Richard P. Evans

Diagnosis of periprosthetic joint infections of the hip and knee.

&NA; No preferred test for diagnosis of periprosthetic joint infection exists, and the algorithm for the workup of patients suspected of infection remains unclear. The work group evaluated the available literature to determine the role of each diagnostic modality and devise a practical algorithm that allows physicians to reach diagnosis of periprosthetic joint infection. Ten of the 15 recommendations have strong or moderate evidence in support. These include matters involving erythrocyte sedimentation rate and C‐reactive protein level testing, knee and hip aspiration, and stopping the use of antibiotics prior to obtaining intra‐articular cultures. The group recommends against the use of intraoperative Gram stain but does recommend the use of frozen sections of peri‐implant tissues in reoperation patients in whom infection has not been established, as well as multiple cultures in reoperation patients being assessed for infection. The group recommends against initiating antibiotic treatment in patients with suspected infection until after joint cultures have been obtained, but recommends that prophylactic preop‐erative antibiotics not be withheld in patients at lower probability for infection.

American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis of periprosthetic joint infections of the hip and knee.

AAOS Guideline on The Diagnosis of Periprosthetic Joint Infections of the Hip and Knee Summary of Recommendations The following is a summary of the recommendations in the AAOS’ clinical practice guideline, The Diagnosis of Periprosthetic Joint Infections of the Hip and Knee. This summary does not contain rationales that explain how and why these recommendations were developed nor does it contain the evidence supporting these recommendations. All readers of this summary are strongly encouraged to consult the full guideline and evidence report for this information. We are confident that those who read the full guideline and evidence report will note that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility. This summary of recommendations is not intended to stand alone. Clinical decisions should be made in light of all circumstances presented by the patient. Procedures applicable to the individual patient rely on mutual communication between patient, physician, and other healthcare practitioners. 1. In the absence of reliable evidence about risk stratification of patients with a potential periprosthetic joint infection, it is the opinion of the work group that testing strategies be planned …

Successful treatment of total hip and knee infection with articulating antibiotic components: a modified treatment method.

There are many problems associated with the use of articulating antibiotic cement spacer blocks and articulating components in the two-stage treatment of total hip replacement and total knee replacement infections. These include loss of motion during and after treatment, bone loss, generation of cement debris, inadequate dosing of cement with the appropriate antibiotic, and biologic failure. Forty-four patients with 54 consecutive periprosthetic hip and knee infections (31 septic total knee arthroplasties and 23 septic total hip arthroplasties) had treatment with a modified two-stage reimplantation protocol using articulating components made of antibiotic–cement-only prosthetic components and antibiotic–cement-covered prosthetic components between January 1995 and May 2002. Second-stage revision, after six weeks of parenteral antibiotics, was completed an average of 84 days after the first stage. A minimum two-year followup after final treatment is evaluated. One of the 23 total hip replacement infections persisted or recurred with the original organism(s) after treatment (95.7% success) as did two of the 31 total knee replacement infections (93.5% success). Combined success rate was 94.4%. This modified treatment method incorporates early range of motion during first-stage treatment with articulating components that provide local high-dose elution of broad-spectrum antibiotics, provides the flexibility of customizing the antibiotic cement components with culture-directed antibiotics, and results in a high biologic success rate.

Prophylaxis against infection in total joint arthroplasty. One day of cefuroxime compared with three days of cefazolin.

The efficacy of cefuroxime was compared with the efficacy of cefazolin for prophylaxis against postoperative wound infection in a prospective, double-blind, multicenter study of 1354 patients who had had elective primary or revision total hip or knee arthroplasty. The patients were randomly assigned to receive either 1.5 grams of cefuroxime followed by 750 milligrams eight and sixteen hours later (for a total of one day of antibiotic treatment), or one gram of cefazolin every eight hours for nine doses (for a total of three days of antibiotic treatment). The first dose of each drug was administered fifteen to sixty minutes before the operative incision was made (for a primary operation) or after tissue samples had been obtained for culture (for a revision procedure). After the operation, the patients were assessed daily while hospitalized and then at two to three months and one year after the operation. Demographic characteristics and risk factors were similar in the two groups. For the patients who had had a primary hip arthroplasty, the rate of deep wound infection was 0.5 per cent (one of 187) for those who had received cefuroxime and 1.2 per cent (two of 168) for those who had received cefazolin. For the patients who had had a primary knee arthroplasty, the rate of deep wound infection was 0.6 per cent (one of 178) for those who had received cefuroxime and 1.4 per cent (three of 207) for those who had received cefazolin.(ABSTRACT TRUNCATED AT 250 WORDS)

Gentamicin-impregnated polymethylmethacrylate beads compared with systemic antibiotic therapy in the treatment of chronic osteomyelitis

A model of chronic osteomyelitis was used to evaluate the efficacy of treatment with debridement alone; debridement plus gentamicin-polymethylmethacrylate (PMMA) bead implantation; debridement plus systemic antibiotic therapy; and debridement plus systemic antibiotics and bead implantation. Debridement with the implantation of gentamicin-PMMA beads and debridement followed by systemic antibiotics were significantly more successful forms of treatment for chronic osteomyelitis than debridement alone or debridement with the implantation of PMMA beads not impregnated with antibiotics. Debridement followed by the implantation of PMMA-gentamicin beads and the use of systemic antibiotics produced the greatest success rate. Treatment with a combination of gentamicin-PMMA beads and systemic antibiotics resulted in a 100% success rate, which, although not statistically better than either treatment alone, suggests a trend.

Current Concepts for Clean Air and Total Joint Arthroplasty: Laminar Airflow and Ultraviolet Radiation: A Systematic Review

BackgroundWith the trend toward pay-for-performance standards plus the increasing incidence and prevalence of periprosthetic joint infection (PJI), orthopaedic surgeons must reconsider all potential infection control measures. Both airborne and nonairborne bacterial contamination must be reduced in the operating room.Questions/purposesAnalysis of airborne bacterial reduction technologies includes evaluation of (1) the effectiveness of laminar air flow (LAF) and ultraviolet light (UVL); (2) the financial and potential health costs of each; and (3) an examination of current national and international standards, and guidelines.MethodsWe systematically reviewed the literature from Ovid, PubMed (Medline), Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA, NHSEED, CINAHLPLUS, and Google Scholar published until June 2010 focusing on ultraclean air, ultraviolet light, and laminar air.ResultsHigh-level data demonstrating substantial PJI reduction of any infection control method may not be feasible as a result of the relatively low rates of occurrence and the expense and difficulty of conducting a large enough study with adequate power. UVL has potentially unacceptable health costs and the Centers for Disease Control and Prevention (CDC) recommends against its use. European countries have standardized LAF and it is used by the majority of American joint surgeons.ConclusionsBoth LAF and UVL reduce PJI. The absence of a high level of evidence from randomized trials is not proof of ineffectiveness. The historically high cost of LAF has decreased substantially. Only LAF has been standardized by several European countries. The CDC recommends further study of LAF but recommends UVL not be used secondary to documented potential health risks to personnel.

Surgical Site Infection Prevention and Control: An Emerging Paradigm

The Centers for Disease Control and Prevention (CDC) estimates that 22% of all health-care-associated infections are surgical site infections. A CDC estimate from 2001 suggests that approximately 290,000 surgical site infections occur annually in the United States, resulting in

Randomized Controlled Trial of the Safety and Efficacy of Daptomycin versus Standard-of-Care Therapy for Management of Patients with Osteomyelitis Associated with Prosthetic Devices Undergoing Two-Stage Revision Arthroplasty

1 billion to

Prevention of orthopaedic implant infection in patients undergoing dental procedures

10 billion in direct and indirect medical costs. Approximately 8000 patient deaths are associated with these infections. Staphylococcus species including Staphylococcus aureus are the leading nosocomial pathogens in hospitals throughout the world and altogether total almost 30% of the pathogenic isolates of health-care-associated infection reported to the National Healthcare Safety Network from January 2006 to October 20071. Multiple-drug-resistant organisms include methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, which colonize the skin and are spread by contact. Over 30% of the population is colonized with Staphylococcus aureus, and an increasing proportion of these resident bacteria is methicillin-resistant Staphylococcus aureus . As many as 4% of health-care workers may be colonized with methicillin-resistant Staphylococcus aureus, with up to 5% of these persons having a clinical infection2. These contribute to two types of infection, surgical and so-called nonsurgical (methicillin-resistant Staphylococcus aureus ) infection. Additionally, there are two types of methicillin-resistant Staphylococcus aureus . Community-acquired methicillin-resistant Staphylococcus aureus and hospital-associated methicillin-resistant Staphylococcus aureus together have resulted in an increase in the incidence of nonsurgical infection of all types. Because of the increasing incidence, severity, and extent of disease caused by multiple-drug-resistant organisms, the prevention and treatment of these infections have become a national priority. The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal advisory committee made up of fourteen external infection control experts who provide advice and guidance to the CDC and the Secretary of the Department of Health and Human Services regarding the practice of health-care infection control and strategies for surveillance, prevention, and control of health-care-associated …

Visualization of bacterial glycocalyx with a scanning electron microscope.

ABSTRACT The prevalence of Staphylococcus aureus causing prosthetic joint infection (PJI) supports investigation of higher doses of daptomycin in the management of PJI. This was a prospective, randomized controlled trial studying safety and efficacy of daptomycin (6 and 8 mg/kg of body weight) compared with standard-of-care therapy for PJI. This open-label study randomized 75 patients undergoing 2-stage revision arthroplasty to daptomycin at 6 or 8 mg/kg or a comparator (vancomycin, teicoplanin, or semisynthetic penicillin). After prosthesis removal, patients received 6 weeks of antibiotic treatment and a 2- to 6-week antibiotic-free period before implantation of a new prosthesis. Test of cure (TOC) was within 1 to 2 weeks after reimplantation. The primary objective was evaluation of creatine phosphokinase (CPK) levels. Secondary objectives were clinical efficacy and microbiological assessments. Of 73 CPK safety population patients, CPK elevation of >500 U/liter occurred in 4 of 25 (16.0%) (daptomycin, 6 mg/kg) and 5 of 23 (21.7%) (daptomycin, 8 mg/kg) daptomycin-treated patients and 2 of 25 (8.0%) comparator patients. Adverse-event rates were similar among daptomycin and comparator groups. Among modified intent-to-treat patients at TOC, clinical success rates were 14 of 24 (58.3%) for 6 mg/kg daptomycin, 14 of 23 (60.9%) for 8 mg/kg daptomycin, and 8 of 21 (38.1%) for the comparator. Overall microbiological success at TOC was 12 of 24 (50.0%) for 6 mg/kg daptomycin, 12 of 23 (52.2%) for 8 mg/kg daptomycin, and 8 of 21 (38.1%) for comparator patients. In conclusion, daptomycin at 6 and 8 mg/kg given for up to 6 weeks was safe and appeared to be effective in managing staphylococcal PJI using a 2-stage revision arthroplasty technique in a total of 49 patients.