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Prosthetic Joint Infections
Introduction to the Infectious Patient
Susanne Barnett, PharmD, BCPS
Objectives
Understand the pathophysiology of prosthetic joint infections (PJIs)
List bacterial pathogens commonly implicated in PJIs
Identify first-line therapy for PJIs
Evidence-Based Resources
Osmon DR, et al. Diagnosis and management of prosthetic joint infection: Clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2012;56:e1-25.
Prosthetic Joints
Images accessed 3/17/13 at: http://www.scripps.org/articles/2029-knee-joint-replacement; http://www.antimicrobe.org/new/printout/e3printout/e3treat.htm
Epidemiology
Patients receiving total hip (THA) and knee (TKA) arthroplasties in U.S. annually is ~1,000,000
Risk of infection is ~ 1-2%
Prosthesis removal is usually necessary to treat these infections
Annual U.S. healthcare costs up to $700 million
Osmon DR, et al. Clin Infect Dis. 2012;56:e1-25.Brause BD. Chptr 104 in Mandell et al. Principles and practice of infectious diseases. 7th ed. 2010.
Pathophysiology
Route of infection Local (contiguous) Hematogenous – 20-40% (e.g. bacteremia)
Infection often occurs in osseous tissue adjacent to a foreign body (bone-cement interface)
Clinical Presentation
Joint pain (95%)
Fever (43%)
Periarticular swelling (38%)
Drainage (32%)
Early, Delayed, or Chronic Infections
Causative Pathogen(s)
Pathogens Frequency (%)Coagulase-negative staphylococci 22Staphylococcus aureus 22Viridans Streptococci 9ß-Hemolytic streptococci groups A,B, G
5
Enterococci 7Gram negative aerobic bacilli 25Anaerobes 10
Brause BD. Chptr 104 in Mandell et al. Principles and practice of infectious diseases. 7th ed. 2010.
Diagnostics
Pre-operative Radiographic studies CRP and ESR Arthocentesis (cultures)
Intra-operative Histopathological examination 3-6 peri-prosthetic tissue samples/explanted prosthesis for
culture
Osmon DR, et al. Clin Infect Dis. 2012;56:e1-25.; Images accessed 3/18/13 at: http://www.hss.edu/conditions_revision-total-hip-replacement-overview.asp
Prosthetic Joint Infections Assessment Q #1
Which of the following is FALSE regarding prosthetic joint infections?
A) Local or contiguous infection is more common than hematogenous infection
B) Incidence of PJIs is declining
C) Patients w/ PJIs often present with a cc of joint pain
D) Staphylococcus species are a common cause of PJIs
Prosthetic Joint Infections Assessment Q #1
Which of the following is FALSE regarding prosthetic joint infections?
A) Local or contiguous infection is more common than hematogenous infection
B) Incidence of PJIs is declining
C) Patients w/ PJIs often present with a cc of joint pain
D) Staphylococcus species are a common cause of PJIs
Prosthetic Joint Infections…defined
Definitive definition Presence of a sinus tract communicating to the prosthesis Purulence without another known etiology surrounding the
prosthesis ≥2 intraoperative cultures yielding the same organism Combination of intraoperative cultures and preoperative aspiration
yielding the same organism
Highly suggestive Acute inflammation seen on histopathologic examination at time of
prosthesis removal Growth of virulent organism in single sample
Osmon DR, et al. Clin Infect Dis. 2012;56:e1-25.
Treatment of Choice
Debridement and retention of prosthesis Staphylococcus aureus: Nafcillin, cefazolin, ceftriaxone
Alt: Vancomycin, daptomycin, or linezolid 2-6 weeks pathogen specific IV antimicrobials + po rifampin bid Followed by po levo/cipro + rifampin Alternative: TMP/SMX, minocycline/doxycycline, cephalexin,
dicloxacillin Total DOT: 3 months (hip) or 6 months (knee)
Other organisms 4-6 weeks pathogen specific IV or highly bioavailable oral abx
Consider chronic, long-term suppression if device removal not possible Cephalexin, dicloxacillin, TMP/SMX, minocycline
Osmon DR, et al. Clin Infect Dis. 2012;56:e1-25.
Antimicrobial Therapy
Resection +/- staged reimplantation (2-stage) 4-6 wks pathogen specific IV or highly bioavailable oral abx
Following 1-stage exchange (uncommon) Staphylococcus aureus
2-6 weeks pathogen specific IV antimicrobials + po rifampin bid Followed by po levo/cipro + rifampin Alternative: TMP/SMX, minocycline/doxycycline, cephalexin,
dicloxacillin Total DOT: 3 months (hip or knee)
Other organisms 4-6 weeks pathogen specific IV or highly bioavailable oral abx
Can consider chronic oral suppression in select cases
Osmon DR, et al. Clin Infect Dis. 2012;56:e1-25.
Antimicrobial Therapy
Following amputation Removal of all infected bone/tissue AND no
sepsis/bacteremia Pathogen specific IV abx 24-48 h post procedure
Residual infected bone and/or soft tissue 4-6 weeks pathogen specific IV or highly bioavailable oral
therapy
Osmon DR, et al. Clin Infect Dis. 2012;56:e1-25.
Attachment and growth of bacterial communities
Common in staphylococci, Pseudomonas spp.
Biofilm microbes are 10–1000 times less susceptible to antimicrobials
Rifampin has high activity against biofilm organisms
Esposito S. Int J Antimicrob Agents. 2008 Oct;32(4):287-93.; Osmon DR, et al. Clin Infect Dis. 2012;56:e1-25. Images accessed 3/18/13 at: http://hardinmd.lib.uiowa.edu/cdc/staph/sem3.html.
Biofilms in Prosthetic Devices
PJI Assessment Q #2
Which of the following regimens is the best initial choice for a patient undergoing a 2-stage reimplantation for methicillin-susceptible S. aureus?
A) Cefazolin IV + PO rifampin
B) Ciprofloxacin IV + PO rifampin
C) Levofloxacin PO + nafcillin IV
D) Cefazolin IV
PJI Assessment Q #2
Which of the following regimens is the best initial choice for a patient undergoing a 2-stage reimplantation for methicillin-susceptible S. aureus?
A) Cefazolin IV + PO rifampin
B) Ciprofloxacin IV + PO rifampin
C) Levofloxacin PO + nafcillin IV
D) Cefazolin IV
Role of the Pharmacist
Monitor culture results and susceptibilities
Monitoring of patient response ESR, CRP, pain, swelling, tenderness
Monitoring for adverse events to long term IV antimicrobial therapy Long-term oral therapy for those with chronic suppressive
therapy