Update on Prosthetic Joint Infections 2017

Transcription

1 Update on Prosthetic Joint Infections 2017 George F. Chimento, MD, FACS Chair, Department of Orthopaedic Surgery Associate Professor, University of Queensland School of Medicine Ochsner Medical Center New Orleans, LA DISCLOSURE Consultant Stryker Paid Research Support-Depuy Stock Holder- Sight Medical Editorial Board- Journal of Arthroplasty 1

2 MSIS DEFINITION MAJOR CRITERIA Two positive periprosthetic cultures with phenotypically identical organism A sinus tract that communicates with the joint MINOR CRITERIA- (need three) Elevated Serum ESR/CRP Elevated Synovial Fluid Leukocyte Count or Positive Leukocyte Esterase Strip Elevated Synovial Polymorphonuclear Neutrophil Count Positive Histological Periprosthetic Tissue Analysis (Frozen Section) Single Positive Culture TIMING OF INFECTION Early 3 Months from Surgery Usually Virulent Organism Delayed 3-24 months Less Virulent Organism Late >24 Months Hematogenous Seeding 2

3 COMMON INFECTING ORGANISMS Organism United States United Kingdom Australia S. aureus 35% 29% 40% Coag neg Staph 31% 36% 13% Strep 11% 7% 3% Enterococcus 7% 9% 1.5% Gram neg bacilli 5% 12% 5% Other 11% 7% 37% Table From PJI Management Guide-J. Parvizi BIOFILM Definition (Costerton) Community of bacterial cells that is adherent to a surface interface or to each other and encased in a self-produced polymeric matrix Formed by Staph Allows Survival in Sub-optimal Periods of Growth Stages Attachment/Micro-colony Formation/Maturation/Shedding Anti-Microbial Resistance 3

4 INCIDENCE and BURDEN 1 Million Hip and Knee Arthroplasties Annually Projected 4 Million by % Incidence for THA % Incidence for TKA Incidence Higher First Two Years After Surgery Risk of Late Infection 0.5% Cost Expected to exceed 1.62 Billion by 2020 PREDISPOSING FACTORS Morbid Obesity BMI > 50 over 20X chance of getting an infection Older Age/ Male Gender Race/Socioeconomic Status Smoking Co-Morbidities Diabetes Hb A1C/ Glycemic Control ASA > 3 RA Depression/Psychosis 4

5 PREDISPOSING FACTORS Malnutrition Serum Albumin < 3.5 g/dl Serum Transferrin < 200 mg/dl Total lymphocyte count <1,500 mm 3 Vitamin D Deficiency Post-Traumatic Arthritis Revision Surgery Recent Corticosteroid Injection Anticoagulation PREVENTION Pre Operative Optimization Decolonization with Mupirocin and Chlorhexidine Universal vs. Screened Antibiotic Prophylaxis Prior to Incision?Vancomycin No Need for Dosing after Incision is Closed 5

6 PREVENTION Intra-Operative Methods Normothermia + Alcohol Based Skin Prep + Adhesive Dressing +- Betadine Irrigation +- Space Suit +- Bone Cement +- Transfusion DIAGNOSIS History/Examination Labs ESR > 30 CRP> 10 Aspiration Off antibiotics at least two weeks Leukocyte Count > 2500 PMN > 70% Leukocyte Esterase Alpha Defensin 97% Sensitive and Specific 88 % positive Predictive Value/99% Negative Predictive Value 6

7 DIAGNOSIS Radiographs Peri-prosthetic Lucency Nuclear Imaging High Sensitivity/Low Specificity Not Useful First Year Post-operatively CT/MRI/PET Scan Intra-Operative Frozen Section > 10 Polys/High Power Field Gram Stain DIAGNOSIS Methods to Improve Sensitivity of Cultures Sonication Frees Bacteria from Prosthesis Multiplex Polymerase Chain Reaction (PCR) Isolate Bacterial DNA Fluorescence in situ Hybridization (FISH) Visualize Biofilm 7

8 DIAGNOSIS Special Circumstances Post Operative (Within 6 Weeks) Serum CRP> 95 Synovial WBC> 27,800 Synovial PMN > 89% Partial Knee CRP> 14 Synovial WBC> 6200 Inflammatory Arthritis CRP >17 Synovial WBC> 3400 TREATMENT Debridement, Antibiotics, and Implant Retention (DAIR) Indications Acute Infections Adequate Soft Tissue-No Sinus No immunocompromise Low Virulence Organisms Technique No Role for Arthroscopic Debridement Don t Hold Pre-op Antibiotics Antibiotics Choice Duration 8

9 TREATMENT Debridement, Antibiotics, and Implant Retention (DAIR) Results % Best with Low Virulence Organisms No Role for Multiple Procedures Culture Negative Infections Results of Subsequent Two-Stage Procedure TREATMENT Two Stage Exchange Gold Standard Technique Removal Antibiotic Spacer = Articulating? Antibiotics = Type/Duration Re-implantation Criteria Labs Antibiotic Holiday Re-aspirate 9

10 TREATMENT Two Stage Exchange Re-Implantation?Frozen Section Obtain Soft Tissue Cultures Suppressive Antibiotics = Organisms (MRSA/Fungal/Mycobacterium) = Duration? TREATMENT Two Stage Exchange Results 80-85% Successful Eradication Poorer Functional Results Equal Patient Satisfaction Increase in Complications Increased Mortality at One Year Risks of Failure Culture Negative Resistant Organisms Increased Re-implantation Operative Time 10

11 TREATMENT One Stage Exchange Less Morbidity Indications Good Soft Tissue Minimal Bone Loss Known Organism Sensitivities Meticulous Technique 77% Successful Eradication TREATMENT Suppression Traditionally Reserved for Medically Frail Patients Antibiotic Associated Complications Unknown Optimal Duration Success Rates 20-80% Resection Arthroplasty Arthrodesis Amputation 11

12 QUESTIONS THANK YOU 12