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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] - in the first 3 months after surgery, prosthetic joint infection are generally related to surgical contamination at the time of implantation - most often caused by more virulent organisms, including Staphylococcus aureus, anaerobes, gram-negative bacilli, & polymicrobial infection [1] - 3-24 months after surgery less virulent organisms including Cutibacterium (Propionibacterium) species, Enterococcus faecalis, Staphylococcus epidermidis Clinical manifestations: 1) previously painless prosthetic joint becomes painful - first 3 months after surgery - acute pain, warmth, effusion, & fever. - wound drainage & dehiscence may also develop - 3-24 months after surgery - insidious onset, subacute persistent joint pain, mild effusion, slight warmth, less frequent systemic signs of infection 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 - Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  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
  13. Beam E, Osmon D. Prosthetic joint infection update. Infect Dis Clin North Am. 2018;32:843-859. PMID: 30241717