infected prosthesis
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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
- previously painless prosthetic joint becomes painful
- loosening of prosthesis
Laboratory
- 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
- cell count may be as low as 3000/uL (50,000-100,000/uL characteristic)
- gram stain (negative in up to 40% of cases)
- synovial fluid culture
- synovial fluid cell count
- blood cultures even if afebrile[1]
- systemic inflammatory markers may be elevated
- open biopsy of bone
- neutrophils plus positive cultures indicate infection
Radiology
- X-ray may show loosening or migration of cemented prosthesis
- indium 111-labeled autologous leukocyte scan
- arthrography
- CT, MRI, or bone scan should not delay treatment & do not change initial management[1]
Management
- strategies[2]
- 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]
- resection arthroplasty with or without subsequent reimplantation
- amputation
- joint irrigation, 1-stage or 2-stage surgery (debridement with retention of the prosthesis), & 2-6-weeks of IV antibiotics
- surgery:
- in most cases removal of the prosthesis
- antibiotic-loaded cement spacers may be used with prosthesis replacement
- antibiotics
- 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]
- synergistic effect of rifampin
- lifelong oral therapy
- surgery refused
- no systemic infection
- not severe local sign of infection
- joint prosthesis is not loose
- 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]
- parenteral antibiotics for 4-6 weeks (4 weeks may be adequate[9])
- prophylactic antibiotics (cefazolin or vancomycin) before high-risk procedures in patients with prosthetic joints[1]
More general terms
Additional terms
References
- ↑ Jump up to: 1.0 1.1 1.2 1.3 1.4 1.5 Medical Knowledge Self Assessment Program (MKSAP) 11,14,16,17,18,19. American College of Physicians, Philadelphia 1998,2006,2012,2015,2018,2022.
- ↑ Jump up to: 2.0 2.1 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23230301 <Internet> http://cid.oxfordjournals.org/content/early/2012/11/29/cid.cis803.full
- ↑ Cobo J, Del Pozo JL. Prosthetic joint infection: diagnosis and management. Expert Rev Anti Infect Ther. 2011 Sep;9(9):787-802 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21905787
- ↑ Del Pozo JL, Patel R. Clinical practice. Infection associated with prosthetic joints. N Engl J Med. 2009 Aug 20;361(8):787-94 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19692690
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/23223583
- ↑ Jump up to: 6.0 6.1 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26246256 <Internet> http://jbjs.org/content/97/15/1220
- ↑ Jump up to: 7.0 7.1 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: https://www.ncbi.nlm.nih.gov/pubmed/26453989
- ↑ Jump up to: 8.0 8.1 8.2 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: https://www.ncbi.nlm.nih.gov/pubmed/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: https://www.ncbi.nlm.nih.gov/pubmed/28526565 Free Article - ↑ Jump up to: 9.0 9.1 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: https://www.ncbi.nlm.nih.gov/pubmed/31106353 https://academic.oup.com/jac/article-abstract/74/8/2394/5491482?redirectedFrom=fulltext
- ↑ Jump up to: 10.0 10.1 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: https://www.ncbi.nlm.nih.gov/pubmed/34042388 https://www.nejm.org/doi/full/10.1056/NEJMoa2020198
- ↑ Jump up to: 11.0 11.1 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
- ↑ Jump up to: 12.0 12.1 NEJM Knowledge+ Rheumatology
Patient information
infected prosthesis (prosthetic joint infection) patient information