Primary foci of hematogenous periprosthetic joint infections

Transcription

1 Primary foci of hematogenous periprosthetic joint infections Dr. Anastasia Rakow Dr. Nora Renz Charité-Universitätsmedizin Berlin

2 C.S., w. 73 y.o. 07/2015: presentation with painful knee prosthesis, back pain CRP 48 mg/l, no fever Primary implantation TKA 2008 Multiple septic revisions, S. epidermidis repeatedly isolated (2012, 2013, 2014) Implantation pacemaker 2009 Aspiration of knee joint leukocyte count 2892/ul, 85% granulocytes PJI CT spine: Spondylodiscitis L3/4 and L5/S1 Blood cultures: S. epidermidis in 3/3 pairs bacteremia

3 Pathogenesis?? Perioperative (with secondary spread to spine)? Hematogenous?

4 Pathogenesis of PJI Contiguous spread from adjacent infected tissue Peri- /postinterventional colonisation 5% 20% Hematogenous spread from a distant focus through blood 75% PJIs treated at Charité, 01/ /2018

5 Pathogenesis Cardiovacular system: Pacemaker infection Bacteremia with S. epidermidis S. epidermidis (sonication) Hematogenous PJI knee Hematogenous spondylodiscitis S. epidermidis (sonication, tissue) S. epidermidis (biopsy)

6 Number of episodes Hematogenous PJI Risk 0.07% / prosthesis / year Huotari K, Acta Orthop, % in S. aureus bacteremia Murdoch DR, Clin Inf Dis, 2001 Most cases (75%) present with acute onset of symptoms after an painless period after implantation Occurr at any time after primary implantation Knee PJI Hip PJI Rakow A, Renz N (own data) Time (years)

7 Diagnostic tests Positive test All episodes (n = 106) Increased serum CRP (>10 mg/l) 96/104 (92) Pathological WBC (>10 G/l or <4G/l) 61/104 (59) Elevated synovial fluid leukocyte count 64/64(100) Peri-implant tissue histopathology 86/95 (91) Culture (synovial fluid, tissue or sonication fluid) 99/106 (93) Blood culture 43/70 (61) PJI is easy to diagnose Rakow A, Renz N (own data)

8 Pathogens Highly virulent, i.e. S. aureus, gram-negative bacilli, Streptococcus spp. Rodriguez D, CMI 2010; Uckay I, CMI 2009; Tande AJ, Clin Microbiol Rev 2014 Predominantly monobacterial infections Coagulase-negative staphylococci, 8 Clostridium innocuum, 1 Culture-negative, 1 Gram-negative bacteria, monobacterial 1 polymicrobial 1 culture-negative Enterococcus faecalis, 13 Staphylococcus aureus, 43 Streptococcus spp., 32 Rakow A, Renz N (own data)

9 Primary foci: cohort of 106 episodes 1 (+3?) colon adenoma 1 GI bleeding 2 GI infections Gastrointestinal tract, 7 Others, 3 1 contralat. PJI 1 pneumonia 1 epidural abscess 7 dental treatments 5 dental infections Oral cavity, 12 Unknown, 34 2 manipulations 10 infections Urogenital tract, 12 Skin and soft tissue, 16 Cardiovascular system, 22 9 skin erosion (pedicure, skin disease, chronic ulcers) 7 skin and soft tissue infections 14 endocarditis 5 infected CIED 3 catheter infections Rakow A, Renz N (own data)

10 Number of pathogens Pathogens primary foci Clostridia (n=1) Coagulase-negative staphylococci (n=8) Gram-negative bacteria (n=9) Enterococcus spp. (n=13) Streptococcus spp. (n=32) S. aureus (n=43) Unknown (n=34) Intravascular (n=22) Skin (n=16) Oral cavity (n=12) Focus Urogenital (n=12) Gastrointestinal (n=7) Other (n=3) Rakow A, Renz N (own data)

11 Investigation of cause Pathogen Source Diagnostics Staphylococci Blood cultures Echocardiography (TEE) Skin examination Streptococci S. oralis/mitis S. agalactiae S. dysgalactiae S. bovis/gallolyticus Enterococci Orthopantomogram (OPTG), dentist, TEE Urinanalysis, imaging abdomen, skin examination, OPTG Colonoscopy Urinanalysis, TEE Enterobacteriaceae Urinanalysis, CT Abdomen Renz N., Chirurg, 2017

12 Prophylaxis prior to procedures?

13 Reality Bacteremia after tooth brushing and dental extraction Studies not usable (wrong design) Significant bacteremia after dental interventions Prophylaxis reduces bacteremia Clinical practice: association exsists 0 min 1.5min 5min 20min 40min 60min Lockhart PB. Circulation Prospective studies needed

14 Conclusions Prostheses are at lifelong risk of hematogenous infection Recognition and treatment of primary infectious focus are crucial for high treatment success Investigation of cause according to isolated pathogen teamwork with internal medicine or ID specialist Blood cultures in every PJI with acute onset after a painless period Prevention: controversially discussed

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