin or linezolid
Pseudomonas aeruginosa cefepime or meropenem ciprofloxacin or ceftazidime
Enterobacter 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 exist2
  • Alternatively , can potentially use rifabutin 300 mg PO daily3

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 (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 (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 (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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