GUIDELINES FOR PROSTHETIC JOINT INFECTION CID 2013 IDSA GUIDELINES FOR PROSTHETIC JOINT INFECTION CID 2013

EXECUTIVE SUMMARY Joint replacement remains a highly effective intervention for OA -Becoming increasingly more common with an aging patient demographic Prosthetic joint infection (PJI) is one of the more serious complications of joint replacement Management involves surgical intervention and often long courses of antibiotics A multidisciplinary team approach is essential Despite extensive research, there is ongoing uncertainly regarding diagnosis and management with many different approaches Aim of guidelines is to help reduce the morbidity, mortality and costs associated with PJI

Evidence level

1. What preoperative evaluation and intraoperative testing should be performed to diagnose PJI and what is the definition of PJI PREOPERATIVE EVALUATION Suspect PJI in patients with the following (B-III) -sinus tract/ persistent wound discharge over joint prosthesis -painful prosthesis, both acute and chronic (particularly early after implantation and if there was a history of surrounding infection)

Evaluation should include thorough history and exam (C-III) -type of prosthesis and date implanted -any wound healing issues -past surgery of the same joint -current clinical symptoms (infective) -drug history and allergies -current microbiology if available

INVESTIGATIONS Combination of CRP and ESR offers best sensitivity and specificity (A- III) Plain radiograph should be performed in all patients (A-III) Diagnostic arthocentesis in all patients unless diagnosis clinically evident and surgery planned. Synovial fluid analysis for total cell count and differential, culture for aerobic and anaerobic organisms (A-III)

INVESTIGATIONS If medically stable- withhold antibiotics for at least two weeks prior to obtaining microbiology specimens to increase yield (B-III/ A-II) Obtain blood cultures if sudden onset of symptoms or febrile or suspected concomitant infection (B-III) Imaging studies such as bone scans, leukocyte scans, MRI, CT or PET scans should not be routinely used to diagnose PJI (B-III)

INTRAOPERATIVE MANAGEMENT Intraoperative histopathological examination should be performed at revision surgery if the presence of infection is in doubt and the results would affect management (deciding between immediate revision and a 2 stage approach) (B-III) A minimum of 3 and ideally 6 peri-prosthetic intraoperative samples or the explanted prosthesis itself should be submitted for aerobic and anaerobic culture to maximise a microbiologic diagnosis (B-II)

DEFINITION OF PJI (there is no standard defined definition) The presence of a sinus tract communicating with the prosthesis is definitive evidence of PJI (B-III) The presence of purulence, without another known etiology, surrounding a prosthesis is definitive evidence of PJI (B-III) The presence of histological signs of acute inflammation on surgical peri-prosthetic specimens is highly suggestive of PJI (B-II) Two or more microbiologic specimens containing the same organism should be considered as definitive evidence of PJI (B-III)

II. What different surgical strategies should be considered for a patient with PIJ? Ultimate decision up to orthopedic surgeon in consultation with infectious diseases and other appropriate input as necessary (C-III) Decision is to remove prosthesis or not? -depends on clinical status of patient -may need to modify ideal treatment on light of circumstances, although this may risk relapse (B-III) If to remove- one stage vs two stage

A-II

B-III, C-III

What about the poor surgical candidates? Permanent resection arthoplasty in patients who are not ambulatory, patients with limited bone stock, poor soft tissue coverage, infection due to a highly resistant organism or patients with multiple medical conditions (B-III) Amputation as a last resort but expert opinion from a center with experience in management of PJI needs to be considered first (B-III)

III. What is the medical treatment for a patient with PJI following debridement and retention of the prosthesis? Staphylococcal PJI (A-I) 2-6/52 of pathogen-specific IV therapy in combination with rifampin 300- 450mg PO BD Followed by: THA (and others)- rifampin and companion drug* for 3/12 TKA- rifampin and companion drug* for 6/12 * Depending of allergy and sensitivity profile can include ciprofloxacin, levofloxacin, Bactrim, minocycline, doxycycline, cephalexin, dicloxacillin

PJI DUE TO OTHER ORGANISMS 4-6/52 of pathogen specific IV therapy or highly bioavailable oral antimicrobial therapy (B-II) In PJI with all organisms the decision to continue chronic suppressive therapy needs to be made on a case by case basis (there was no group consensus), with monitoring for treatment failure and antibiotic toxicity

IV. What is the medical treatment for a patient with PJI following resection arthoplasty with or without planned staged reimplantation? 4-6/52 of pathogen specific IV therapy or highly bioavailable oral antimicrobial therapy (A-II)

V. What is the medical management of a patient with PJI following 1-stage exchange? Staphylococcal PJI (C-III) 2-6/52 of pathogen-specific IV therapy in combination with rifampin 300- 450mg PO BD followed by rifampin and companion drug* for 3/12 PJI DUE TO OTHER ORGANISMS 4-6/52 of pathogen specific IV therapy or highly bioavailable oral antimicrobial therapy (A-II) For all organisms chronic suppression therapy needs to be considered on a case by case basis

VI. What is the medical management of a patient with PJI following amputation? Pathogen specific antimicrobial therapy should be given 24-48 hours post amputation assuming all infected bone and soft tissue has been surgically removed and there is no bacteraemia or sepsis syndrome (C- III) If residual infected material remain then for 4-6 weeks of pathogen specific IV therapy or highly bioavailable oral therapy (C-III)

Research Gaps EPIDEMIOLOGY -Incidence rates of PJI in different arthroplasties and risk factors for PJI? DIAGNOSTICS -Could PCR be used to optimally identify organisms causing PJI? -What is the role of prosthesis sonication? -Is there an optimal incubation time to recover biofilm organisms? -What is the role of inflammatory markers in the diagnosis of PJI (both synovial and serum)?

Research gaps MANAGEMENT -There is a paucity of published randomized clinical trials to address the optimal selection of the various surgical approaches in the management of PJI (January 2013) -efficacy of oral vs parenteral therapy? -role of suppression therapy and optimal duration? -optimal time frame for 2-stage exchange? PREVENTION -Any role for antibiotic prophylaxis in patients undergoing dental or invasive procedures? -Is there a benefit of S aureus screening and decolonization?