Oral Antibiotics Following Two Stage Exchange: Listen Up! I Know - PowerPoint PPT Presentation

Oral Antibiotics Following Two Stage Exchange: Listen Up! I Know the Answer Michael P . Ast, MD Director, Outpatient Joint Replacement Program Mercer County Surgery Center Director, Robotic Joint Replacement Program RWJ-Barnabas University Hospital- Hamilton Some slides courtesy of C Della Valle

Disclosures • I have no relevant disclosures for this talk

Periprosthetic Joint Infection • Gold Standard remains 2-Stage revision • Keys to success – Making the diagnosis – Identifying an organism – Good relationship with ID partners – Careful and thorough surgical technique – Post-operative care

Making the Diagnosis • MSIS Criteria • Clinical Exam – Sinus Tract • Synovial Fluid Analysis – 2 positive cultures from separate samples • Lab markers (ESR/CRP) • Synovial Cell Count and Neutrophil %

Identifying the Organism • One of the most important determinants of clinical success • Understanding resistance • Planning antibiotics for spacer • Planning post-operative antibiotics

ID Partnership • Must have good relationship with ID • If chronic infection have patient seen pre-operatively to facilitate postop care and planning • Seen by ID weekly or bi-weekly after surgery until reimplantation • Seen prior to termination of antibiotic therapy

Surgical Technique • Thorough debridement most important • Evaluate soft tissue remaining for planning of future surgery • Mobile vs. Static spacer • As many cultures as possible • Hold for 21 days for p. Acnes • DNA analysis of Biofilm?

Post-operative Care • Question regarding post-operative antibiotics after re-implantation • A significant number of patients fail 2- Stage revision with either recurrence of previous infection or new infection • Small retrospective study 2011 showed decreased failures with prolonged post- op oral abx Zywiel et al. Int Orthop 2011

Oral Antibiotics Reduce Failure Following Two-Stage Exchange For PJI: A Multi-Center Randomized Controlled Trial The Knee Society Research Group

• Jonathan M. Frank • Javad Parvizi • Erdan Kayupov • Thomas Vail • Gregory K Deirmengian • Erik Hansen • Mario Moric • Antonia Chen • John Segreti • David Backstein • Matthew S. Austin • Timothy Tan • Scott Sporer • David Dalury • Curtis W. Hartman • Michael Mont • Kevin L. Garvin • Craig J Della Valle • James J. Purtill

Methods 94 Patients enrolled from 7 Centers following invitation to all members of the Knee Society • All patients met MSIS criteria for PJI at stage-1 • All had no evidence of infection at stage-2 Randomized to no further abx OR 3-Month course of po abx tailored to the original infecting organism • Abx selection discussed with a single ID attending to standardize treatment

Results Failures Secondary to PJI Log Rank Survival Controls: p < .0232 8 of 40 20% Abx: 2 of 40 5%

Results 7 of 8 Failures in control group NEW organism Both failures in the abx group SAME organism Group Days to Fail Original Failure Control 9 E. Faecalis S. Epi Control 16 Peptostreptococcus S. Epi Control 21 S. Epi, MSSA MSSA Control 29 MSSA Serratia Marcens Control 30 MSSA S. Epi Control 40 MSSA Group B Strep Control 175 Proteus Morganella Control 468 B. Fragilis S. Lugdunensis Abx (Duricef) 347 MAI, S. Epi S. Epi Abx (Ceftin) 467 MSSA MSSA

Discussion • Results suggest that 3 months of oral antibiotics after 2 Stage revision reduces the rate of failure secondary to PJI • Majority of failures in the control group were NEW organisms (7 of 8) • Majority of the failures in the controls were EARLY (6 of 8) • Both failures in the treatment group SAME organism Is the 3 months of po abx further treatment or extended prophylaxis?

PREVENTION! • Data is mixed but simple pragmatic approach to preventing infections is prudent • Options: – Pre-operative Hibiclens wipes – Nasal decolonization – Adding Vanco to Ancef for high risk patients or locations – Intra-operative betadine lavage – No routine use of Abx cement

Thank you!