Odds and Ends Javad Parvizi MD, FRCS Jam es Edwards Professor of - - PowerPoint PPT Presentation

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Odds and Ends Javad Parvizi MD, FRCS Jam es Edwards Professor of - - PowerPoint PPT Presentation

Jun 05, 2023 574 likes •990 views

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

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Odds and Ends

Javad Parvizi MD, FRCS

Jam es Edwards Professor of Orthopaedics Rothm an Institute at Thom as Jefferson University, Philadelphia

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Orthopedic Infections

Antibiotics

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Rothman Institute of Orthopaedics at Thomas Jefferson University

PJI and Antibiotics

  • ABX in irrigation
  • ABX in spacer
  • ABX in wound
  • Abx for prevention
  • PMMA
  • Urinary tract
  • Perioperative ABX
  • ABX only treatment
  • Duration of Abx after resection
  • Suppression after reimplantation
  • Dental prophylaxis
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Rothman Institute of Orthopaedics at Thomas Jefferson University

  • Antibiotics in PJI
  • Group 3
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Rothman Institute of Orthopaedics at Thomas Jefferson University

PJI and Antibiotics

  • Abx for prevention
  • PMMA
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Rothman Institute of Orthopaedics at Thomas Jefferson University

PJI and Antibiotics

  • Abx for prevention
  • PMMA
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Antibiotic Cem ent Registry Data

Jämsen et al: Acta Orthop 2010 Systemic & antibiotic cement Systemic antibiotics Antibiotic cement

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Antibiotic Cem ent

Meta analysis

Rate of deep infection after revision

arthroplasty is half when antibiotics was used in cement

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 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

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 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%.

International Consensus on PJI

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Rothman Institute of Orthopaedics at Thomas Jefferson University

PJI and Antibiotics

  • Abx for prevention
  • Urinary tract
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PJI Consensus

 Urine culture for

patients with sym ptom s

 Cover UTI during

surgery

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Rothman Institute of Orthopaedics at Thomas Jefferson University

PJI and Antibiotics

  • Abx for prevention
  • Perioperative ABX
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Perioperative Antibiotics

Cephalosporins Within one hour One dose may be enough

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 Prophylactic antibiotics

Prevention of PJI

Antibiotics

Vancomycin (needs 1 hour)

  • MRSA carriers
  • Remote or recent MRSA Infection
  • Institutionalized patients
  • Healthcare workers
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Rothman Institute of Orthopaedics at Thomas Jefferson University

PJI and Antibiotics

  • ABX in irrigation solution
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Antibiotic In Irrigation Solution

  • Methods:

 Washings (by bulb syringe or jet lavage) of

bacteria-coated stainless steel screws with:

1 L saline 1 L antibiotic solution (bacitracin vs.

neomycin vs. polymyxin/ neomycin)

1 L of saline containing liquid soap.

 Power irrigation >100x more effective at

bacerial removal than bulb syringe of same volume, no matter which solution.

 Antibiotics had no significant effect on

bacterial removal compared to saline alone

 Liquid soap significantly removed bacteria

almost 10-fold, compared to polymyxin (best antibiotic solution in the study) (p=0.01)

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Rothman Institute of Orthopaedics at Thomas Jefferson University

PJI and Antibiotics

  • ABX in spacer

 Not a single randomized study  Speculation  Elevating local concentration of ABX  Elution-

 Antibiotic  Cement  Individual patient

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Rothman Institute of Orthopaedics at Thomas Jefferson University

ABX in PMMA

Systematic review FDA members

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Rothman Institute of Orthopaedics at Thomas Jefferson University

PJI and Antibiotics

  • ABX in wound

 Some studies (spine)—

 Addition of vancomycin to wound

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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.

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Rothman Institute of Orthopaedics at Thomas Jefferson University

PJI and Antibiotics

  • ABX only treatment
  • Rare if ever
  • ABX cannot

eradicate biofilm

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Severe Lym phodem a

  • 75 year old woman
  • Hip Pain
  • Drainage from knee for

6 years

  • Multiple previous

surgeries

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Severe Lym phodem a

7.5 years post-op

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Rothman Institute of Orthopaedics at Thomas Jefferson University

PJI and Antibiotics

  • Duration of Abx after resection
  • Area of controversy
  • Little science
  • Gulf between Europe and

the US

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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%.

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So where did 6 weeks com e from ?

The 6 week cut-off stems

from the treatment of skeletal infections as a whole (osteomyelitis)

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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.

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Rothman Institute of Orthopaedics at Thomas Jefferson University

PJI and Antibiotics

  • Suppression after reimplantation
  • Little science
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Rothman Institute of Orthopaedics at Thomas Jefferson University

PJI and Antibiotics

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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

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Rothman Institute of Orthopaedics at Thomas Jefferson University

Suppression after Reimplantation

Results

Controls:

8 of 40 20%

Abx: 2 of 40

5%

Failures Secondary to PJI

Log Rank Survival p < .0232

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Rothman Institute of Orthopaedics at Thomas Jefferson University

PJI and Antibiotics

  • Dental prophylaxis
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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%.

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Rothman Institute of Orthopaedics at Thomas Jefferson University

Dental Prophylaxis after TJA

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Rothman Institute of Orthopaedics at Thomas Jefferson University

Koch’s Postulate does not Apply to Orthopedic (chronic) Infections

Ehrlich et al, CORR 2005

Orthopedics and Antibiotics

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Rothman Institute of Orthopaedics at 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
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Rothman Institute of Orthopaedics at Thomas Jefferson University

Data

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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
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Thank You for Your Attention