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infected prosthesis

Etiology: - most cases of infectious arthritis arise from hematogenous spread [1] - 41% of Staphylococcal bacteremia develop infected prosthesis [7] - coagulase negative Staphylococcus (Staphylococcus epidermidis) & other skin organisms [1] Clinical manifestations: 1) previously painless prosthetic joint becomes painful 2) loosening of prosthesis Laboratory: 1) joint aspiration for synovial fluid analysis (most useful) - synovial fluid cell count - cell count may be as low as 3000/uL (50,000-100,000/uL characteristic) - > 75% neutrophils - gram stain (negative in up to 40% of cases) - synovial fluid culture 2) blood cultures even if afebrile [1] 3) systemic inflammatory markers may be elevated - erythrocyte sedimentation rate (ESR) - C-reactive protein (CRP) 4) open biopsy of bone - neutrophils plus positive cultures indicate infection Radiology: 1) X-ray may show loosening or migration of cemented prosthesis 2) indium 111-labeled autologous leukocyte scan 3) arthrography 4) CT, MRI, or bone scan should not delay treatment & do not change initial management [1] Management: 1) strategies [2] a) joint irrigation, 1-stage or 2-stage surgery (debridement with retention of the prosthesis), & 2-6-weeks of IV antibiotics - long-term antibiotics (> 5 years) may be of benefit, especially with Staphylococcus aureus infections [6] b) resection arthroplasty with or without subsequent reimplantation c) amputation 2) surgery: a) in most cases removal of the prosthesis b) antibiotic-loaded cement spacers may be used with prosthesis replacement 3) antibiotics a) parenteral antibiotics for 4-6 weeks (4 weeks may be adequate [9]) - vancomycin + ceftriaxone [12] - 12 weeks of antibiotics results in 1/2 as many persistent infections as 6 weeks [10] - follow with oral rifampin + beta-lactam, tetracycline or fluoroquinolone for 11 months [11] b) synergistic effect of rifampin c) lifelong oral therapy 1] surgery refused 2] no systemic infection 3] not severe local sign of infection 4] joint prosthesis is not loose 5] appears to be safe in the elderly [8] - 61% 2-year survival without an adverse event or death - 1.5% of deaths related to infected prosthesis [8] 4) prophylactic antibiotics (cefazolin or vancomycin) before high-risk procedures in patients with prosthetic joints [1]

Related

prosthesis

General

infectious arthritis (septic arthritis) prosthetic disorder

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11,14,16,17,18,19. American College of Physicians, Philadelphia 1998,2006,2012,2015,2018,2022.
  2. 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) December 6 PMID: 23230301 http://cid.oxfordjournals.org/content/early/2012/11/29/cid.cis803.full
  3. Cobo J, Del Pozo JL. Prosthetic joint infection: diagnosis and management. Expert Rev Anti Infect Ther. 2011 Sep;9(9):787-802 PMID: 21905787
  4. Del Pozo JL, Patel R. Clinical practice. Infection associated with prosthetic joints. N Engl J Med. 2009 Aug 20;361(8):787-94 PMID: 19692690
  5. Osmon DR, Berbari EF, Berendt AR et al Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013 Jan;56(1):e1-e25 PMID: 23223583
  6. Siqueira MBP et al. Chronic suppression of periprosthetic joint infections with oral antibiotics increases infection-free survivorship. J Bone Joint Surg Am 2015 Aug 5; 97:1220 PMID: 26246256 http://jbjs.org/content/97/15/1220
  7. Tande AJ et al. Clinical presentation, risk factors, and outcomes of hematogenous prosthetic joint infection in patients with Staphylococcus aureus bacteremia. Am J Med 2016 Feb; 129:221.e11. PMID: 26453989
  8. Prendki V, Ferry T, Sergent P et al. Prolonged suppressive antibiotic therapy for prosthetic joint infection in the elderly: A national multicentre cohort study. Eur J Clin Microbiol Infect Dis 2017 Apr 04 PMID: 28378243 - Prendki V, Sergent P, Barrelet A et al Efficacy of indefinite chronic oral antimicrobial suppression for prosthetic joint infection in the elderly: a comparative study. Int J Infect Dis. 2017 May 16. PMID: 28526565 Free Article
  9. Benkabouche M, Racloz G, Spechbach H et al. Four versus six weeks of antibiotic therapy for osteoarticular infections after implant removal: A randomized trial. J Antimicrob Chemother 2019 Aug 1; 74:2394 PMID: 31106353 https://academic.oup.com/jac/article-abstract/74/8/2394/5491482?redirectedFrom=fulltext
  10. Bernard L, Arvieux C, Brunschweiler B et al Antibiotic Therapy for 6 or 12 Weeks for Prosthetic Joint Infection. N Engl J Med 2021; 384:1991-2001. May 27 PMID: 34042388 https://www.nejm.org/doi/full/10.1056/NEJMoa2020198
  11. Tai DBG et al. Truth in DAIR: Duration of therapy and the use of quinolone/rifampin-based regimens following debridement and implant retention for periprosthetic joint infections. Open Forum Infect Dis 2022 Jul 25; [e-pub] https://academic.oup.com/ofid/advance-article/doi/10.1093/ofid/ofac363/6649571
  12. NEJM Knowledge+ Rheumatology