Optimal Irrigation and Debridement of Infected Total Joint Implants with Chlorhexidine Gluconate

Smith, Daniel C.; Maiman, Richard; Schwechter, Evan M.; Kim, Jong Hun; Hirsh, David M.

doi:10.1016/j.arth.2015.05.005

Cited by 47 publications

(28 citation statements)

References 21 publications

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“…Chlorine dioxide directly kills the bacteria by disrupting transport across cell walls and effectively penetrates the glycocalyx. Chlorine dioxide was chosen as a treatment for this study instead of chlorhexidine, because unlike chlorine dioxide, chlorhexidine has been shown to be efficacious against PJI . The purpose of this investigation was to evaluate the efficacy of topical applications against Methicillin‐sensitive S. aureus biofilms grown in vitro on metals commonly used in hip and knee arthroplasties, including cobalt chrome (CoCr), titanium alloy (Ti), and stainless steel (SS).…”

mentioning

confidence: 99%

Topical adjuvants incompletely remove adherent Staphylococcus aureus from implant materials

Ernest

Machi

Karolcik

et al. 2017

Journal Orthopaedic Research

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Adjuvant treatments including Betadine, Dakin's solution (sodium hypochlorite), or hydrogen peroxide (H O ) have been attempted to eradicate prosthetic joint infection caused by biofilm or intracellular bacteria. The purpose of this study was to evaluate the in vitro abilities of chemical adjuvants to decrease Staphylococcus aureus (S. aureus) biofilm presence on orthopaedic implant grade materials, including titanium, stainless steel, and cobalt chrome. S. aureus biofilms were grown for 48 h and evaluated for baseline colony forming units/centimeter squared (CFU/cm ) and compared to treatments with Betadine, Dakin's solution, H O , or 1% chlorine dioxide (ClO ). Control discs (n = 18) across all metals had an average of 4.2 × 10 CFU/cm . All treatments had statistically significant reductions in CFU/cm when compared to respective control discs (p < 0.05). For all metals combined, the most efficacious treatments were Betadine and H O , with an average 98% and 97% CFU/cm reduction, respectively. There were no significant differences between reductions seen with Betadine and H O , but both groups had statistically greater reductions than Dakin's solution and ClO . There was no change in antibiotic resistance patterns after treatment. Analysis of S. aureus biofilms demonstrated a statistically significant reduction in biofilm after a five-minute treatment with the modalities, with an average two log reduction in CFU/cm . Statement of clinical significance: While statistically significant reductions in CFU/cm were accomplished with chemical adjuvant treatments, the overall concentration of bacteria never fell below 10 CFU/cm , leading to questionable clinical significance. Further techniques to eradicate biofilm should be investigated. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1599-1604, 2018.

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confidence: 99%

Topical adjuvants incompletely remove adherent Staphylococcus aureus from implant materials

Ernest

Machi

Karolcik

et al. 2017

Journal Orthopaedic Research

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“…Furthermore, it has been shown to be more efficacious in removing methicillin-resistant Staph. aureus (MRSA) biofilms than other solutions [28]. In this study, only 2438 patients had chlorhexidine as the irrigation fluid as compared to 5071 patients who had Betadine® when pooling the included studies.…”

Section: Discussionmentioning

confidence: 99%

The Effect of Irrigation Fluid on Periprosthetic Joint Infection in Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis

Wood

Ekhtiari

Mundi

et al. 2020

Cureus

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Introduction Rates of osteoarthritis and total joint arthroplasty (TJA) are on the rise globally. Periprosthetic joint infection (PJI) is the most devastating complication of TJA. A number of different intraoperative interventions have been proposed in an effort to reduce infection rates, including antibiotic cements, local antibiotic powder, and various irrigation solutions. The evidence on the importance of irrigation solutions is limited but has gained prominence recently, including the publication of a large randomized controlled trial (RCT). Thus, the purpose of this study was to evaluate the effectiveness of various irrigation solutions and pressures at reducing the rates of PJI. Methods A systematic review was performed using the electronic databases MEDLINE, Embase, and Web of Science. All records were screened in duplicate. Data collected included basic study characteristics, the details of the intervention and comparison solutions, if applicable, and rates of superficial and deep infection. A meta-analysis of comparative studies was performed to assess for consistency and potential direction of effect. Results A total of ten studies were included, of which one was an RCT, eight were retrospective cohorts, and one was a case series. In total, there were 29,630 TJAs in 29,596 patients. The mean age ranged from 61 to 80 years. Six studies compared povidone-iodine (Betadine®) to normal saline, two studies compared chlorhexidine to saline, one study compared "triple prophylaxis" to standard practice, and one study used gentamicin but had no comparison group. The pooled risk ratio for deep infection in studies using Betadine® compared to saline was 0.62 (95% confidence interval [CI]: 0.33-1.19), while for chlorhexidine it was 0.74 (95%CI: 0.33-1.65).

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“…Schwechter et al 61 showed that CHG solutions could be potentially used to decrease biofilm load on orthopedic implants using an in vitro model of MRSA infection. In a later study published by the same group, the optimal concentration of CHG was evaluated and it was demonstrated that concentrations above 2% was required to provide persistent decrease in the biofilm 62. Although lower concentrations of CHG decreased biofilm, there was a rebound growth of biofilm with prolonged incubation suggesting that the lower concentrations are likely to be ineffective in vivo.…”

Section: Irrigation Solutionmentioning

confidence: 99%

Use of Chlorhexidine Preparations in Total Joint Arthroplasty

George

Klika

Higuera

2017

J. Bone Joint Infect.

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Prosthetic joint infection (PJI) is a serious complication after total joint arthroplasty (TJA). Chlorhexidine is a widely used antiseptic because of its rapid and persistent action. It is well tolerated and available in different formulations at various concentrations. Chlorhexidine can be used for pre-operative skin cleansing, surgical site preparation, hand antisepsis of the surgical team and intra-articular irrigation of infected joints. The optimal intra-articular concentration of chlorhexidine gluconate in irrigation solution is 2%, to provide a persistent decrease in biofilm formation, though cytotoxicity might be an issue. Although chlorhexidine is relatively cheap, routine use of chlorhexidine without evidence of clear benefits can lead to unnecessary costs, adverse effects and even emergence of resistance. This review focuses on the current applications of various chlorhexidine formulations in TJA. As the treatment of PJI is challenging and expensive, effective preparations of chlorhexidine could help in the prevention and control of PJI.

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Optimal Irrigation and Debridement of Infected Total Joint Implants with Chlorhexidine Gluconate

Cited by 47 publications

References 21 publications

Topical adjuvants incompletely remove adherent Staphylococcus aureus from implant materials

Topical adjuvants incompletely remove adherent Staphylococcus aureus from implant materials

The Effect of Irrigation Fluid on Periprosthetic Joint Infection in Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis

Use of Chlorhexidine Preparations in Total Joint Arthroplasty

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