Treatment of prosthetic joint infections
- Elie Berbari, MD, FIDSA
Elie Berbari, MD, FIDSA
- Associate Professor of Medicine
- Mayo Clinic College of Medicine
- Larry M Baddour, MD, FIDSA
Larry M Baddour, MD, FIDSA
- Professor of Medicine
- Mayo Clinic College of Medicine
Periprosthetic joint infection occurs in 1 to 2 percent of joint replacement surgeries and is one of the leading causes of arthroplasty failure [1-3]. The issues relating to the medical and surgical treatment of prosthetic joint infections (PJIs) will be reviewed here. Infections associated with other implanted orthopedic devices, such as pins and rods, will not be specifically discussed but similar principles apply .
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 "Clinical manifestations and diagnosis of prosthetic joint infections", section on 'Biofilm'.)
The pathogenesis, clinical manifestations, and prevention of these infections are discussed separately. (See "Clinical manifestations and diagnosis of prosthetic joint infections" and "Epidemiology and prevention of prosthetic joint infections".)
TIMING OF INFECTION
Prosthetic joint infections (PJIs) 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 S. aureus, gram-negative bacilli, anaerobic organisms, or mixed infections [1,4].
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- 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.
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- 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
- Replacement arthroplasty
- - 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
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS