Odds and Ends Javad Parvizi MD, FRCS Jam es Edwards Professor of Orthopaedics Rothm an Institute at Thom as Jefferson University, Philadelphia
Orthopedic Infections Antibiotics
PJI and Antibiotics • Abx for prevention • ABX in irrigation • PMMA • ABX in spacer • Urinary tract • ABX in wound • Perioperative ABX • ABX only treatment • Duration of Abx after resection • Suppression after reimplantation • Dental prophylaxis Rothman Institute of Orthopaedics at Thomas Jefferson University
Antibiotics in PJI • Group 3 • Rothman Institute of Orthopaedics at Thomas Jefferson University
PJI and Antibiotics • Abx for prevention • PMMA Rothman Institute of Orthopaedics at Thomas Jefferson University
PJI and Antibiotics • Abx for prevention • PMMA Rothman Institute of Orthopaedics at Thomas Jefferson University
Antibiotic Cem ent Registry Data Systemic & antibiotic cement Antibiotic cement Systemic antibiotics Jämsen et al: Acta Orthop 2010
Antibiotic Cem ent Meta analysis Rate of deep infection after revision arthroplasty is half when antibiotics was used in cement
International Consensus on PJI Question: Does antibiotic-im pregnated cem ent reduce the incidence of PJI following elective total joint arthroplasty (TJA)? Consensus: Yes. Antibiotic-impregnated polymethylmethacrylate cement (ABX-PMMA) reduces the incidence of PJI following TJA and should be used in patients at high risk (see definition) for PJI following elective arthroplasty. Delegate Vote: Agree: 90 %, Disagree: 9%, Abstain: 1%.
International Consensus on PJI Question: Does antibiotic-im pregnated cem ent reduce the incidence of PJI following elective revision total joint arthroplasty (TJA)? Consensus: Yes. Antibiotic should be added to cement in all patients undergoing cemented or hybrid fixation as part of revision arthroplasty. Delegate Vote: Agree: 8 8 %, Disagree: 9%, Abstain: 3% .
PJI and Antibiotics • Abx for prevention • Urinary tract Rothman Institute of Orthopaedics at Thomas Jefferson University
PJI Consensus Urine culture for patients with sym ptom s Cover UTI during surgery
PJI and Antibiotics • Abx for prevention • Perioperative ABX Rothman Institute of Orthopaedics at Thomas Jefferson University
Perioperative Antibiotics Cephalosporins Within one hour One dose may be enough
Prevention of PJI Antibiotics Prophylactic antibiotics Vancomycin (needs 1 hour) • MRSA carriers • Remote or recent MRSA Infection • Institutionalized patients • Healthcare workers
PJI and Antibiotics • ABX in irrigation solution Rothman Institute of Orthopaedics at Thomas Jefferson University
Antibiotic In Irrigation Solution Power irrigation >100x more effective at bacerial removal than bulb syringe of same • Methods: volume, no matter which solution. Washings (by bulb syringe or jet lavage) of Antibiotics had no significant effect on bacteria-coated stainless steel screws with: bacterial removal compared to saline alone 1 L saline Liquid soap significantly removed bacteria 1 L antibiotic solution (bacitracin vs. almost 10-fold, compared to polymyxin neomycin vs. polymyxin/ neomycin) (best antibiotic solution in the study) 1 L of saline containing liquid soap. (p=0.01)
PJI and Antibiotics • ABX in spacer Not a single randomized study Speculation Elevating local concentration of ABX Elution- Antibiotic Cement Individual patient Rothman Institute of Orthopaedics at Thomas Jefferson University
ABX in PMMA Systematic review FDA members Rothman Institute of Orthopaedics at Thomas Jefferson University
PJI and Antibiotics • ABX in wound Some studies (spine)— Addition of vancomycin to wound Rothman Institute of Orthopaedics at Thomas Jefferson University
Povidone-iodine Irrigation Review of: 15 studies: 11 RCTs, 4 prospective comparative studies 10 studies found povidone-iodine irrigation to be significantly more effective at preventing SSI than saline, water, or no irrigation.
PJI and Antibiotics • ABX only treatment • Rare if ever • ABX cannot eradicate biofilm Rothman Institute of Orthopaedics at Thomas Jefferson University
Severe Lym phodem a •75 year old woman •Hip Pain •Drainage from knee for 6 years •Multiple previous surgeries
Severe Lym phodem a 7.5 years post-op
PJI and Antibiotics • Area of controversy • Little science • Gulf between Europe and the US • Duration of Abx after resection Rothman Institute of Orthopaedics at Thomas Jefferson University
International Consensus on PJI Question: Which is the ideal length of antibiotic treatm ent following rem oval of the infected im plant? Consensus: There is no conclusive evidence regarding the ideal duration of antibiotic therapy. However, we recommend a period of antibiotic therapy between 4-6 weeks. Delegate Vote: Agree: 93%, Disagree: 5%, Abstain: 2%.
So where did 6 weeks com e from ? The 6 week cut-off stems from the treatment of skeletal infections as a whole (osteomyelitis)
So where did 6 weeks com e from ? 1980 paper Failure was lower Six weeks of ABX Osteomyelitis and septic arthritis. Kolyvas, E., G. Ahronheim , M. I. Marks, R. Gledhill, H. Owen, and L. Rosenthall. “Oral Antibiotic Therapy of Skeletal Infections in Children.” Ped ia trics 65, no. 5 (May 198 0 ): 8 67– 71.
PJI and Antibiotics • Little science • Suppression after reimplantation Rothman Institute of Orthopaedics at Thomas Jefferson University
PJI and Antibiotics Rothman Institute of Orthopaedics at Thomas Jefferson University
Oral Antibiotics Reduce Failure Following Two-Stage Exchange For PJI: A Multi-Center Random ized Controlled Trial J Frank, E Kayupov, GK Deirm engian , M Moric, J Segreti, MS Austin, SM Sporer, E Hansen, C Hartm an, Garvin KL, JJ Purtill, J Parvizi, TP Vail, A Chen, D Backstein, T Tan, D Dalury, M Mont M, C Della Valle and The Knee Society
Suppression after Reimplantation Results Failures Secondary to PJI Log Rank Survival Controls: p < .0232 8 of 40 20% Abx: 2 of 40 5% Rothman Institute of Orthopaedics at Thomas Jefferson University
PJI and Antibiotics • Dental prophylaxis Rothman Institute of Orthopaedics at Thomas Jefferson University
International Consensus on PJI Question: Should a patient with TJA be given dental antibiotic prophylaxis? Consensus: The use of dental antibiotic prophylaxis in patients with TJA should be individualized, based on patient risk factors and the complexity of the dental procedure to be performed. Delegate Vote: Agree: 8 1%, Disagree: 16%, Abstain: 3%.
Dental Prophylaxis after TJA Rothman Institute of Orthopaedics at Thomas Jefferson University
Orthopedics and Antibiotics Koch’s Postulate does not Apply to Orthopedic (chronic) Infections Rothman Institute of Orthopaedics at Ehrlich et al, CORR 2005 Thomas Jefferson University
Liposom al Bupivacaine • I do not use it • Multiple studies showing it is no better than free bupivacaine • I was excited about liposomal delivery in 2003!!! Parvizi J et al Multimodal Pain Management. JBJS 2003 Rothman Institute of Orthopaedics at Thomas Jefferson University
Data Rothman Institute of Orthopaedics at Thomas Jefferson University
Alpha Defensin Would NOT use • Pus pouring out of the joint • Sinus tract • Culture already positive • All parameters for infection are positive Would use • Suspect PJI but unable to prove it Rothman Institute of Orthopaedics at Thomas Jefferson University
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