1. Prevention and Management of Infected Joint Replacements Jim Nairus, MD New England Baptist Hospital

2. Financial Disclosure I have received no funding from any sources related to topics of this discussion

3. Three Major Sources of Infection Patient Surgical Team Hospital Environment

4. Incidence With Prophylaxis 0.5% to 2% with primary joint replacements 0.5% to 2% with primary joint replacements 3-5% after revision joint replacements 3-5% after revision joint replacements Incidence lowered with perioperative antibiotics Controversial: Antibiotic Cement, UV lights, space suits, laminar flow, less traffic in operating room

5. Ramifications Most devastating complication High cost to hospital and patient $15,000 to $30,000 loss to hospital per patient $15,000 to $30,000 loss to hospital per patient Barrack CORR 1996 3 mos to 1 year out of life 3 mos to 1 year out of life Very debilitating Very debilitating

6. Organisms 75% caused by staph Staph epidermidis (non-aureus) most common, followed by staph aureus and then MRSA Staph epidermidis (non-aureus) most common, followed by staph aureus and then MRSA 10% strep usually viridens 10% gram negatives Not as bad as previously thought Not as bad as previously thought 5% Others

7. Optimizing Patient Lose weight Obesity with increased infection rate due to longer surgical time, greater surgical dissection, and high calorie poor nutrition diet Obesity with increased infection rate due to longer surgical time, greater surgical dissection, and high calorie poor nutrition diet Namba et al in 2005 showed obese patients 6.7% higher risk of infection Namba et al in 2005 showed obese patients 6.7% higher risk of infection Control perioperative blood sugar in diabetics Stop TNF Alpha Antagonists one dosing cycle prior to surgery

8. Optimizing Patient Pre-operative staph screening Molecular DNA studies have shown majority of infecting strains are part of resident’s nasal flora Molecular DNA studies have shown majority of infecting strains are part of resident’s nasal flora PCR test for staph aureus and MRSA PCR test for staph aureus and MRSA Nasal Bactroban if nares positive for MSSA or MRSA Nasal Bactroban if nares positive for MSSA or MRSA Rao in 2008 showed reduced infections from 2.6% to 1.5% Vancomycin and isolation precautions for MRSA Vancomycin and isolation precautions for MRSA

9. Antibiotic Prophylaxis The Most Important Factor in Lowering Infections Charnley lowered infection rate from 7% to 0.5% Charnley lowered infection rate from 7% to 0.5% Want highest blood concentration of antibiotic at time of incision Should be completed within 20 to 60 minutes prior to incision Should be repeated if surgery lasts more than 2 hours or when patient loses more that 30% of blood volume (1.5L) Should be continued for 24 hours post-op No evidence of efficacy beyond 24 hours No evidence of efficacy beyond 24 hours

10. Kefzol Considered by many to be best Bactericidal Excellent tissue penetration, rapid (within minutes) and good bioavailability Broad spectrum (active against all skin flora including gram negatives) Disadvantage: does not cover MRSA or MRSE Patients weighing greater than 80 kg should get 2 gr

11. Vancomycin Should be administered to patients colonized with MRSA or MRSE Not best for MSSA Disadvantage: needs to be administered over 1 to 1.5 hours and is oftentimes not timed correctly Does not cover any gram negatives Probably best for revisions JBJS ’04 – 30% of pos revision cultures resistant to Kefzol JBJS ’04 – 30% of pos revision cultures resistant to Kefzol

12. Penicillin Allergic Patients 5% of individuals allergic to penicillin are allergic to cephalsporins (Kefzol) Can give test dose of Kefzol Especially if allergy is rash Especially if allergy is rash Probably not with anaphylaxis or swelling Probably not with anaphylaxis or swelling Should never give Clindamycin Bacterostatic only Bacterostatic only Consider Vancomycn

13. Kefzol and Vancomycin Covers almost all organisms Controversial because of development of resistance especially to Vancomycin Consider in high risk patients Obesity, revisions, anemia, diabetes, smokers, immunocompromised, prior surgeries Obesity, revisions, anemia, diabetes, smokers, immunocompromised, prior surgeries

14. Antibiotic Impregnated Cement Advantages: Lower incidence of infection Lower incidence of infection Norwegian Arthroplasty Registry (10,611 THR’s) and Swedish Joint Registry (92,675 THR’s) Disadvantages Higher incidence resistant organisms (Swedish Registry, Kendall JArthrop ’96) Higher incidence resistant organisms (Swedish Registry, Kendall JArthrop ’96) Structural support (can use up to 2g per 40g bag of cement) Structural support (can use up to 2g per 40g bag of cement) Cost Cost

15. Cost Bag of cement approximately $60 Tobramycin cement as high as $300 Usually use two bags of cement Adding Vancomycin to cement only costs extra $10 to $20 Unfortunately have to mix at time of surgery Unfortunately have to mix at time of surgery Costs time and ?sterility Costs time and ?sterility

16. Chiu et al, JBJS 2001 Prospective randomized study (340 TKR’s) 0 infections in atbx cement group and 5 (3.1%) infections in non-atbx group Chiu et al, JBJS 2002 showed 5 cases of infection were all in diabetics

17. Personal Preference Tobramycin cement in all revisions not replanted for infection Vancomycin cement in all replant TJR’s after infection Tobramycin cement in TJR’s in diabetics, rheumatoid’s, UTI’s, and immunocompromised Non-antibiotic cement in all others

18. Operating Room Environment Multiple studies show contamination from people present in OR (surgical team, anesthesia team, patient) People shed from 1,000 to 10,000 bacteria per minute Bacterial contamination not shown to be prevented by surgical gowns although switching from cloth to plastic gowns lessened bacterial shed

19. Laminar Flow and Ventilated Suits Swedish registry > 150,000 TJR’s No decrease risk for infection with ventilated suits or laminar flow as long as prophylactic antibiotics used New Zealand Registry showed higher incidence of infection with both laminar flow and space suits

20. Operating Room Ritter has shown that number of bacteria cultured at surgical site and on surgical table directly proportional to number of people in operating room Number of times door opens directly proportional to number of bacteria present

21. Avoid Overuse of Antibiotics Wound drainage TemperaturesErythema Can mask deep infection where antibiotics are not helpful and change classification from acute to chronic infection

22. Persistent Wound Drainage Established Knee Infections 17-50% have persistent wound drainage beyond 3-4 days 17-50% have persistent wound drainage beyond 3-4 days Krakow ’93 J Arthroplasty 8/597 (1.3%) – Persistent Drainage 8/597 (1.3%) – Persistent Drainage All taken back to OR All taken back to OR Average 12.5 days post-op Average 12.5 days post-op Two (25%) had positive deep cultures Two (25%) had positive deep cultures None developed clinical infection None developed clinical infection Conclusions: Conclusions: Persistent drainage = impending infection Aggressive operative treatment recommended

23. Etiology ½ infections introduced at the time of surgery or immediately post-op 1/3 are hematogenous Remainder not sure

24. Classification All based on the duration of signs and symptoms Acute AcutePost-operative Within 4 weeks of surgery Within 4 weeks of surgeryHematogenous Within 4 weeks of symptoms Within 4 weeks of symptoms Chronic Chronic More than 4 weeks from surgery or symptoms

25. Diagnosis LabsX-rays Bone scan Aspiration Intra-op Frozen section Intra-op culture

26. LabsCBC Rarely positive Rarely positive Sed rate Very sensitive but not specific Very sensitive but not specific Usually > 35 Usually > 35 Takes 1 yr to return to normal after surgery Takes 1 yr to return to normal after surgery C-reactive Protein Peaks 48 hrs post-op and declines to normal 2-3 weeks later Peaks 48 hrs post-op and declines to normal 2-3 weeks later Used to monitor treatment Used to monitor treatment Can be elevated with CAD Can be elevated with CAD

27. Plain Radiographs Only positive with osteolysis in chronic infections

28. Bone scan Positive with aseptic loosening and infection Need tagged WBC scan to be more specific May not be reliable May not be reliable

29. Aspiration False positive in 0- 15% False negative when organisms have poor vitality Should be selective and use with labs Get cell count with it

30. Cell Count Cut-off value shown to be 1,100 to 3,000 WBC Lower glucose than blood glucose Lower glucose than blood glucose Differential with 60-80% Neutrophils Differential with 60-80% Neutrophils Definitely not the 50,000 WBC for native knee Definitely not the 50,000 WBC for native knee Higher value for recently operated on knee Higher value for recently operated on knee With these parameters shown to be very good test

31. Intra-op Frozen Section Intra-op Gram stain Poor sensitivity and poor predictive value Poor sensitivity and poor predictive value Morgan JBJS 2009 Can get false positives from debris Using 5 PMN’s/PHPF 84% sensitive and 96% specific Lonner suggests 10 PMN’s/PHPF Lonner suggests 10 PMN’s/PHPF Should always use when replanting after infection or when highly suspicious

32. Intra-op Cultures Gold standard Send 5 samples (2/5 for positive) 6-13% false positive Correlate with pathology

33. Treatment Based on Classification Need to know duration of symptoms Need to do in a timely fashion

34. Acute Early Post-op Surgical debridement with change of anything easily removable Then treat with at least 6 wks of IV antibiotics 10 to 50% success rate 10 to 50% success rate No role for arthroscopy

35. Late Chronic Resection with or without antibiotic cement spacer Staged revision with frozen section after normal labs and aspiration (80% to 96% successful) Recurrence rate 10% Use antibiotic cement in knees 1 stage exchange not as successful 58% to 83% 58% to 83%

36. Acute Hematogenous Surgical debridement and change easily removable parts and 6 wks IV atbx Surgical emergency 80% success rate if done within one week of onset of symptoms 10 to 50% success rate if done within four weeks of symptoms

37. Surgical Debridement and Component Retention Results improve with urgency of procedure Need one-year or lifetime oral suppressive antibiotics after 6 wks IV antibiotics 1 yr failure rate 54% 2 yr failure rate 69%

38. Girldestone Resection Arthroplasty For Poor medical candidates Those unable to comply with post-op rehab Immunosuppressed Excellent success rate Pain-free and some younger patients can ambulate with assistive devices

39. Arthrodesis Instead of resection arthroplasty in knee Wichita Nail, plates, or external fixator

40. PROSTALAC for Hips Allows better patient mobilization Control over limb length discrepancy Easier second surgery 90-97% success rate Cultures more likely to be positive if infection still present Longer O.R. time

41. My Results 28 PROSTALAC’s 4 cement coated Austin Moore, 24 Depuy 2 failures for recurrent infection Both in same patient 3 failures for dislocation or failure of acetabular component 7 reimplantations after Girdlestones 2 late dislocations No infections

42. Knee Antibiotic Cement Spacer Cement spacer or PROSTALAC Should have at least 3g vanco powder per 40g bag of cement Tobramycin cement not good enough

43. PROSTALAC in KNEES Advantages Able to mobilize with less scarring Able to mobilize with less scarring Easier second surgery Easier second surgeryDisadvantages Components do not fit well Components do not fit well Some studies have shown longer persistent drainage Some studies have shown longer persistent drainage

44. Thank You