J Antimicrob Chemother 2014; 69 Suppl 1: i3 – i4 doi:10.1093/jac/dku246
Prosthetic joint infection: managing infection in a bionic era Matthew Dryden* Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester SO22 5DG, UK *Tel: +44-1962-824451; Fax: +44-1962-825431; E-mail: [email protected]
There is increasing demand for prosthetic joint surgery and patients are becoming more challenging due to an ageing population often with comorbidities and immunosuppression. While prosthetic joint infection (PJI) rates are generally low, infection can be catastrophic for the patient and hence prevention of infection is critical. Infection, when it does occur, is further complicated by the global rise in antimicrobial resistance. This article introduces a series of papers on the epidemiology of PJI, its diagnosis, use of novel inflammatory markers and molecular techniques, clinical presentation, importance of biofilms, treatment guidelines and, finally, various strategies and novel antibiotic treatment regimens. Keywords: septic arthritis, antibiotics, surgical infection, infection rates
Two critical and interrelated factors in the success of ever-moretechnical surgery to replace or reconstruct damaged biological structures such as joints with prosthetic or foreign material are the prevention of infection and having means to treat infection when it occurs. While the demand for such surgery is increasing, ensuring good clinical outcomes is becoming more challenging due to an ageing population often with comorbidities, such as obesity or immunosuppression. In addition, there is increasing concern that rising global antibiotic resistance may make such surgery less effective in the future. It is imperative that there is global cooperation in ensuring responsible antibiotic use in human medicine, veterinary practice and agriculture, improving public health and infection control and supporting research in infection management.1 This Supplement comprises a series of articles that provide a combination of review of current practice as well as discussions of novel approaches to the optimal diagnosis and management of prosthetic joint infection (PJI) and discussions of novel and optimal treatments of PJI. Replacement of damaged joints improves quality of life immensely.2 Infection is among the most serious complications as this can subject the sufferer to weeks and months of pain, discomfort and misery. Many of the standard techniques involved in prosthetic joint surgery have been developed to prevent infection3 and by and large these work well. Among the strategies that are employed are screening patients pre-operatively for staphylococcal carriage, pre-operative antiseptic baths, skin antisepsis at operation, antibiotic prophylaxis, laminar air flow in the operating theatre, skilled and aseptic surgical technique, minimizing blood loss and maintaining body temperature. Trends in the epidemiology of PJI in the UK are reported by Lamagni.4,5 Infection rates are generally low and voluntary reporting in the UK to Public Health England (formerly the HPA)
gives national figures for surgical site infection (SSI) and PJI.4,5 Approximately 1 in 100 patients undergoing hip prosthesis surgery and 1 in 200 undergoing knee prosthesis surgery developed an SSI. Of these infections, just over half affected the deeper tissue or joint. The risk of SSI was highest in repair of neck of femur procedures, where 1 in 60 patients developed an SSI. Rates of SSI increased with patient age and the number of risk factors for infection present at the time of operation. Inclusion of post-discharge surveillance data (readmissions) has increased the number of SSIs detected. Post-discharge infections comprised 41% of SSIs overall and 58% in knee prosthesis during 2009/10. In 485194 procedures in the UK over 5 years (2005 – 10), there were 3496 (0.72%) reported SSIs. European and international PJI rates are similar.2,3 The diagnosis of PJI remains difficult. In addition to conventional diagnosis, novel techniques in molecular diagnosis and assessment of novel inflammatory markers are reviewed. Saeed6 reports a wide range of existing and experimental diagnostic techniques and Hartley 7 comments on highly sensitive molecular diagnosis, which may also provide greater insights into the aetiology of PJI. Diagnostic investigations often involve complex collaboration between the orthopaedic surgeon, radiologist and microbiologist/infection specialist. The main challenge is often establishing the depth of infection and whether the prosthesis is actually involved. As highlighted by Barrett and Atkins8 in their article on clinical presentation, the diagnosis of PJI can be a challenge and has major consequences for the patient. Conventional microbiology remains relatively straightforward. Staphylococcus aureus remains the most common pathogen and is reported as causing 40% of SSIs. In knee prostheses, the most common organisms reported for inpatient SSIs were coagulase-negative staphylococci (30%). The second most common organisms were Enterobacteriaceae for inpatient SSIs.
# The Author 2014. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: [email protected]
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However, the proportion of infections associated with these pathogens was higher in recent years. The proportion of S. aureus isolates resistant to methicillin (MRSA) was lower than the proportion of methicillin-susceptible S. aureus (MSSA). MRSA and MSSA now account for 16% and 22% of all inpatient SSIs, respectively, with MSSA now the most common cause of all inpatient SSIs. The data suggest that in the UK at least, the proportion of MRSA causing SSI is falling. The surveillance of the microbial aetiology is important because guidelines for treatment, reviewed by Minassian et al.9 in this Supplement, will need to be reviewed as the epidemiology changes and in relation to geographical differences. The specific challenges of biofilms in PJI and antibiotic penetration are reviewed by Jaqueline and Caillon10 while other authors discuss their experiences or review the roles of newer antibiotics, singly or in combination, in the treatment of PJI in two European centres.11,12 Preventing infection is a critically important aspect of joint replacement. However, when complications arise, infection, if present, must be accurately diagnosed. If infection is present, successful treatment of confirmed PJI requires close collaboration between the surgeon and infection specialist. No two patients are the same and treatment strategies often need to be individually tailor-made involving antimicrobial treatment, soft tissue care, removal of prostheses and early or late revision. All of these have a place, as occasionally does long-term antibiotic suppressive therapy for those patients who are medically unfit or mechanically unsuitable for further surgery.
References 1 Annual Report of the Chief Medical Officer 2011: Volume 2. https://www. gov.uk/government/publications/chief-medical-officer-annual-reportvolume-2 (4 August 2013, date last accessed). 2 Osman DR. Diagnosis and management of prosthetic joint infection. Clin Infect Dis 2013; 56: 1 –25. 3 Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med 2004; 351: 1645– 54. 4 Sixth Report of the Mandatory Surveillance of Surgical Site Infection in Orthopaedic Surgery. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_ C/1287147699571 (1 March 2013, date last accessed). 5 Lamagni T. Epidemiology and burden of prosthetic joint infections. J Antimicrob Chemother 2014; 69 Suppl 1: i5 –10. 6 Saeed K. Diagnostics in prosthetic joint infections. J Antimicrob Chemother 2014; 69 Suppl 1: i11–19. 7 Hartley JC, Harris KA. Molecular techniques for diagnosing prosthetic joint infections. J Antimicrob Chemother 2014; 69 Suppl 1: i21– 24. 8 Barrett L, Atkins B. The clinical presentation of prosthetic joint infection. J Antimicrob Chemother 2014; 69 Suppl 1: i25– 27. 9 Minassian AM, Osmon DR, Berendt AR. Clinical guidelines in the management of prosthetic joint infection. J Antimicrob Chemother 2014; 69 Suppl 1: i29–35. 10 Jacqueline C, Caillon J. Impact of bacterial biofilm on the treatment of prosthetic joint infections. J Antimicrob Chemother 2014; 69 Suppl 1: i37–40.
Transparency declaration
11 Bassetti M, Cadeo B, Villa G et al. Current antibiotic management of prosthetic joint infections in Italy: the ‘Udine strategy’. J Antimicrob Chemother 2014; 69 Suppl 1: i41–45.
This article is part of a Supplement sponsored by the BSAC and supported by an unrestricted educational grant from Pfizer. The author has no conflict of interest to declare.
12 Morata L, Tornero E, Martı´nez-Pastor JC et al. Clinical experience with linezolid for the treatment of orthopaedic implant infections. J Antimicrob Chemother 2014; 69 Suppl 1: i47– 52.
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Prosthetic joint infection: managing infection in a bionic era Matthew Dryden* Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester SO22 5DG, UK *Tel: +44-1962-824451; Fax: +44-1962-825431; E-mail: [email protected]
There is increasing demand for prosthetic joint surgery and patients are becoming more challenging due to an ageing population often with comorbidities and immunosuppression. While prosthetic joint infection (PJI) rates are generally low, infection can be catastrophic for the patient and hence prevention of infection is critical. Infection, when it does occur, is further complicated by the global rise in antimicrobial resistance. This article introduces a series of papers on the epidemiology of PJI, its diagnosis, use of novel inflammatory markers and molecular techniques, clinical presentation, importance of biofilms, treatment guidelines and, finally, various strategies and novel antibiotic treatment regimens. Keywords: septic arthritis, antibiotics, surgical infection, infection rates
Two critical and interrelated factors in the success of ever-moretechnical surgery to replace or reconstruct damaged biological structures such as joints with prosthetic or foreign material are the prevention of infection and having means to treat infection when it occurs. While the demand for such surgery is increasing, ensuring good clinical outcomes is becoming more challenging due to an ageing population often with comorbidities, such as obesity or immunosuppression. In addition, there is increasing concern that rising global antibiotic resistance may make such surgery less effective in the future. It is imperative that there is global cooperation in ensuring responsible antibiotic use in human medicine, veterinary practice and agriculture, improving public health and infection control and supporting research in infection management.1 This Supplement comprises a series of articles that provide a combination of review of current practice as well as discussions of novel approaches to the optimal diagnosis and management of prosthetic joint infection (PJI) and discussions of novel and optimal treatments of PJI. Replacement of damaged joints improves quality of life immensely.2 Infection is among the most serious complications as this can subject the sufferer to weeks and months of pain, discomfort and misery. Many of the standard techniques involved in prosthetic joint surgery have been developed to prevent infection3 and by and large these work well. Among the strategies that are employed are screening patients pre-operatively for staphylococcal carriage, pre-operative antiseptic baths, skin antisepsis at operation, antibiotic prophylaxis, laminar air flow in the operating theatre, skilled and aseptic surgical technique, minimizing blood loss and maintaining body temperature. Trends in the epidemiology of PJI in the UK are reported by Lamagni.4,5 Infection rates are generally low and voluntary reporting in the UK to Public Health England (formerly the HPA)
gives national figures for surgical site infection (SSI) and PJI.4,5 Approximately 1 in 100 patients undergoing hip prosthesis surgery and 1 in 200 undergoing knee prosthesis surgery developed an SSI. Of these infections, just over half affected the deeper tissue or joint. The risk of SSI was highest in repair of neck of femur procedures, where 1 in 60 patients developed an SSI. Rates of SSI increased with patient age and the number of risk factors for infection present at the time of operation. Inclusion of post-discharge surveillance data (readmissions) has increased the number of SSIs detected. Post-discharge infections comprised 41% of SSIs overall and 58% in knee prosthesis during 2009/10. In 485194 procedures in the UK over 5 years (2005 – 10), there were 3496 (0.72%) reported SSIs. European and international PJI rates are similar.2,3 The diagnosis of PJI remains difficult. In addition to conventional diagnosis, novel techniques in molecular diagnosis and assessment of novel inflammatory markers are reviewed. Saeed6 reports a wide range of existing and experimental diagnostic techniques and Hartley 7 comments on highly sensitive molecular diagnosis, which may also provide greater insights into the aetiology of PJI. Diagnostic investigations often involve complex collaboration between the orthopaedic surgeon, radiologist and microbiologist/infection specialist. The main challenge is often establishing the depth of infection and whether the prosthesis is actually involved. As highlighted by Barrett and Atkins8 in their article on clinical presentation, the diagnosis of PJI can be a challenge and has major consequences for the patient. Conventional microbiology remains relatively straightforward. Staphylococcus aureus remains the most common pathogen and is reported as causing 40% of SSIs. In knee prostheses, the most common organisms reported for inpatient SSIs were coagulase-negative staphylococci (30%). The second most common organisms were Enterobacteriaceae for inpatient SSIs.
# The Author 2014. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: [email protected]
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Dryden
However, the proportion of infections associated with these pathogens was higher in recent years. The proportion of S. aureus isolates resistant to methicillin (MRSA) was lower than the proportion of methicillin-susceptible S. aureus (MSSA). MRSA and MSSA now account for 16% and 22% of all inpatient SSIs, respectively, with MSSA now the most common cause of all inpatient SSIs. The data suggest that in the UK at least, the proportion of MRSA causing SSI is falling. The surveillance of the microbial aetiology is important because guidelines for treatment, reviewed by Minassian et al.9 in this Supplement, will need to be reviewed as the epidemiology changes and in relation to geographical differences. The specific challenges of biofilms in PJI and antibiotic penetration are reviewed by Jaqueline and Caillon10 while other authors discuss their experiences or review the roles of newer antibiotics, singly or in combination, in the treatment of PJI in two European centres.11,12 Preventing infection is a critically important aspect of joint replacement. However, when complications arise, infection, if present, must be accurately diagnosed. If infection is present, successful treatment of confirmed PJI requires close collaboration between the surgeon and infection specialist. No two patients are the same and treatment strategies often need to be individually tailor-made involving antimicrobial treatment, soft tissue care, removal of prostheses and early or late revision. All of these have a place, as occasionally does long-term antibiotic suppressive therapy for those patients who are medically unfit or mechanically unsuitable for further surgery.
References 1 Annual Report of the Chief Medical Officer 2011: Volume 2. https://www. gov.uk/government/publications/chief-medical-officer-annual-reportvolume-2 (4 August 2013, date last accessed). 2 Osman DR. Diagnosis and management of prosthetic joint infection. Clin Infect Dis 2013; 56: 1 –25. 3 Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med 2004; 351: 1645– 54. 4 Sixth Report of the Mandatory Surveillance of Surgical Site Infection in Orthopaedic Surgery. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_ C/1287147699571 (1 March 2013, date last accessed). 5 Lamagni T. Epidemiology and burden of prosthetic joint infections. J Antimicrob Chemother 2014; 69 Suppl 1: i5 –10. 6 Saeed K. Diagnostics in prosthetic joint infections. J Antimicrob Chemother 2014; 69 Suppl 1: i11–19. 7 Hartley JC, Harris KA. Molecular techniques for diagnosing prosthetic joint infections. J Antimicrob Chemother 2014; 69 Suppl 1: i21– 24. 8 Barrett L, Atkins B. The clinical presentation of prosthetic joint infection. J Antimicrob Chemother 2014; 69 Suppl 1: i25– 27. 9 Minassian AM, Osmon DR, Berendt AR. Clinical guidelines in the management of prosthetic joint infection. J Antimicrob Chemother 2014; 69 Suppl 1: i29–35. 10 Jacqueline C, Caillon J. Impact of bacterial biofilm on the treatment of prosthetic joint infections. J Antimicrob Chemother 2014; 69 Suppl 1: i37–40.
Transparency declaration
11 Bassetti M, Cadeo B, Villa G et al. Current antibiotic management of prosthetic joint infections in Italy: the ‘Udine strategy’. J Antimicrob Chemother 2014; 69 Suppl 1: i41–45.
This article is part of a Supplement sponsored by the BSAC and supported by an unrestricted educational grant from Pfizer. The author has no conflict of interest to declare.
12 Morata L, Tornero E, Martı´nez-Pastor JC et al. Clinical experience with linezolid for the treatment of orthopaedic implant infections. J Antimicrob Chemother 2014; 69 Suppl 1: i47– 52.
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