Treatment of Prosthetic Joint Infections: Validation of a Surgical Algorithm and Proposal of a Simplified Alternative

Département de Microbiologie et Immunologie, Université de Montréal, Montréal, Canada.
The Journal of arthroplasty (Impact Factor: 2.67). 11/2012; 28(3). DOI: 10.1016/j.arth.2012.06.034
Source: PubMed


The Del Pozo and Patel (DPP) algorithm permits to identify suitable candidates for debridement and implant retention (DR) in prosthetic joint infections (PJI), but does not include gram-negative bacilli (GNB) as a risk factor of worst outcome. We conducted a retrospective study to validate the DPP algorithm and propose a simplified algorithm including GNB PJI. From 2002 to 2009, 73 PJI underwent surgery; 55% were chosen according to PDD algorithm. Non-adherence increased the risk of treatment failure (HR = 4.2). Performing DR in the presence of GNB PJI and performing DR in a joint prosthesis implanted for >3 months without hematogenous infection were independent risk factors. Our simplified algorithm, based on these 2 criteria, showed comparable performance to the DPP algorithm but increased eligibility for DR by a 2.4 fold.

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    ABSTRACT: In this prospective study, we evaluate the impact of adherence to a diagnostic and therapeutic protocol on prosthetic joint infections (PJI) diagnostic accuracy and outcome. Patients and methods Patients with early or delayed PJI referred over a 5-year period were included. Diagnosis was based on characteristic clinical signs, radiographic findings and microbiological evidence. Antibiotics were chosen on the basis of microbiological findings, and drugs active against methicillin-resistant staphylococci were administered if no microbiological evidence had been obtained. Results Inclusion criteria were met in 159 cases (median age 64 years, males 45%). 56 were early infections and 103 delayed infections. Comorbidities were reported in 99 (62%) cases. Positive cultures were obtained in 122/159 (77%), coagulase-negative staphylococci were cultured in 20%, Staphylococcus aureus in 28%, and Pseudomonas aeruginosa in 7%. In early infections, cure rate after debridement and antibiotic therapy was 80%. In delayed infections, cure rate after two-stage exchange was 85%. Of 28 patients with delayed infection treated with antibiotics without surgery, only 8 (29%) infections were suppressed 48 weeks after treatment discontinuation. Rifampin afforded a better outcome. Conclusion Appropriate diagnostic and surgical procedures and microbiologically driven antibiotic therapy including rifampin are recommended to improve diagnostic accuracy and outcome.
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    ABSTRACT: We aim to evaluate the epidemiology and outcome of gram-negative prosthetic joint infection (GN-PJI) treated with debridement, antibiotics, and implant retention (DAIR), identify factors predictive of failure, and determine the impact of ciprofloxacin use on prognosis. We performed a retrospective, multicenter, observational study of GN-PJI diagnosed from 2003 through 2010 in 16 Spanish hospitals. We define failure as persistence or reappearance of the inflammatory joint signs during follow-up leading to unplanned surgery or repeat debridement's > 30 days from the index surgery related death, or suppressive antimicrobial therapy. Parameters predicting failure were analyzed with a Cox regression model. A total of 242 patients (33% men; median age 76 years, interquartile range [IQR] 68-81) with 242 episodes of GN-PJI were studied. The implants included 150 (62%) hip, 85 (35%) knee, 5 (2%) shoulder, and 2 (1%) elbow prostheses. There were 189 (78%) acute infections. Causative microorganisms were Enterobacteriaceae in 78%, Pseudomonas spp. in 20%, and other gram-negative bacilli in 2%. Overall, 19% of isolates were ciprofloxacin resistant. DAIR was used in 174 (72%) cases, with an overall success rate of 68%, which increased to 79% after a median of 25 months’ follow-up in ciprofloxacin-susceptible GN-PJIs treated with ciprofloxacin. Ciprofloxacin treatment exhibited an independent protective effect (adjusted hazard ratio [aHR] 0.23, 95%CI, 0.13-0.40; P<0.001), whereas chronic renal impairment predicted failure (aHR, 2.56, 95%CI, 1.14-5.77; P=0.0232). Our results confirm a 79% success rate in ciprofloxacin-susceptible GN-PJI treated with debridement, ciprofloxacin, and implant retention. New therapeutic strategies are needed for ciprofloxacin-resistant PJI.This article is protected by copyright. All rights reserved.
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    ABSTRACT: Prosthetic joint infection (PJI) is a serious complication of arthroplasty that is associated with significant mortality, morbidity and costs. PJI is difficult to cure because causative bacteria form and persist in biofilm adherent to the prosthesis surface. PJI can be classified in to early, delayed or late according to the time of onset after insertion of the prosthesis and this classification can help determine pathogenesis and appropriate management. Traditional treatment has been with prolonged intravenous antibiotics and prosthesis exchange, which has been successful in treating infection but is technically difficult and has high rates of associated morbidity. On the basis of in vitro and animal studies, interest has turned to the use of antimicrobials that are particularly active against biofilm-associated bacteria. Recent clinical evidence shows success in more than 77% of early PJI with surgical debridement, retention of prosthesis and the use of rifampicin-based combinations for staphylococcal PJI. Fluoroquinolones are preferred for Gram-negative PJI. Optimal antimicrobial treatment duration and the management of polymicrobial, enterococcal, fungal and culture-negative infections is still yet to be defined but will become more clear as the results of current research comes to hand.
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