Oral Therapy, Microbiological Findings, and Comorbidity Influence the Outcome of Prosthetic Joint Infections Undergoing 2-Stage Exchange

doi:10.1016/j.arth.2017.02.057

The Journal of Arthroplasty

Volume 32, Issue 7, July 2017, Pages 2239-2243

https://doi.org/10.1016/j.arth.2017.02.057 Get rights and content

Abstract

Background

The aim of the present study was to investigate potential predictive factors of an unfavorable outcome in patients with prosthetic joint infection (PJI) undergoing 2-stage exchange.

Methods

Patients with PJI undergoing 2-stage exchange and observed over a 5-year period (2009-2013) were included. Cure was defined by the disappearance of infection after a 96-week follow-up period. Statistical analysis was performed using the Mann-Whitney U test, the Fisher exact test, and the multivariate analysis.

Results

One-hundred twenty-two patients with PJI were included (median age, 69 years [range, 36-80 years]; 48% males, 47 hip PJI, and 75 knee PJI). Known comorbidities related to an increased risk of infection were reported in 43 patients (35%). Microbiological definition was obtained in 101 (83%) patients, and Staphylococcus aureus was isolated in 44 (36%) patients. Coagulase-negative staphylococci were isolated in 41 (34%) patients. A favorable outcome was obtained in 102 of 122 patients (84%). After univariate analysis, bacterial growth from operative specimens (P = .007), growth of Gram-positive bacteria (P < .001), use of oral therapy (P = .01), and absence of known comorbidities (P = .02) were associated with favorable outcome. Administration of rifampin (P = .99) and results of blood analysis were not predictive of outcome. After multivariate analysis was applied, infection sustained by Gram-positive bacteria, administration of oral antibiotics, and absence of known comorbidities frequently resulted in favorable outcome.

Conclusion

A favorable outcome in patients with PJI undergoing 2-stage procedure was associated with an infection sustained by Gram-positive bacteria, absence of known comorbidities, and administration of oral therapy. Therefore, failure rate can be reduced with appropriate treatment choices.

Section snippets

Materials and Methods

This was a cohort study including consecutive patients with PJI undergoing 2-stage exchange, who were referred to our Department of Infectious Diseases over a 5-year period (2009-2013) for ID consultation. The research was conducted in accordance with the Declaration of Helsinki and national and institutional standards, and patients gave their informed consent before being included in this observational study.

When the study was planned, diagnosis of PJI had to be defined by at least 3 of the

Results

One hundred twenty-two patients with PJI were included in the study. The median age was 69 years (range, 36-80 years), and 48% were males. Previous surgery was hip arthroplasty in 47 (39%) cases and knee arthroplasty in 75 (61%). One hundred seven patients (88%) had a delayed infection, and 15 (12%) had an early infection failure after DAIR. A value for CCI >2 was reported in 71 (59%) cases. Known comorbidities related to an increased risk of infection were reported in 43 (35%) patients, and

Discussion

Patients failing treatment after 2-stage revision of an infected prosthetic implant report a definitive disability despite the efforts of physicians and the resources used [2]. In this study, we attempted to identify the factors related to an unfavorable outcome in a cohort of patients undergoing the 2-stage procedure, who were consecutively observed in our center for an ID consultation.

In our study, no association between CCI and a successful procedure was reported, but patients with

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Cited by (35)

Short Course of Oral Antibiotic Treatment After Two-Stage Exchange Arthroplasty Appears to Decrease Early Reinfection
2023, Journal of Arthroplasty
Recent evidence has suggested a benefit to extended postoperative prophylactic oral antibiotics after two-stage exchange arthroplasty for treatment of periprosthetic joint infections. We sought to determine reinfection rates with and without a short course of oral antibiotics after two-stage exchange procedures.
A retrospective review identified patients undergoing two-stage exchange arthroplasty for periprosthetic joint infection of the hip or knee. Patients were excluded if they failed a prior two-stage exchange, had positive cultures at reimplantation, prolonged intravenous antibiotics postoperatively, and/or life-long suppression. This resulted in 444 reimplantations (210 hips and 234 knees). Patients were divided into three cohorts based on the duration of oral antibiotics after reimplantation: no antibiotics (102), ≤2 weeks (266), or >2 weeks (76). The primary endpoint was reinfection within 1 year of reimplantation.
Within 1 year of reimplantation, there were 34 reinfections. In the no-antibiotic, ≤ 2-week, and >2-week cohorts the reinfection rates were 14.1, 7.0, and 6.4%, respectively. Multivariate Cox regression showed a reduced reinfection rate in the ≤2-week cohort relative to no antibiotics (hazard ratio [HR]: 0.38, P = .01). While the smaller cohort with >2 weeks of antibiotics did not significantly reduce the reinfection rate (HR: 0.41, P = .12), when combined with the ≤2-week cohort, use of oral antibiotics had an overall reduction of the reinfection rate (HR: 0.39, P = .01).
These data support the hypothesis that a short course of oral antibiotics after reimplantation decreases the 1-year reinfection rate. Future randomized studies should seek to examine the efficacy of different durations of oral antibiotics to reduce reinfection.
Prognostic Level IV.
The Use of Rifampin in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis of Comparative Studies
2022, Journal of Arthroplasty
Periprosthetic joint infection (PJI) is a devastating complication of total joint arthroplasty (TJA). Rifampin is an antibiotic with the ability to penetrate bacterial biofilms, and thus has been considered as a potentially important adjunct in the prevention and treatment of PJI. The aim of this systematic review is to evaluate and summarize the use of rifampin in TJA, particularly in the context of PJI.
A literature search of all relevant electronic databases was performed. All comparative studies assessing the use of rifampin in the context of TJA were included. Descriptive data are reported, and a meta-analysis was performed using all studies which compared the addition of rifampin to standard care in treating PJI.
A total of 33 studies met inclusion criteria. A meta-analysis of 22 studies comparing the addition of rifampin to standard care for treating PJI found a significant reduction in failure rates (26.0% vs 35.9%; odds ratio 0.61, 95% confidence interval 0.43-0.86). The protective effect of rifampin was maintained in studies which included exchange arthroplasty as a treatment strategy, but not in studies only using an implant retention strategy. Among studies reporting adverse events of rifampin, there was a 20.5% adverse event rate.
Overall, rifampin appears to confer a protective effect against treatment failure following PJI. This treatment effect is particularly pronounced in the context of exchange arthroplasty. Further high-level evidence is needed to clarify the exact indications and doses of rifampin which can most effectively act as an adjunct in the treatment of PJI.
Level III, Systematic Review and Meta-Analysis of Level I-III Studies.
High Mortality After Total Knee Arthroplasty Periprosthetic Joint Infection is Related to Preoperative Morbidity and the Disease Process but Not Treatment
2022, Journal of Arthroplasty
Citation Excerpt :
Examination of specific preoperative comorbidities revealed higher rates of congestive heart failure (CHF) and less patients with zero comorbidities in the septic revision TKA cohort. The correlation between increased morbidity and worse postoperative outcomes is well established [2,3,10,33–35]. CHF and chronic pulmonary disease have been shown to be independent predictors for the development of PJI [10,19,36].
Periprosthetic joint infection (PJI) mortality rate is approximately 20%. The etiology for high mortality remains unknown. The objective of this study was to determine whether mortality was associated with preoperative morbidity (frailty), sequalae of treatment, or the PJI disease process itself.
A multicenter observational study was completed comparing 184 patients treated with septic revision total knee arthroplasty (TKA) to a control group of 38 patients treated with aseptic revision TKA. Primary outcomes included time and the cause of death. Secondary outcomes included preoperative comorbidities and Charlson Comorbidity Index (CCMI) measured preoperatively and at various postoperative timepoints.
The septic revision TKA cohort experienced earlier mortality compared to the aseptic cohort, with a higher mortality rate at 90 days, 1, 2, and 3 years after index revision surgery (P = .01). There was no significant difference for any single cause of death (P > .05 for each). The mean preoperative CCMI was higher (P = .005) in the septic revision TKA cohort. Both septic and aseptic cohorts experienced a significant increase in CCMI from the preoperative to 3 years postoperative (P < .0001 and P = .002) and time of death (P < .0001 both) timepoints. The septic revision TKA cohort had a higher CCMI 3 years postoperatively (P = .001) and at time of death (P = .046), but not one year postoperatively (P = .119).
Compared to mortality from aseptic revision surgery, septic revision TKA is associated with earlier mortality, but there is no single specific etiology. As quantified by changes in CCMI, PJI mortality was associated with both frailty and the PJI disease process, but not treatment.
Reply to the Letter to the Editor on “Continuous Antibiotic Therapy Can Reduce Recurrence of Prosthetic Joint Infection in Patients Undergoing 2-Stage Exchange” by Castaño et al
2019, Journal of Arthroplasty
Timing of implant-removal in late acute periprosthetic joint infection: A multicenter observational study
2019, Journal of Infection
Citation Excerpt :
A periprosthetic joint infection (PJI) is a serious complication after joint arthroplasty and is accompanied by increased morbidity and mortality.1,2
We evaluated the treatment outcome in late acute (LA) periprosthetic joint infections (PJI) treated with debridement and implant retention (DAIR) versus implant removal.
In a large multicenter study, LA PJIs of the hip and knee were retrospectively evaluated. Failure was defined as: PJI related death, prosthesis removal or the need for suppressive antibiotic therapy. LA PJI was defined as acute symptoms <3 weeks in patients more than 3 months after the index surgery and with a history of normal joint function.
445 patients were included, comprising 340 cases treated with DAIR and 105 cases treated with implant removal (19% one-stage revision (n = 20), 74.3% two-stage revision (n = 78) and 6.7% definitive implant removal (n = 7). Overall failure in patients treated with DAIR was 45.0% (153/340) compared to 24.8% (26/105) for implant removal (p < 0.001). Difference in failure rate remained after 1:1 propensity-score matching. A preoperative CRIME80-score ≥3 (OR 2.9), PJI caused by S. aureus (OR 1.8) and implant retention (OR 3.1) were independent predictors for failure in the multivariate analysis.
DAIR is a viable surgical treatment for most patients with LA PJI, but implant removal should be considered in a subset of patients, especially in those with a CRIME80-score ≥3.
Continuous Antibiotic Therapy Can Reduce Recurrence of Prosthetic Joint Infection in Patients Undergoing 2-Stage Exchange
2019, Journal of Arthroplasty
Citation Excerpt :
This beneficial outcome was higher among the immunocompromised patients. An association between the presence of comorbidity and immunosuppression and poor outcome has previously been reported [6,13]. Bacteria present in sanctuaries such as bone sequestration or on the spacer surface before the second stage of the procedure can actively replicate because of compromised immunity against capsulate agents, as reported in aging patients, in those with chronic inflammatory diseases receiving immunosuppressive drugs, or in those with diabetes mellitus or chronic hepatitis [15,25,27,32–36].
Reimplantation microbiology and serum C-reactive protein have low diagnostic accuracy in predicting recurrence in patients with prosthetic joint infection (PJI) undergoing 2-stage exchange. We aimed at identifying factors relating to failure and comparing effect of continuous antibiotic therapy versus a holiday antibiotic period pre-reimplantation.
This observational study included patients with PJI undergoing 2-stage exchange. Group A patients did not discontinue antibiotic treatment pre-reimplantation; in group B patients, antibiotic treatment was followed with 2 weeks of holiday antibiotic period pre-reimplantation. We defined cure as absence of recurrence for 96 weeks post-reimplantation. Statistical analyses were performed using Mann-Whitney U test, Fisher exact test, and multivariate analysis.
We evaluated 196 patients with PJI (median age, 66 years [interquartile range, 59-72], 91 [46%] males). Comorbidity was reported in 77 (39%), and microbiologic evidence was obtained in 164 (84%). Staphylococcus aureus was isolated in 63 of 164 (38%) patients; coagulase-negative staphylococci were isolated in 71 of 164 (43%). Favorable outcome was achieved for 169 (86%) patients (91% and 79% in groups A and B, respectively). No immunocompromise (odds ratio [OR], 2.73; 95% confidence interval [CI], 1.3-7.3; P = .04), a positive culture (OR, 3.96; 95% CI, 1.55-10.19; P = .02), and no antibiotic discontinuation (OR, 3.32; 95% CI, 1.3-8.44; P = .02) predicted favorable outcome using multivariate analysis.
Treatment with continuous antibiotic therapy ameliorated success rate, permitting a better outcome in immunocompromised and reducing the time to reimplantation. Continuous antibiotic therapy can be considered a valid option for the treatment of patients with PJI undergoing 2-stage exchange.
Therapeutic level II.

View all citing articles on Scopus

: No funding was received for this study.

: No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.02.057.

: Compliance with ethical standards: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Patients gave their informed consent before being included in this observational study.

: The research was conducted in accordance with the Declaration of Helsinki and national and institutional standards.

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Complications - InfectionOral Therapy, Microbiological Findings, and Comorbidity Influence the Outcome of Prosthetic Joint Infections Undergoing 2-Stage Exchange

Abstract

Background

Methods

Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Lancet

J Arthroplasty

J Arthroplasty

J Infect

J Arthroplasty

J Infect

J Arthroplasty

Clin Microbiol Infect

Economic burden of periprosthetic joint infection in the United States

J Arthroplasty

Incidence, secular trends, and outcomes of prosthetic joint infection: a population-based study, Olmsted county, Minnesota, 1969-2007

Infect Control Hosp Epidermiol

Infection associated with prosthetic joints

N Engl J Med

Italian guidelines for the diagnosis and infectious disease management of osteomyelitis and prosthetic joint infections in adults

Infection

Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the infectious diseases society of America

Clin Infect Dis

Two-stage revision arthroplasty for management of chronic periprosthetic hip and knee infection: techniques, controversies, and outcomes

J Am Acad Orthop Surg

What is the evidence base to guide surgical treatment of infected hip prostheses? Systematic review of longitudinal studies in unselected patients

BMC Med

Antibiotic treatment and timing of reimplantation

J Orthop Res

What is the role of serological testing between stages of two-stage reconstruction of the infected prosthetic knee?

Clin Orthop Relat Res

Staged revision for knee arthroplasty infection what is the role of serologic tests before reimplantation?

Clin Orthop Relat Res

Complications - Infection
Oral Therapy, Microbiological Findings, and Comorbidity Influence the Outcome of Prosthetic Joint Infections Undergoing 2-Stage Exchange