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Prolonged suppressive antibiotic therapy is successful in the management of prosthetic joint infection

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Introduction Prosthetic joint infection (PJI) remains one of the major challenges facing orthopaedic surgeons. There is a paucity of evidence on non-operative management of PJI. We present the results of prolonged antibiotic suppression therapy (PSAT) in PJI from a single centre. Methods A retrospective study was performed. Twenty-six patients were included. Two patients were excluded due to the lack of follow-up data. Failure was defined as admission for sepsis from the joint or amputation. Results Average age was 72 years (range 35–93). Mean Charlson co-morbidity index was 4.3. Mean follow-up was 3.2 years (range 1.3–5.7). Staphylococcal species were isolated in 11 cases (44%) (MRSA 1, MSSA 5, Staph. epidermidis 4 and Staph Pasteuri 1). Other bacteria included E. Coli (2), Streptococci spp. (3), Propionebacterium acnes (1) and Pseudomonas aeruginosa (1). Four cases were polymicrobial infection (16%), and no organisms were identified in two cases (8%). Candida albicans was identified in one case. All cases of bacterial infection were treated with prolonged oral doxycycline or amoxicillin. Twenty patients (80%) received 6 weeks of intravenous antibiotics prior to commencing prolonged oral antibiotics. Two patients experienced persistent symptoms and required amputation (both TKA). Two patients experienced sepsis but were treated successfully with IV antibiotics alone. The success rate of PSAT was 84% (21/25) successful at an average 3.2-year follow-up. Discussion and conclusion Prolonged suppressive antibiotic therapy is a viable option for the management of PJI with a low incidence of complications.
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European Journal of Orthopaedic Surgery & Traumatology (2020) 30:313–321
https://doi.org/10.1007/s00590-019-02559-4
ORIGINAL ARTICLE • KNEE - ARTHROPLASTY
Prolonged suppressive antibiotic therapy issuccessful
inthemanagement ofprosthetic joint infection
N.A.Sandiford1 · J.R.Hutt1· D.O.Kendo2· P.A.Mitchell1· M.Citak3· L.Granger1
Received: 21 April 2019 / Accepted: 23 September 2019 / Published online: 1 October 2019
© Springer-Verlag France SAS, part of Springer Nature 2019
Abstract
Introduction Prosthetic joint infection (PJI) remains one of the major challenges facing orthopaedic surgeons. There is a
paucity of evidence on non-operative management of PJI. We present the results of prolonged antibiotic suppression therapy
(PSAT) in PJI from a single centre.
Methods A retrospective study was performed. Twenty-six patients were included. Two patients were excluded due to the
lack of follow-up data. Failure was defined as admission for sepsis from the joint or amputation.
Results Average age was 72years (range 35–93). Mean Charlson co-morbidity index was 4.3. Mean follow-up was 3.2years
(range 1.3–5.7). Staphylococcal species were isolated in 11 cases (44%) (MRSA 1, MSSA 5, Staph. epidermidis 4 and Staph
Pasteuri 1). Other bacteria included E. Coli (2), Streptococci spp. (3), Propionebacterium acnes (1) and Pseudomonas aer-
uginosa (1). Four cases were polymicrobial infection (16%), and no organisms were identified in two cases (8%). Candida
albicans was identified in one case. All cases of bacterial infection were treated with prolonged oral doxycycline or amoxi-
cillin. Twenty patients (80%) received 6weeks of intravenous antibiotics prior to commencing prolonged oral antibiotics.
Two patients experienced persistent symptoms and required amputation (both TKA). Two patients experienced sepsis but
were treated successfully with IV antibiotics alone. The success rate of PSAT was 84% (21/25) successful at an average
3.2-year follow-up.
Discussion and conclusion Prolonged suppressive antibiotic therapy is a viable option for the management of PJI with a low
incidence of complications.
Keywords PJI· Infection· Prosthetic joint infection· Suppressive antibiotics· Revision· PSAT
Introduction
The incidence of prosthetic joint infection (PJI) is 1–2% and
followed by total joint arthroplasty is expected to rise as the
total number of primary hip and knee arthroplasties per-
formed each year increases [1]. It remains one of the main
reasons for revision total hip and revision total knee arthro-
plasty. Management is often prolonged, resource intensive
and expensive. If treatment strategies such as debridement
and implant retention (DAIR) and single- or two-stage
revision fail, the surgeon may be forced to consider sal-
vage options such as excision arthroplasty, arthrodesis or
amputation [2]. However, if the patient is not fit for surgery,
declines further surgery or all surgical options have been
exhausted, suppression therapy with long-term antibiotics
has been described [3]. Several terms have been coined for
long-term administration of suppressive antibiotics includ-
ing prolonged antibiotic suppression therapy (PSAT) and
antibiotic suppression therapy (AST). Antibiotic suppres-
sion therapy can be defined as the administration of antibi-
otics for an extended period, potentially lifelong, to prevent
episodes of sepsis arising from the joint, improve symp-
toms and prevent or prolong progression to further surgery.
Indications for PSAT are a defined organism and sensitiv-
ity profile; a safe oral antibiotic that is compatible with the
organism susceptibility; and a system to facilitate continued
follow-up and monitoring of the patient in the community.
* N. A. Sandiford
nemsandiford@gmail.com
1 The Complex Arthroplasty Unit, St George’s Hospital,
London, UK
2 Chefarzt Zentrum für Orthopädie und Unfallchirurgie, Berlin,
Germany
3 Helios EndoKlinik, Hamburg, Germany
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... In this subset of patients, nonoperative treatment has to be considered. There is a relative paucity of data available on the outcomes of the management of PJI with prolonged suppressive antibiotic therapy (PSAT) [7]. This article presents a brief but comprehensive review of the role of PSAT in the management of PJI. ...
... Contemporary results vary with regard to the results of suppressive therapy. Sandiford et al. found that 83% of patients treated with PSAT were infection free at mean 2-year follow-up [7]. These encouraging results were attributed to modern approaches to management such as having a multidisciplinary team (MDT) approach. ...
... These encouraging results were attributed to modern approaches to management such as having a multidisciplinary team (MDT) approach. The importance of MDTs has been highlighted in the literature [7]. Rao et al. [12] reported encouraging results at a mean 5-year follow-up after rapid, accurate detection of the infecting species followed by surgical management after which PSAT therapy was commenced, with functioning prostheses in 86.2%. ...
... It is noteworthy that with infection-free survival reaching 60%, numbers in chronic antibiotic suppression are not far from two-stage revision (true success rate of approximately 65%) [55]. Another study by Sandiford et al. evaluated 26 patients receiving prolonged antibiotic suppression therapy and showed a success rate as high as 84% [82]. In their study, only four patients had an event, two had persistent symptoms and underwent amputation, and two had sepsis successfully managed with intravenous antibiotics [82]. ...
... Another study by Sandiford et al. evaluated 26 patients receiving prolonged antibiotic suppression therapy and showed a success rate as high as 84% [82]. In their study, only four patients had an event, two had persistent symptoms and underwent amputation, and two had sepsis successfully managed with intravenous antibiotics [82]. Prolonged suppressive antibiotic therapy seems to be a viable option for selected patients with PJI. ...
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... When surgery is not a viable option or patients have a low life expectancy, suppressive antibiotic therapy can be considered. A recent publication presents the results of 26 patients treated with suppressive antibiotic therapy for PJI of the hip or the knee, describing a success rate of 84% at an average follow-up of 3 years [19]. In a multicenter cohort study of 136 elderly patients, suppressive treatment for PJI was considered a reasonable alternative despite having up to 33% of adverse drug reactions [20]. ...
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... 32 For instance, Prendki et al. recorded that 60% of (n = 38) patients in the age range 80-95 years remained event-free during 2 years of prolonged suppressive antibiotic therapy., 33 Other authors have shown a high success rate (84% of n = 26 patients) for prolonged antibiotic suppression therapy. 34 Additionally, a significantly higher infection-related mortality rate was found in the geriatric population, which is in line with other findings showing that PJI-related death is more common in older patients (6.5% vs .8%, P < .05). ...
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... The surface of prosthetic joints can become infected with biofilms and in many instances antibiotic failure results in surgical replacement. These infections can sometimes appear years after the original surgery and may result in sepsis 40 . There are currently few viable alternatives to surgical treatment 41 . ...
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... The variability in the results may be explained by the heterogeneity of the cohorts, the influence of the duration of the symptoms and of the causative microorganisms, variable definitions of success, and differing follow-up periods. Even a hard outcome, such as reoperation, may result in differences in analysis, as the persistence of infection is not necessarily diagnosed or reoperated and a suppressive antibiotic treatment is possibly started instead (Prendki et al., 2017;Sandiford et al., 2020). Repeated DAIR procedures may also be successful, with persistence of infection after a first DAIR not necessarily requiring component removal (Grammatopoulos et al., 2017b;Wouthuyzen-Bakker et al., 2020). ...
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Background: Debridement-antibiotics-and-implant-retention (DAIR) may be considered a suitable surgical option in periprosthetic joint infections (PJIs) with soundly fixed prostheses, despite chronicity. This study aims to define the long-term outcome following DAIR in hip PJI. Methods: We reviewed all hip DAIRs performed between 1997 and 2013 (n = 122) to define long-term outcome and identify factors influencing it. Data recorded included patient demographics, medical history, type of DAIR performed (+/- exchange of modular components), and organisms identified. Outcome measures included complications and/or mortality rate, implant survivorship, and functional outcome (Oxford Hip Score). Results: Most DAIRs (67%) were of primary arthroplasties and 60% were performed within 6 weeks from the index arthroplasty. Infection eradication was achieved in 68% of the first DAIR procedure. In 32 cases, more than one DAIR was required. Infection eradication was achieved in 85% of the cases (104/122) with the (single or multiple) DAIR approach. The most common complication was PJI-persistence (15%), followed by dislocation (14%). Very good functional outcomes were obtained, especially in primary arthroplasties. All streptococcus infections were resolved with DAIR and had better outcome. Twenty-one hips have been revised (17%) to-date, 16 were for persistence of PJI. The 10-y implant survivorship was 77%. Early PJI and exchanging modular components at DAIR were independent factors for a 4-fold increased infection eradication and improved long-term implant survival. Conclusion: DAIR is, therefore, a valuable option in the treatment of hip PJI, especially in the early postoperative period (≤6 weeks), with good outcomes. However, DAIR is associated with increased morbidity; further surgery may be necessary and instability may occur. Where possible, exchange of modular implants should be undertaken.
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The objective of this study was to develop a prospectively applicable method for classifying comorbid conditions which might alter the risk of mortality for use in longitudinal studies. A weighted index that takes into account the number and the seriousness of comorbid disease was developed in a cohort of 559 medical patients. The 1-yr mortality rates for the different scores were: "0", 12% (181); "1-2", 26% (225); "3-4", 52% (71); and "greater than or equal to 5", 85% (82). The index was tested for its ability to predict risk of death from comorbid disease in the second cohort of 685 patients during a 10-yr follow-up. The percent of patients who died of comorbid disease for the different scores were: "0", 8% (588); "1", 25% (54); "2", 48% (25); "greater than or equal to 3", 59% (18). With each increased level of the comorbidity index, there were stepwise increases in the cumulative mortality attributable to comorbid disease (log rank chi 2 = 165; p less than 0.0001). In this longer follow-up, age was also a predictor of mortality (p less than 0.001). The new index performed similarly to a previous system devised by Kaplan and Feinstein. The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies. Further work in larger populations is still required to refine the approach because the number of patients with any given condition in this study was relatively small.
Article
The clinical benefit of chronic suppression with oral antibiotics as a salvage treatment for periprosthetic joint infection is unclear. The purpose of this study was to compare infection-free prosthetic survival rates between patients who received chronic oral antibiotics and those who did not following irrigation and debridement with polyethylene exchange or two-stage revision for periprosthetic joint infection. We reviewed the records on all irrigation and debridement procedures with polyethylene exchange and two-stage revisions performed at our institution from 1996 to 2010 for hip or knee periprosthetic joint infection. Of 625 patients treated with a total of 655 eligible revisions, ninety-two received chronic oral antibiotics for a minimum of six months and were eligible for inclusion in our study. These patients were compared with a matched cohort (ratio of 1:3) who did not receive chronic oral antibiotics. The five-year infection-free prosthetic survival rate was 68.5% (95% confidence interval [CI] = 59.2% to 79.3%) for the antibiotic-suppression group and 41.1% (95% CI = 34.9% to 48.5%) for the non-suppression group (hazard ratio [HR] = 0.63, p = 0.008). Stratification by the type of surgery and the infecting organism showed a higher five-year survival rate for the patients in the suppression group who underwent irrigation and debridement with polyethylene exchange (64.7%) compared with those in the non-suppression group who underwent irrigation and debridement with polyethylene exchange (30.4%, p < 0.0001) and a higher five-year survival rate for the patients in the suppression group who had a Staphylococcus aureus infection (57.4%) compared with those in the non-suppression group who had a Staphylococcus aureus infection (40.1%, p = 0.047). Chronic suppression with oral antibiotics increased the infection-free prosthetic survival rate following surgical treatment for periprosthetic joint infection. Patients who underwent irrigation and debridement with polyethylene exchange and those who had a Staphylococcus aureus infection had the greatest benefit. Therapeutic Level III. See the Instructions for Authors for a complete description of levels of evidence. Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.