Pathogen-driven decision for implant retention in the management of infected total knee prostheses

Abstract

Purpose In prosthetic joint infections (PJIs) of the knee, debridement with implant retention is associated with a high risk of recurrence. Methods A single-centre cohort study was performed with extensive analysis of the literature covering 1980-2012. Results In 21 patients (mean age 80.4 years, 19 immunosuppressed), in association with 1.5-three months of antibiotic treatment, an attempt was made to salvage the prosthesis by open (11 patients) or arthroscopic (ten patients) debridement. After a mean follow-up of seven years (range four-20 years), patients were in remission in seven cases (33 %). Remission was achieved in 0 % of all methicillin-resistant Staphylococcus aureus (MRSA) infections (zero/three), in 0 % (zero/three) of methicillin-resistant coagulase-negative staphylococcal infections, in 29 % (two/seven) of methicillin-sensitive S. aureus infections and in 75 % (three/four) of infections due to streptococci. The literature review focused on implant preserving approaches yielded 599 cases with an overall success rate of 47 % (284/599) and significantly more remissions in streptococcal vs staphylococcal knee PJIs (43/54 vs 144/324; p< 0.01, odds ratio 4.9, 95 % confidence interval 2.4-10.9).Conclusions In addition to established indications for explantation such as implant loosening, sinus tract or methicillin resistance, the decision for debridement and retention of knee PJIs should also depend on the pathogen. Implant preservation is futile with methicillin-resistant staphylococci, but seems to be a valid option for streptococcal PJIs.

Increased risk of joint failure in hip prostheses infected with Staphylococcus aureus treated with debridement, antibiotics and implant retention compared to Streptococcus

“…Indeed, the DAIR protocol led to an average 21 % failure rate in S. aureus-infected patients compared to a much lower failure rate with monomicrobial streptococcal infections. These findings are similar to those previously reported for infected knee prostheses where streptococci led to a lower DAIR failure risk than S. aureus [11]. These data lend support to the inclusion of the pathogen nature in clinical guidelines for DAIR decisions, in particular the presence of S. aureus (even if methicillin-susceptible) or Streptococcus spp.…”

“…infections [4,6,7]. We recently reported that for DAIR-treated prosthetic total knee joint infections failure rates for S. aureus-infected patients were nearly five times higher than those due to streptococci [11]. Using a similar approach, this study reports the outcome of DAIR treatment in prosthetic hip infections due to S. aureus compared to Streptococcus spp.…”

Evaluation of a Genus- and Group-Specific Rapid PCR Assay Panel on Synovial Fluid for Diagnosis of Prosthetic Knee Infection

“…The diagnosis and management of these infections are complex (3)(4)(5)(6), with outcome contingent on detection and identification of the causative microorganism(s) (6,7). The gold standard, culture of synovial fluid, periprosthetic tissue, and/or the implant itself, has been associated with a range of sensitivities (8)(9)(10)(11)(12)(13)(14) and has various turnaround times of up to 2 weeks.…”

One-stage Revision With Catheter Infusion of Intraarticular Antibiotics Successfully Treats Infected THA

“…Finally, nearly all the hips in this study were infected with staphylococcus, so little can be determined regarding the effectiveness of this method of treatment for Gram-negative, mixed bacterial, or fungal infections. However, staphylococcal infections, especially those involving methicillin-resistant bacteria, are difficult to treat [28,34,59] and certainly represent a challenging test for our method.…”

“…Zurcher-Pfund et al [59] found that 33% of patients treated with débridement and retention of their implants survived without reinfection if the patients had antibiotic-sensitive bacteria, but that no patient who had either MRSA or MRSE was treated successfully. A similar study [30] reported that 96% of patients treated with débridement and implant retention had successful treatment and avoided reinfection, but that only 45% were successfully treated if the infecting organism was staphylococcus.…”