Ivor Byren

The diagnosis and management of prosthetic joint infections

A host of technical and operative improvements have seen the rates of infection associated with joint replacement reach historic lows. However, the increasing number of operations being performed means that the absolute number of such infections remains significant. Diagnosis may be challenging and delaying appropriate treatment can lead to reduced joint function and the need for more complex, perhaps multiple, procedures. Individual centres tend to see small numbers of such cases, and in the absence of large clinical trials management varies. Early diagnosis, selection of an appropriate surgical strategy, accurate identification of the responsible microorganisms and construction of an appropriate antibiotic regimen are essential elements of any management strategy. Such packages of care are best delivered by a multidisciplinary team composed of orthopaedic and plastic surgeons, microbiologists, infectious disease physicians, specialist nurses, physiotherapists and occupational therapists. Each treatment plan must be developed in consultation with the patient, taking into account their aims and realistic goals. This review provides an overview of current understanding regarding diagnosis and treatment of prosthetic joint infections and suggests a treatment algorithm.

Diagnosis and management of prosthetic joint infection

Joint replacement is safe, cost effective,1 and widely undertaken. Most prosthetic joint replacements are hips and knees; more than 130 000 people underwent such procedures in England and Wales in the 12 months from April 2006.w1 Subsequent prosthetic joint infection is uncommon—the incidence varies between 0.6% and 2% per joint per year.2 3 4 5 However, this complication is associated with substantial morbidity and economic cost (

Treatment of Bacterial Prostatitis

30 000 (£20 500; €22 800) to

Two-stage revision for prosthetic joint infection: predictors of outcome and the role of reimplantation microbiology

50 000 per patient).3 4 6 w2 The diagnosis of prosthetic joint infection is difficult,w2 because symptoms, signs, and investigations may all be non-specific.7 w3 Defining diagnostic criteria and optimum management is complicated by patient heterogeneity and the small numbers in many published studies.w4 However, prompt recognition and diagnosis of prosthetic joint infection facilitates timely intervention to salvage infected joints, preserve joint function, prevent morbidity, and reduce costs. #### Summary points #### Sources and selection criteria We performed Medline searches between November 2008 and January 2009 using the search terms “prosthetic joint” and “arthroplasty” combined with “infection”, “guidelines”, “septic arthritis”, “infection diagnosis”, “infection epidemiology”, and “infection revision arthroplasty”. Where possible, we focused on articles published in the past five years and restricted our search to literature published in English. We also drew from the experience of, and articles and documents published by, our multidisciplinary bone infection unit in the United …

Cutaneous Tuberculosis of the Penis and Sexual Transmission of Tuberculosis Confirmed by Molecular Typing

Prostatitis is characterized by voiding symptoms and genitourinary pain and is sometimes associated with sexual dysfunction. Up to 25% of men receive a diagnosis of prostatitis in their lifetime, but <10% have a proven bacterial infection. The causes and treatment of nonbacterial prostatitis are largely unknown, but bacterial prostatitis is caused by infection with uropathogens, especially gram-negative bacilli, although infection is sometimes due to gram-positive and atypical microorganisms. Acute bacterial prostatitis is easily diagnosed (by abrupt urogential and often systemic symptoms, along with bacteriuria) and treated (by systemic antibiotic therapy). Chronic bacterial prostatitis is characterized by prolonged or recurrent symptoms and relapsing bacteriuria; diagnosis traditionally requires comparing urinary specimens obtained before with specimens obtained after prostatic massage. Treating chronic bacterial prostatitis requires prolonged therapy with an antibiotic that penetrates the prostate (ie, one with high lipid solubility, a low degree of ionization, high dissociation constant, low protein binding, and small molecular size). We review recent pharmacological and clinical data on treating bacterial prostatitis.

Pharmacotherapy of diabetic foot osteomyelitis.

Objectives We describe rates of success for two-stage revision of prosthetic joint infection (PJI), including data on reimplantation microbiology. Methods We retrospectively collected data from all the cases of PJI that were managed with two-stage revision over a 4 year period. Patients were managed with an antibiotic-free period before reimplantation, in order to confirm, clinically and microbiologically, that infection was successfully treated. Results One hundred and fifty-two cases were identified. The overall success rate (i.e. retention of the prosthesis over 5.75 years of follow-up) was 83%, but was 89% for first revisions and 73% for re-revisions [hazard ratio = 2.9, 95% confidence interval (CI) 1.2–7.4, P = 0.023]. Reimplantation microbiology was frequently positive (14%), but did not predict outcome (hazard ratio = 1.3, 95% CI 0.4–3.7, P = 0.6). Furthermore, most unplanned debridements following the first stage were carried out before antibiotics were stopped (25 versus 2 debridements). Conclusions We did not identify evidence supporting the use of an antibiotic-free period before reimplantation and routine reimplantation microbiology. Re-revision was associated with a significantly worse outcome.

Native hip joint septic arthritis in 20 adults: Delayed presentation beyond three weeks predicts need for excision arthroplasty

A case of culture-positive primary cutaneous Mycobacterium tuberculosis infection of the penis was diagnosed in a male patient; 1 year later, endometrial tuberculosis was diagnosed in the patients wife. These organisms were confirmed to be indistinguishable by use of molecular techniques.

Serial measurement of the C-reactive protein is a poor predictor of treatment outcome in prosthetic joint infection

Diabetic foot osteomyelitis (DFO) complicates about 20% of diabetic foot infections (DFIs) and increases the risk of lower extremity amputation. This contentious infection is important to discuss, given the frequency with which diabetes mellitus and its complications occur and the devastating consequences of amputation. The diagnosis and management of DFO is complicated by the diverse presentations, delayed recognition, poorly defined diagnostic criteria, and lack of validated treatment regimens. Major issues of concern include when to undertake bone resection surgery and which antimicrobial agents to use, by what route, and for how long. Patients in whom DFO is suspected are best cared for by a multidisciplinary team, including infectious disease physicians or clinical microbiologists, orthopaedic, plastic and vascular surgeons, diabetologists, primary care physicians, podiatrists and specialist (especially tissue viability) nurses. Such multidisciplinary teams have repeatedly been shown to improve disease outcomes. We herein analyse the limited, and recently published, literature on the pharmacotherapy of DFO and put it into the broader context of management of DFI and osteomyelitis.

Pristinamycin as adjunctive therapy in the management of Gram-positive multi-drug resistant organism (MDRO) osteoarticular infection

OBJECTIVES Septic arthritis of native hip joints is an uncommon condition in adults in Western Europe, but continues to present a challenge to medical and surgical management. We set out to study the natural history and bacteriology of the disease in this group, with a particular focus on patients requiring excision arthroplasty (EA). METHODS We retrospectively studied 26 secondary referral cases (20 adults) managed by a specialist bone infection unit over a 12 year period. RESULTS Our patient cohort was diverse, affecting all age groups in the presence and absence of co-morbid conditions. The commonest pathogen was Staphylococcus aureus. Of 20 adults studied, five (25%) required EA. Symptom duration prior to presentation was a statistical predictor of the requirement for EA (p<0.003); in particular, symptom duration of over three weeks was strongly associated with requirement for this procedure (p<0.0003). CONCLUSIONS In cases that present promptly, combined surgical drainage and intravenous antibiotics should be expected to eradicate infection and to salvage the femoral head. Cases presenting following a delay are more likely to require EA and subsequent hip reconstruction.

Chronic osteomyelitis of the pubic bones following radiotherapy for urological malignancy

OBJECTIVES Prosthetic joint infection is usually treated using surgery and antibiotics. The response to the treatment regimen is often evaluated using serial monitoring of plasma C-reactive protein (CRP) concentrations. In order to examine how useful this monitoring is, we calculated the sensitivity and specificity of CRP concentrations for predicting treatment failure. PATIENTS AND METHODS We examined 3732 CRP measurements from 260 patients who were treated by either two-stage revision or debridement and retention. We tested the association between CRP concentration and outcome using logistic regression models, and assessed sensitivity and specificity by using receiver operator curves. RESULTS The areas under receiver operator curves for CRP concentrations predicting outcome ranged from 0.55 to 0.65. CONCLUSIONS CRP concentrations did not accurately predict treatment failure. Serial monitoring may not be of benefit.