Biofilm Theory Can Guide the Treatment of Device-Related Orthopaedic Infections

Jw, Costerton

doi:10.1097/00003086-200508000-00003

Cited by 380 publications

(307 citation statements)

References 20 publications

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“…Furthermore, we show that Ti pins in synovial fluid that contains CFZ due to preoperative prophylaxis can be colonized by added S. aureus at clinically significant numbers. In the presence of metal implants, it is now known that both in vitro (24,25) and in vivo, as few as 100 CFU of S. aureus are sufficient to establish infection (26). Accompanying this diminished level of efficacy of antibiotics in synovial fluid, our in vitro findings show that in general, up to 90% of bacteria survive, suggesting that preoperative prophylaxis may be ineffective in the synovial fluid environment.…”

Section: Discussionmentioning

confidence: 70%

Staphylococcal Persistence Due to Biofilm Formation in Synovial Fluid Containing Prophylactic Cefazolin

Dastgheyb

Hammoud

Ketonis

et al. 2015

Antimicrob Agents Chemother

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Antibiotic prophylaxis is standard for patients undergoing surgical procedures, yet despite the wide use of antibiotics, breakthrough infections still occur. In the setting of total joint arthroplasty, such infections can be devastating. Recent findings have shown that synovial fluid causes marked staphylococcal aggregation, which can confer antibiotic insensitivity. We therefore asked in this study whether clinical samples of synovial fluid that contain preoperative prophylactic antibiotics can successfully eradicate a bacterial challenge by pertinent bacterial species. This study demonstrates that preoperative prophylaxis with cefazolin results in high antibiotic levels. Furthermore, we show that even with antibiotic concentrations that far exceed the expected bactericidal levels, Staphylococcus aureus bacteria added to the synovial fluid samples are not eradicated and are able to colonize model implant surfaces, i.e., titanium pins. Based on these studies, we suggest that current prophylactic antibiotic choices, despite high penetration into the synovial fluid, may need to be reexamined.I nfection remains a major concern with orthopedic procedures, although infection rates are generally Ͻ1% (1). Because of the high prophylactic antibiotic levels within synovial fluid, the use of minimally invasive techniques, and short surgical times, infection rates remain low. However, with increasing numbers of total knee arthroplasties, infections are projected to exceed 60,000 to 70,000 cases in the United States by 2020 (2, 3). When hardware, such as a prosthesis, is present, infection is recalcitrant to antibiotic treatment. Once established, infection can cause prolonged disability, multiple operations, and increased health care costs (3, 4). According to the WHO, patients with a surgical site infection have twice the mortality rate, are twice as likely to spend time in an intensive care unit, and are five times more likely to be readmitted to the hospital than uninfected patients (5).To avoid the establishment of infection, antibiotic prophylaxis has become the standard of care (6, 7). For orthopedic procedures, cefazolin (CFZ), which is bactericidal for staphylococci, streptococci, and Escherichia coli (8, 9), is commonly used in the absence of a penicillin allergy (10). Alternative prophylactic antibiotics include fusidic acid, cloxacillin (11), cefixime (12), vancomycin, and gentamicin (13). Interestingly, synovial fluid has been suggested to possess antibacterial properties (14-16) that are attributed to hyaluronic acid within the synovial fluid (17), the induction of bactericidal/permeability-increasing protein (15), or unknown compounds, including antimicrobial peptides, within the synovial fluid (14). We recently reported that this ostensible decrease in bacterial numbers, which is perceived to be an "antibacterial" effect, is actually due to the clumping of bacteria within synovial fluid, which masks the true microbial load levels (18).The recognition of this behavior also helps to elucidate the difficulties ...

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Section: Discussionmentioning

confidence: 70%

Staphylococcal Persistence Due to Biofilm Formation in Synovial Fluid Containing Prophylactic Cefazolin

Dastgheyb

Hammoud

Ketonis

et al. 2015

Antimicrob Agents Chemother

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“…Correct handling of the samples, immediate inoculation, and immediate transfer to the laboratory are mandatory to prevent contamination of the samples. Because bacteria that lead to a periprosthetic infection sometimes exist in low numbers and grow slowly [10,16,45], an adequate length of incubation is important. We chose to incubate our specimens for 14 days [21,25,28,60].…”

Section: Discussionmentioning

confidence: 99%

Is There a Role for Tissue Biopsy in the Diagnosis of Periprosthetic Infection?

Meermans

Haddad

2010

Clinical Orthopaedics &Amp; Related Research

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Background Successful treatment of an infected joint arthroplasty depends on correctly identifying the responsible pathogens. The value of a preoperative biopsy remains controversial. Questions/purposes We (1) compared the sensitivity and specificity of both tests separately and in combination, and (2) asked whether the combination of tissue biopsy and aspiration would improve our diagnostic yield in the evaluation of periprosthetic joint infections. Patients and Methods We prospectively followed 120 patients with suspected infection of a total joint arthroplasty: 64 with THAs and 56 with TKAs. All patients had aspiration with culture and biopsy. Results The sensitivity was 83% for aspiration, 79% for biopsy, and 90% for the combination of both techniques. The specificity was 100% for aspiration and biopsy and the combination. The overall accuracy was 84%, 81%, and 90%, respectively.

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“…In an experimental study, the rate of infection for steel plates was significantly higher than that for titanium plates [2]. The bacteria within matrix-enclosed communities (biofilm) are protected against host defence and antibiotics, and clinical experience has shown that they must be removed and compromised tissue must be debrided before the infection can be resolved [10,16]. According to the above mentioned procedures of infected implants, their metallic composition and the known effect of the biofilm, in our clinic, usually remove or exchange the implants by one or two stage procedures.…”

Section: Discussionmentioning

confidence: 99%

Wound conditioning by vacuum assisted closure (V.A.C.) in postoperative infections after dorsal spine surgery

et al. 2006

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The use of vacuum assisted closure (V.A.C.) therapy in postoperative infections after dorsal spinal surgery was studied retrospectively. Successful treatment was defined as a stable healed wound that showed no signs of acute or chronic infection. The treatment of the infected back wounds consisted of repeated debridement, irrigation and open wound treatment with temporary closure by V.A.C. The instrumentation was exchanged or removed if necessary. Fifteen patients with deep subfascial infections after posterior spinal surgery were treated. The implants were exchanged in seven cases, removed completely in five cases and left without changing in one case. In two cases spinal surgery consisted of laminectomy without instrumentation. In two cases only the wound defects were closed by muscle flap, the remaining ones were closed by delayed suturing. Antibiotic treatment was necessary in all cases. Follow up was possible in 14 patients. One patient showed a new infection after treatment. The study illustrates the usefulness of V.A.C. therapy as a new alternative management for wound conditioning of complex back wounds after deep subfascial infection.

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Biofilm Theory Can Guide the Treatment of Device-Related Orthopaedic Infections

Cited by 380 publications

References 20 publications

Staphylococcal Persistence Due to Biofilm Formation in Synovial Fluid Containing Prophylactic Cefazolin

Staphylococcal Persistence Due to Biofilm Formation in Synovial Fluid Containing Prophylactic Cefazolin

Is There a Role for Tissue Biopsy in the Diagnosis of Periprosthetic Infection?

Wound conditioning by vacuum assisted closure (V.A.C.) in postoperative infections after dorsal spine surgery

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