Optimal Irrigation and Debridement of Infected Total Joint Implants with Chlorhexidine Gluconate

doi:10.1016/j.arth.2015.05.005

The Journal of Arthroplasty

Volume 30, Issue 10, October 2015, Pages 1820-1822

https://doi.org/10.1016/j.arth.2015.05.005 Get rights and content

Abstract

Previous study at our institution demonstrated that scrubbing a methicillin-resistant Staphylococcus aureus (MRSA)-coated titanium disk with chlorhexidine gluconate (CG) solution achieved superior biofilm eradication compared to alternative solutions. The current study aimed to identify the minimum CG concentration for effective bacteria eradication of an in vitro periprosthetic joint infection (PJI) model. MRSA colony-forming units (CFUs) were counted following simulated irrigation and debridement with varying CG solutions before and after a 24-hour reincubation period. Significant decrease was noted on all disks before reincubation. Postreincubation, significant decrease in CFUs was found in the 4% and 2% groups. This study demonstrated that I + D of an infected PJI model with 4% CG solution was effective at treating MRSA biofilm at concentrations as low as 2%.

Section snippets

Background

Demand for total joint arthroplasty (TJA) has increased dramatically, with an estimated 770,000 total joint arthroplasties per year and a projected 4 million primary TJAs in the year 2030 [1]. Infection is the second most common complication, occurring in approximately 1–2% of cases [2]. Several options exist for the management of periprosthetic joint infection (PJI), depending on the onset of infection relative to prosthetic implantation. For treatment of a chronic infection, defined by

Bacterial Strain

Due to its high incidence as a pathogen in periprosthetic joint infections MRSA was chosen as our experimental bacteria 16., 17.. The USA300 subtype of MRSA was chosen for this study due to its tendency to form biofilm. The MRSA was suspended in a liquid culture of trypticase soy broth (TSB) and incubated at 37 °C overnight.

Biofilm Production and Verification

Biofilm was grown by inoculating 1:40 dilution of overnight MRSA culture (~ 1 × 10⁸ cells) in 3 mL TSB onto each of 9 titanium alloy (Ti-6Al-4v) disks (Stryker, Mahwah, NJ) in

Group 1: Without Reincubation

Group A, the positive control, showed the highest level of bacterial growth. The 2% CG (group C) had the fewest CFUs. The 1% solution (group D) had the next fewest CFUs, followed by the 0.5% (group E), 4% (group B), and finally the 0.25% solution (group F) (Fig. 2).

Group 2: With Reincubation

Again, the positive control (group A), had the most CFUs while the 2% solution (group C), had the fewest, followed by the 4% solution (group B) had the next fewest CFUs. Groups D–F each had significantly more CFUs than both groups B

Discussion

The results without reincubation indicate that CG scrub is effective in eliminating MRSA from a titanium disk at a variety of concentrations ranging from 4% to 0.25%. While the data suggest that the 2% solution eradicated a higher percentage of bacteria than the 4%, the difference between the two is not statistically significant, and supports our hypothesis that CG scrub eliminated biofilm in a dose-dependent manner. However, in vivo, the operative wound is closed, allowing bacteria a moist,

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Cited by (39)

The Impact of Exchanging Cerclage Fixation after Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty for Periprosthetic Joint Infection
2023, Journal of Arthroplasty
An extended trochanteric osteotomy (ETO) is a powerful tool for femoral component revision. There is limited evidence that directly supports its use in the setting of a periprosthetic joint infection (PJI). Cerclage fixation raises the theoretical concern for persistent infection.
Our institutional database included 76 ETOs for revision hip arthroplasty between January 1, 2008 and December 31, 2019. The cohort was divided based on indication for femoral component revision: PJI versus aseptic revision. The PJI group was subdivided based on second-stage exchange versus retention of initial cerclage fixation. Operative time, estimated blood loss, complications, and rate of repeat revision surgery were evaluated.
Forty-nine patients (64%) underwent revision for PJI and 27 patients (36%) underwent aseptic revision. There was no significant difference in operative times (P = .082), postoperative complications (P = .258), or rate of repeat revision surgery (P = .322) between groups. Of the 49 patients in the PJI group, 40 (82%) retained cerclage fixation while 9 (18%) had cerclage exchange. Cerclage exchange did not significantly impact operative time (P = .758), blood loss (P = .498), rate of repeat revision surgery (P = .302), or postoperative complications (P = .253) including infection (P = .639).
An ETO remains a powerful tool for femoral component removal, even in the presence of a PJI. A multi-institutional investigation would be required to validate observed trends toward better infection control with cerclage exchange. Cerclage exchange did not appear to increase operative time, blood loss, or postoperative complication rates.
Irrigation Solutions and Antibiotic Powders: Should I Use Them in Primary and Revision Total Joint Arthroplasty?
2022, Journal of Arthroplasty
The prevention and treatment of periprosthetic joint infection is of utmost importance to orthopedic surgeons. Irrigation solutions have become a popular additive to the prevention and treatment armamentarium.
This symposium summarizes the mechanism of action, basic science, and clinical research to date on the use of irrigation solutions. The four most commonly used irrigation solutions, povidone iodine, chlorhexidine, hydrogen peroxide, and acetic acid, are discussed. In addition, the role of antibiotic powers is reviewed.
Each solution has its risks and benefits that must be weighed by the surgeon. There is no clear irrigation solution that is superior. The role of additive antibiotic powder (vancomycin) remains controversial.
More rigorous prospective clinical trials are needed to determine the optimal irrigation solution for the prevention and treatment of periprosthetic joint infection.
Mark Coventry Award: Efficacy of Saline Wash Plus Antibiotics Doped Polyvinyl Alcohol (PVA) Composite (PVA-VAN/TOB-P) in a Mouse Pouch Infection Model
2022, Journal of Arthroplasty
Citation Excerpt :
An earlier burst release of VAN at higher concentration right after ceramic implantation provided sufficient inhibition of bacterial growth at surgical infection sites, while the slow and sustained TOB release afterward is expected to provide the prevention of residual bacterial adhesion, growth, biofilm formation, and minimize any local or systemic toxicity associated with high fluctuating antibiotic concentrations. There are studies suggesting that in the presence of metallic prosthesis, mechanical and/or chemical agents should be used in addition to saline irrigation to help eliminate the adherent bacteria and biofilms attached to the prosthesis [38]. Although we intend to test these sorts of materials in the future, we focused on the remnant/retained suture materials that may be used to repair ligaments or tendons, to close capsule, deep or superficial tissues.
The efficacy of saline irrigation for treatment of periprosthetic infection (PJI) is limited by the presence of contaminated medical devices. This study evaluated treatment efficacy of locally placed polyvinyl alcohol (PVA)/bioceramic composite doped with vancomycin (PVA-VAN-P) or vancomycin and tobramycin (PVA-VAN/TOB-P) after saline irrigation in a mouse pouch infection model.
Sutures were implanted into air pouches of BALB/cJ mice, then inoculated with Staphylococcus aureus. Mice were randomized into 6 groups (n = 6 each): (1) no bacteria; (2) bacteria without saline wash; (3) saline wash only; (4) saline wash + PVA-P; (5) saline wash + PVA-VAN-P, and (6) saline wash + PVA-VAN/TOB-P. After 7 days, pouches were washed with saline alone or with additional injection of 0.2 mL of the composites. Sacrifice occurred 14 days after the washout. Histology was performed on the pouch tissues and bacteria cultures on the washout fluid.
Bacterial culture (optical density) showed that infection persisted after saline irrigation (0.10 ± 0.14) but was effectively eradicated by the addition of PVA-VAN-P (0.05 ± 0.09) and PVA-VAN/TOB-P (0.002 ± 0.003, P < .05). These effects were confirmed by histology. Importantly, no residues of the PVA-P were detected in either the pouch washouts or pouch tissues.
PJI is common and problematic, and few innovations have changed clinical practice and/or outcome. Our data confirmed that the effect of saline irrigation was very limited in the presence of contaminated sutures. PVA-VAN/TOB-P was biodegradable, biocompatible, and effective in eradicating bacterial retention after saline irrigation. Application of PVA-VAN/TOB-P after saline irrigation could be an option for treatment of PJI and should be evaluated in future PJI animal models.
What Is the Duration of Irrigation? An In Vitro Study of the Minimum Exposure Time to Eradicate Bacteria With Irrigation Solutions
2022, Journal of Arthroplasty
Citation Excerpt :
This could have affected results as some solutions have shown efficacy at greater concentrations than in the commercially available products. For example, chlorhexidine has been shown to eradicate bacteria in vitro after 1 minute of exposure, but at a higher concentration of 2% [26]. Third, we selected 2 of the most common species of bacteria causing PJI: S aureus and S epidermidis.
Antiseptic irrigation solutions are commonly used by arthroplasty surgeons to reduce intraoperative bacterial colonization with the goal of reducing postoperative infections in the setting of primary total joint arthroplasty. Currently, the minimum irrigation time to eliminate common microbes implicated in periprosthetic joint infection is unknown. We sought to determine the minimum effective exposure time required to prevent growth of Staphylococcus aureus, Staphylococcus epidermidis, and Cutibacterium acnes with common antiseptic solutions.
S aureus, S epidermidis, and C acnes cultures were treated with povidone-iodine (0.35%), chlorhexidine (0.05%), sodium hypochlorite (0.5%), polyhexamethylene biguanide, and an acetic acid–based solution for 15, 30, 60, 90, and 120 seconds in triplicate. Bacterial growth was quantified using the drop plate method. Failure to eliminate all bacteria was considered “not effective” at that time point.
Povidone-iodine 0.35% (Betadine), sodium hypochlorite 0.5% (HySept), and acetic acid (Bactisure) eradicated all bacterial growth after 90 seconds of treatment, and as low as 15 seconds in S aureus and C acnes (Betadine) or S epidermidis (Bactisure). Polyhexamethylene biguanide (Prontosan) required 90 seconds for elimination of S aureus and S epidermidis, and 120 seconds for C acnes. Chlorhexidine 0.05% (Irrisept) did eliminate S epidermidis at 120 seconds but did not effectively eradicate S aureus or C acnes.
All tested antiseptic solutions demonstrated successful eradication of all bacterial growth in under 2 minutes of treatment time except chlorhexidine. Povidone-iodine may require the shortest duration of treatment time to successfully eradicate common bacteria.
What Is the Optimal Irrigation Solution in the Management of Periprosthetic Hip and Knee Joint Infections?
2021, Journal of Arthroplasty
Citation Excerpt :
Penn-Barwell et al [83] compared 3 CHG concentrations (0.5%, 0.05%, 0.005%) and found no bacterial load difference of S aureus between multiple CHG concentrations. However, Smith et al [84] investigated the optimal concentration of CHG and found that concentrations >2% were needed to provide persistent decrease in biofilm burden. Although lower CHG concentrations decreased biofilm, the authors reported a rebound biofilm growth with prolonged incubation proposing that lower concentrations are likely to be ineffective in vivo [81,84].
Thorough irrigation and debridement using an irrigation solution is a well-established treatment for both acute and chronic periprosthetic joint infections (PJIs). In the absence of concrete data, identifying the optimal irrigation agent and protocol remains challenging.
A thorough review of the current literature on the various forms of irrigations and their additives was performed to evaluate the efficacy and limitations of each solution as pertaining to pathogen eradication in the treatment of PJI. As there is an overall paucity of high-quality literature comparing irrigation additives to each other and to any control, no meta-analyses could be performed. The literature was therefore summarized in this review article to give readers concise information on current irrigation options and their known risks and benefits.
Antiseptic solutions include povidone-iodine, chlorhexidine gluconate, acetic acid, hydrogen peroxide, sodium hypochlorite, hypochlorous acid, and preformulated commercially available combination solutions. The current literature suggests that intraoperative use of antiseptic irrigants may play a role in treating PJI, but definitive clinical studies comparing antiseptic to no antiseptic irrigation are lacking. Furthermore, no clinical head-to-head comparisons of different antiseptic irrigants have identified an optimal irrigation solution.
Further high-quality studies on the optimal irrigation additive and protocol for the management of PJI are warranted to guide future evidence-based decisions.
Clinical Evidence of Current Irrigation Practices and the Use of Oral Antibiotics to Prevent and Treat Periprosthetic Joint Infection
2021, Orthopedic Clinics of North America

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: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.05.005.

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The Journal of Arthroplasty

Abstract

Section snippets

Background

Bacterial Strain

Biofilm Production and Verification

Group 1: Without Reincubation

Group 2: With Reincubation

Discussion

References (24)

Trends in the treatment of orthopaedic prosthetic infections

J Antimicrob Chemother

Infection after total hip arthroplasty: a study of one hundred and six infections

J Bone Joint Surg

Diagnosis and management of infected total knee arthroplasty

Open Orthop J

Descriptive analysis of the economic costs of periprosthetic joint infection of the knee for the public health system of Andalusia

J Arthroplasty

Two-stage reimplantation for the salvage of total knee arthroplasty complicated by infection. further follow-up and refinement of indications

J Bone Joint Surg Am

Direct demonstration of viable Staphylococcus aureus biofilms in an infected joint arthroplasty

J Bone Joint Surg Am

Optimal irrigation and debridement of infected joint implants: an in vitro methicillin-resistant Staphylococcus aureus biofilm model

J Arthroplasty

Mechanisms underlying chlorhexidine-induced cytotoxicity

Toxicol in Vitro

Chlorhexidine ototoxicity in ear surgery, part 1: review of the literature

J Otolaryngol Head Neck Surg

Ocular surface reconstruction after exposure to high concentrations of antiseptic solutions

Cornea

Chlorhexidine as a canal irrigant: a review

Compend Contin Educ Dent

Cited by (39)

The Impact of Exchanging Cerclage Fixation after Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty for Periprosthetic Joint Infection

Irrigation Solutions and Antibiotic Powders: Should I Use Them in Primary and Revision Total Joint Arthroplasty?

Mark Coventry Award: Efficacy of Saline Wash Plus Antibiotics Doped Polyvinyl Alcohol (PVA) Composite (PVA-VAN/TOB-P) in a Mouse Pouch Infection Model

What Is the Duration of Irrigation? An In Vitro Study of the Minimum Exposure Time to Eradicate Bacteria With Irrigation Solutions

What Is the Optimal Irrigation Solution in the Management of Periprosthetic Hip and Knee Joint Infections?

Clinical Evidence of Current Irrigation Practices and the Use of Oral Antibiotics to Prevent and Treat Periprosthetic Joint Infection