Evaluation of the standard procedure for the treatment of periprosthetic joint infections (PJI) in Germany - results of a survey within the EndoCert initiative

Rimke, Christina; Enz, Andreas; Bail, Hermann Josef; Heppt, Peter; Kladny, Bernd; Lewinski, Gabriela von; Lohmann, Christoph H.; Osmanski-Zenk, Katrin; Haas, Holger; Mittelmeier, Wolfram

doi:10.1186/s12891-020-03670-y

Cited by 16 publications

(10 citation statements)

References 39 publications

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“…In addition to surgical and pharmacological therapy, the diagnosis of a fungal infection presents a central problem. Targeted diagnostics are an important part of the treatment strategy, especially in cases of re-infection [ 45 ]. The proposed algorithm ( Figure 5 ) must be further investigated and validated in prospective studies.…”

Section: Discussionmentioning

confidence: 99%

Periprosthetic Fungal Infections in Severe Endoprosthetic Infections of the Hip and Knee Joint—A Retrospective Analysis of a Certified Arthroplasty Centre of Excellence

Enz¹,

Mueller

Warnke³

et al. 2021

JoF

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The treatment of periprosthetic joint infections (PJI), and especially of re-infections, poses a highly complex problem in orthopaedic surgery. While fungal infections are rare, they present a special challenge. The therapy is often protracted and based on limited evidence. A total of 510 hip and knee revision surgeries were analysed for the occurrence of bacterial and fungal PJI. In patients with PJI, the duration of the hospital stay and the incidence of disarticulation of the infected joint were recorded. Out of the analysed revision arthroplasties, 43.5% were due to PJI. Monomicrobial infection occurred in 55.2%, dual microbial infection in 21.4%, and polymicrobial (≥3 different bacterial or fungal species) infection in 17.2% of the cases. Overall, Candida species were detected in 12.4% cases. Candida albicans was the main fungal pathogen. In 6.9% of cases, disarticulation of the joint was the only option to control PJI. The detection of polymicrobial infection more than doubled in follow-up revisions and there was a strong association between detection of Candida infection and disarticulation (OR 9.39). The majority of fungal infections were mixed infections of bacteria and Candida albicans. The choice of a biofilm penetrating antimycotic, e.g., caspofungin, together with a sufficient standard procedure for detection and surgical treatment can help to control the infection situation. Fungal infection often proves to be more difficult to treat than anticipated and is more frequent than expected.

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Section: Discussionmentioning

confidence: 99%

Periprosthetic Fungal Infections in Severe Endoprosthetic Infections of the Hip and Knee Joint—A Retrospective Analysis of a Certified Arthroplasty Centre of Excellence

Enz¹,

Mueller

Warnke³

et al. 2021

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“…Then a one-step septic exchange of the total hip arthroplasty (THA) was performed. The one-stage exchange is one of the standard procedures for PJI, which is usually based on strict patient criteria and is performed in a selected patient population which meet certain requirements [ 10 ]. The high risk for periprosthetic infections was a consequence of the comorbidities of the patient.…”

Section: Case Presentationsmentioning

confidence: 99%

Severe polymicrobial and fungal periprosthetic osteomyelitis persisting after hip disarticulations treated with caspofungin in risk patients: a case series

Enz

Müller

Mittelmeier

et al. 2021

Ann Clin Microbiol Antimicrob

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Background Periprosthetic fungal infections are considered rare and opportunistic infections. Treatment is difficult, and established standards do not yet exist. The choice of the appropriate antifungal drug might affect the patient outcome. Cases All the three cases presented showed polybacterial recurrent infection of the revision hip arthroplasty. All patients were of younger age, had multiple revisions of the endoprosthesis, each had a large partial femoral replacement greater than 40% of the femoral length, gentamycin-loaded cement, and a long anchoring distance of the used intramedullary stem. Due to the severe life-threatening infection with deep osteomyelitis, an amputation had to be performed. However, despite surgical intervention, the fungal dominated infection persisted. Finally, only the use of caspofungin allowed permanent infection control. Conclusion The polybacterial infection is driven by the symbiosis between fungi and bacteria. Therefore, eradication of the fungus is required to achieve elimination of the bacteria. Antimycotics of the echinocandin-class, such as caspofungin, may be considered as initial treatment.

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“…A first evaluation in 2015 already showed differences in therapy standards depending on the size of the centre, i.e. the number of revision cases per centre per year, influenced the choice of procedure [16]. Choices regarding one-or two-stage procedures and the type of anchorage of the final implant were investigated as well as the preferred interval between the two surgeries in two-stage revision.…”

Section: Introductionmentioning

confidence: 99%

Evaluation of the standard procedure for treatment of periprosthetic joint infections of total knee and hip arthroplasty: a comparison of the 2015 and 2020 census in total joint replacement centres in Germany

Osmanski-Zenk

Klinder

Rimke

et al. 2021

BMC Musculoskelet Disord

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Background There are different procedures for both, the diagnosis and the therapy of a periprosthetic joint infection (PJI), however, national or international guidelines for a standardised treatment regime are still lacking. The present paper evaluates the use of the predominant treatment protocols for PJI in certified total joint replacement centres (EPZ) in Germany based on an EndoCert questionnaire. Materials and methods The questionnaire was developed in cooperation with the EndoCert Certification Commission to survey the treatment protocols for septic revision arthroplasties in EPZ. Questions targeted the various treatment options including prosthesis preserving procedures (DAIR - Debridement, antibiotics, irrigation, and retention of the prosthesis), one-stage revision, two-stage revision, removal of the endoprosthesis and diagnostic sampling prior to re-implantation. All certified EPZ participated (n = 504) and the results from the current survey in 2020 were compared to data from a previous analysis in 2015. Results The number of centres that performed DAIR up to a maximum of 4 weeks and more than 10 weeks after index surgery decreased since 2015, while the number of centres that provided a one-stage revision as a treatment option increased (hip: + 6.3%; knee: + 6.6%). The majority of the centres (73.2%) indicated a 4–8 week period as the preferred interval between prosthesis removal and re-implantation in two-stage revision in hip as well as knee revisions. Centres with a higher number of revision surgeries (> 200 revisions/year), opted even more often for the 4–8 week period (92.3%). In two-stage revision the use of metal-based spacers with/without reinforcement with antibiotic-containing cement as an interim placeholder was significantly reduced in 2020 compared to 2015. There was also a clear preference for cemented anchoring in two-stage revision arthroplasty in the knee in 2020, whereas the majority of hip replacements was cementless. Additionally, in 2020 the number of samples for microbiological testing during the removal of the infected endoprosthesis increased and 72% of the centres took five or more samples. Overall, the number of EPZ with a standardised protocol for the procedure expanded from 2015 to 2020. Conclusion While there was a trend towards standardised therapeutic algorithms for PJI with more uniform choices among the centres in 2020 compared to 2015, the treatment often remains an individual decision. However, since a consistent treatment regime is of vital importance with an expected rise of total numbers of revision arthroplasties, uniform definitions with regard to comparability and standardisation are necessary for the further development of the EndoCert system.

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Evaluation of the standard procedure for the treatment of periprosthetic joint infections (PJI) in Germany - results of a survey within the EndoCert initiative

Cited by 16 publications

References 39 publications

Periprosthetic Fungal Infections in Severe Endoprosthetic Infections of the Hip and Knee Joint—A Retrospective Analysis of a Certified Arthroplasty Centre of Excellence

Periprosthetic Fungal Infections in Severe Endoprosthetic Infections of the Hip and Knee Joint—A Retrospective Analysis of a Certified Arthroplasty Centre of Excellence

Severe polymicrobial and fungal periprosthetic osteomyelitis persisting after hip disarticulations treated with caspofungin in risk patients: a case series

Evaluation of the standard procedure for treatment of periprosthetic joint infections of total knee and hip arthroplasty: a comparison of the 2015 and 2020 census in total joint replacement centres in Germany

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