Prosthetic joint infection: Treatment
- Elie Berbari, MD, FIDSA
Elie Berbari, MD, FIDSA
- Professor of Medicine
- Mayo Clinic College of Medicine
- Larry M Baddour, MD, FIDSA, FAHA
Larry M Baddour, MD, FIDSA, FAHA
- Professor of Medicine
- Mayo Clinic College of Medicine
Periprosthetic joint infection occurs in 1 to 2 percent of joint replacement surgeries and is a leading cause of arthroplasty failure [1-3]. Medical and surgical treatment of prosthetic joint infections (PJIs) will be reviewed here. Similar principles apply to infections associated with other implanted orthopedic devices, such as pins and rods .
Biofilms play an important role in the pathogenesis of PJIs. Organisms within biofilm become resistant to therapy; as a result, antimicrobial therapy is often unsuccessful unless the biofilm is physically disrupted or removed by surgical debridement. Biofilms also account for two other features of PJIs: the propensity of infection to become apparent weeks or months after surgery and the common observation that antimicrobial therapy results in a clinical response that is typically followed by a relapse within days or months if the infected prosthesis is retained. (See "Prosthetic joint infection: Epidemiology, clinical manifestations, and diagnosis", section on 'Biofilm'.)
The pathogenesis, clinical manifestations, and prevention of these infections are discussed separately. (See "Prosthetic joint infection: Epidemiology, clinical manifestations, and diagnosis" and "Prevention of prosthetic joint and other types of orthopedic hardware infection".)
TIMING OF INFECTION
Prosthetic joint infections are categorized according to the timing of symptom onset after implantation: early onset (<3 months after surgery), delayed onset (from 3 to 12 months after surgery), and late onset (>12 months after surgery). These infections have the following characteristics :
●Early-onset infections are usually acquired during implantation and are often due to virulent organisms, such as Staphylococcus aureus, gram-negative bacilli, anaerobic organisms, or mixed infections [1,4].
- Widmer AF. New developments in diagnosis and treatment of infection in orthopedic implants. Clin Infect Dis 2001; 33 Suppl 2:S94.
- Berbari EF, Hanssen AD, Duffy MC, et al. Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis 1998; 27:1247.
- Sperling JW, Kozak TK, Hanssen AD, Cofield RH. Infection after shoulder arthroplasty. Clin Orthop Relat Res 2001; :206.
- Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med 2004; 351:1645.
- Lentino JR. Prosthetic joint infections: bane of orthopedists, challenge for infectious disease specialists. Clin Infect Dis 2003; 36:1157.
- Hsieh PH, Lee MS, Hsu KY, et al. Gram-negative prosthetic joint infections: risk factors and outcome of treatment. Clin Infect Dis 2009; 49:1036.
- Wilde AH. Management of infected knee and hip prostheses. Curr Opin Rheumatol 1994; 6:172.
- Brandt CM, Duffy MC, Berbari EF, et al. Staphylococcus aureus prosthetic joint infection treated with prosthesis removal and delayed reimplantation arthroplasty. Mayo Clin Proc 1999; 74:553.
- 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; 56:e1.
- Hanssen AD, Spangehl MJ. Practical applications of antibiotic-loaded bone cement for treatment of infected joint replacements. Clin Orthop Relat Res 2004; :79.
- Nelson CL. The current status of material used for depot delivery of drugs. Clin Orthop Relat Res 2004; :72.
- Jacobs C, Christensen CP, Berend ME. Static and mobile antibiotic-impregnated cement spacers for the management of prosthetic joint infection. J Am Acad Orthop Surg 2009; 17:356.
- Parvizi J, Saleh KJ, Ragland PS, et al. Efficacy of antibiotic-impregnated cement in total hip replacement. Acta Orthop 2008; 79:335.
- Iarikov D, Demian H, Rubin D, et al. Choice and doses of antibacterial agents for cement spacers in treatment of prosthetic joint infections: review of published studies. Clin Infect Dis 2012; 55:1474.
- Zheng H, Barnett AG, Merollini K, et al. Control strategies to prevent total hip replacement-related infections: a systematic review and mixed treatment comparison. BMJ Open 2014; 4:e003978.
- Biring GS, Kostamo T, Garbuz DS, et al. Two-stage revision arthroplasty of the hip for infection using an interim articulated Prostalac hip spacer: a 10- to 15-year follow-up study. J Bone Joint Surg Br 2009; 91:1431.
- Cui Q, Mihalko WM, Shields JS, et al. Antibiotic-impregnated cement spacers for the treatment of infection associated with total hip or knee arthroplasty. J Bone Joint Surg Am 2007; 89:871.
- Voleti PB, Baldwin KD, Lee GC. Use of static or articulating spacers for infection following total knee arthroplasty: a systematic literature review. J Bone Joint Surg Am 2013; 95:1594.
- Mittal Y, Fehring TK, Hanssen A, et al. Two-stage reimplantation for periprosthetic knee infection involving resistant organisms. J Bone Joint Surg Am 2007; 89:1227.
- Mont MA, Waldman BJ, Hungerford DS. Evaluation of preoperative cultures before second-stage reimplantation of a total knee prosthesis complicated by infection. A comparison-group study. J Bone Joint Surg Am 2000; 82-A:1552.
- Bejon P, Berendt A, Atkins BL, et al. Two-stage revision for prosthetic joint infection: predictors of outcome and the role of reimplantation microbiology. J Antimicrob Chemother 2010; 65:569.
- Kusuma SK, Ward J, Jacofsky M, et al. What is the role of serological testing between stages of two-stage reconstruction of the infected prosthetic knee? Clin Orthop Relat Res 2011; 469:1002.
- Robbins GM, Masri BA, Garbuz DS, Duncan CP. Primary total hip arthroplasty after infection. Instr Course Lect 2001; 50:317.
- Hsieh PH, Shih CH, Chang YH, et al. Two-stage revision hip arthroplasty for infection: comparison between the interim use of antibiotic-loaded cement beads and a spacer prosthesis. J Bone Joint Surg Am 2004; 86-A:1989.
- Waldman BJ, Hostin E, Mont MA, Hungerford DS. Infected total knee arthroplasty treated by arthroscopic irrigation and débridement. J Arthroplasty 2000; 15:430.
- Sia IG, Berbari EF, Karchmer AW. Prosthetic joint infections. Infect Dis Clin North Am 2005; 19:885.
- Zeller V, Lhotellier L, Marmor S, et al. One-stage exchange arthroplasty for chronic periprosthetic hip infection: results of a large prospective cohort study. J Bone Joint Surg Am 2014; 96:e1.
- Raut VV, Siney PD, Wroblewski BM. One-stage revision of total hip arthroplasty for deep infection. Long-term followup. Clin Orthop Relat Res 1995; :202.
- Ure KJ, Amstutz HC, Nasser S, Schmalzried TP. Direct-exchange arthroplasty for the treatment of infection after total hip replacement. An average ten-year follow-up. J Bone Joint Surg Am 1998; 80:961.
- Jackson WO, Schmalzried TP. Limited role of direct exchange arthroplasty in the treatment of infected total hip replacements. Clin Orthop Relat Res 2000; :101.
- Callaghan JJ, Katz RP, Johnston RC. One-stage revision surgery of the infected hip. A minimum 10-year followup study. Clin Orthop Relat Res 1999; :139.
- Hope PG, Kristinsson KG, Norman P, Elson RA. Deep infection of cemented total hip arthroplasties caused by coagulase-negative staphylococci. J Bone Joint Surg Br 1989; 71:851.
- von Foerster G, Klüber D, Käbler U. [Mid- to long-term results after treatment of 118 cases of periprosthetic infections after knee joint replacement using one-stage exchange surgery]. Orthopade 1991; 20:244.
- Byren I, Bejon P, Atkins BL, et al. One hundred and twelve infected arthroplasties treated with 'DAIR' (debridement, antibiotics and implant retention): antibiotic duration and outcome. J Antimicrob Chemother 2009; 63:1264.
- Zimmerli W, Widmer AF, Blatter M, et al. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. Foreign-Body Infection (FBI) Study Group. JAMA 1998; 279:1537.
- El Helou OC, Berbari EF, Lahr BD, et al. Efficacy and safety of rifampin containing regimen for staphylococcal prosthetic joint infections treated with debridement and retention. Eur J Clin Microbiol Infect Dis 2010; 29:961.
- Fisman DN, Reilly DT, Karchmer AW, Goldie SJ. Clinical effectiveness and cost-effectiveness of 2 management strategies for infected total hip arthroplasty in the elderly. Clin Infect Dis 2001; 32:419.
- Peel TN, Buising KL, Dowsey MM, et al. Outcome of debridement and retention in prosthetic joint infections by methicillin-resistant staphylococci, with special reference to rifampin and fusidic acid combination therapy. Antimicrob Agents Chemother 2013; 57:350.
- Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52:e18.
- Gómez J, Canovas E, Baños V, et al. Linezolid plus rifampin as a salvage therapy in prosthetic joint infections treated without removing the implant. Antimicrob Agents Chemother 2011; 55:4308.
- Nguyen S, Pasquet A, Legout L, et al. Efficacy and tolerance of rifampicin-linezolid compared with rifampicin-cotrimoxazole combinations in prolonged oral therapy for bone and joint infections. Clin Microbiol Infect 2009; 15:1163.
- Deirmengian C, Greenbaum J, Lotke PA, et al. Limited success with open debridement and retention of components in the treatment of acute Staphylococcus aureus infections after total knee arthroplasty. J Arthroplasty 2003; 18:22.
- Berbari EF, Osmon DR, Duffy MC, et al. Outcome of prosthetic joint infection in patients with rheumatoid arthritis: the impact of medical and surgical therapy in 200 episodes. Clin Infect Dis 2006; 42:216.
- Marculescu CE, Berbari EF, Hanssen AD, et al. Outcome of prosthetic joint infections treated with debridement and retention of components. Clin Infect Dis 2006; 42:471.
- Lora-Tamayo J, Senneville É, Ribera A, et al. The Not-So-Good Prognosis of Streptococcal Periprosthetic Joint Infection Managed by Implant Retention: The Results of a Large Multicenter Study. Clin Infect Dis 2017; 64:1742.
- 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.
- Keller SC, Cosgrove SE, Higgins Y, et al. Role of Suppressive Oral Antibiotics in Orthopedic Hardware Infections for Those Not Undergoing Two-Stage Replacement Surgery. Open Forum Infect Dis 2016; 3:ofw176.
- Jørgensen PS, Tørholm C. Arthrodesis after infected knee arthroplasty using long arthrodesis nail. A report of five cases. Am J Knee Surg 1995; 8:110.
- Salgado CD, Dash S, Cantey JR, Marculescu CE. Higher risk of failure of methicillin-resistant Staphylococcus aureus prosthetic joint infections. Clin Orthop Relat Res 2007; 461:48.
- Isiklar ZU, Landon GC, Tullos HS. Amputation after failed total knee arthroplasty. Clin Orthop Relat Res 1994; :173.
- Tice AD, Hoaglund PA, Shoultz DA. Outcomes of osteomyelitis among patients treated with outpatient parenteral antimicrobial therapy. Am J Med 2003; 114:723.
- Youngster I, Shenoy ES, Hooper DC, Nelson SB. Comparative evaluation of the tolerability of cefazolin and nafcillin for treatment of methicillin-susceptible Staphylococcus aureus infections in the outpatient setting. Clin Infect Dis 2014; 59:369.
- Lowy FD. Staphylococcus aureus infections. N Engl J Med 1998; 339:520.
- Levine DP, Fromm BS, Reddy BR. Slow response to vancomycin or vancomycin plus rifampin in methicillin-resistant Staphylococcus aureus endocarditis. Ann Intern Med 1991; 115:674.
- Meehan AM, Osmon DR, Duffy MC, et al. Outcome of penicillin-susceptible streptococcal prosthetic joint infection treated with debridement and retention of the prosthesis. Clin Infect Dis 2003; 36:845.
- El Helou OC, Berbari EF, Marculescu CE, et al. Outcome of enterococcal prosthetic joint infection: is combination systemic therapy superior to monotherapy? Clin Infect Dis 2008; 47:903.
- Aboltins CA, Dowsey MM, Buising KL, et al. Gram-negative prosthetic joint infection treated with debridement, prosthesis retention and antibiotic regimens including a fluoroquinolone. Clin Microbiol Infect 2011; 17:862.
- Spinner RJ, Sexton DJ, Goldner RD, Levin LS. Periprosthetic infections due to Mycobacterium tuberculosis in patients with no prior history of tuberculosis. J Arthroplasty 1996; 11:217.
- Berbari EF, Marculescu C, Sia I, et al. Culture-negative prosthetic joint infection. Clin Infect Dis 2007; 45:1113.
- Lora-Tamayo J, Murillo O, Iribarren JA, et al. A large multicenter study of methicillin-susceptible and methicillin-resistant Staphylococcus aureus prosthetic joint infections managed with implant retention. Clin Infect Dis 2013; 56:182.
- TIMING OF INFECTION
- CLINICAL APPROACH
- Resection arthroplasty with reimplantation
- - Two stage
- - One stage
- Debridement and retention of prosthesis
- Permanent resection arthroplasty
- CHOICE OF ANTIBIOTIC THERAPY
- Empiric antibiotic therapy
- Pathogen-specific antibiotic therapy
- - Staphylococci
- - Streptococci (beta-hemolytic)
- - Enterococci
- - Gram-negative bacilli
- - Anaerobes
- - Mycobacterium tuberculosis
- - Fungi
- - Culture negative
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS