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Prosthetic joint infection: Managing infection in a bionic era

Article  in  Journal of Antimicrobial Chemotherapy · September 2014

DOI: 10.1093/jac/dku246 · Source: PubMed

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Matthew Dryden
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J Antimicrob Chemother 2014; 69 Suppl 1: i3 – i4
doi:10.1093/jac/dku246

Prosthetic joint infection: managing infection in a bionic era

Matthew Dryden*

Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester SO22 5DG, UK

*Tel: +44-1962-824451; Fax: +44-1962-825431; E-mail: matthew.dryden@hhft.nhs.uk

There is increasing demand for prosthetic joint surgery and patients are becoming more challenging due to an
ageing population often with comorbidities and immunosuppression. While prosthetic joint infection (PJI) rates
are generally low, infection can be catastrophic for the patient and hence prevention of infection is critical.
Infection, when it does occur, is further complicated by the global rise in antimicrobial resistance. This article
introduces a series of papers on the epidemiology of PJI, its diagnosis, use of novel inflammatory markers and

Downloaded from http://jac.oxfordjournals.org/ by guest on November 3, 2015

molecular techniques, clinical presentation, importance of biofilms, treatment guidelines and, finally, various
strategies and novel antibiotic treatment regimens.

Keywords: septic arthritis, antibiotics, surgical infection, infection rates

Two critical and interrelated factors in the success of ever-more-
technical surgery to replace or reconstruct damaged biological
structures such as joints with prosthetic or foreign material are
the prevention of infection and having means to treat infection
when it occurs. While the demand for such surgery is increasing,
ensuring good clinical outcomes is becoming more challenging
due to an ageing population often with comorbidities, such as
obesity or immunosuppression. In addition, there is increasing
concern that rising global antibiotic resistance may make such
surgery less effective in the future. It is imperative that there is
global cooperation in ensuring responsible antibiotic use in
human medicine, veterinary practice and agriculture, improving
public health and infection control and supporting research in
infection management.1
This Supplement comprises a series of articles that provide a
combination of review of current practice as well as discussions
of novel approaches to the optimal diagnosis and management
of prosthetic joint infection (PJI) and discussions of novel and opti-
mal treatments of PJI. Replacement of damaged joints improves
quality of life immensely.2 Infection is among the most serious
complications as this can subject the sufferer to weeks and months
of pain, discomfort and misery. Many of the standard techniques
involved in prosthetic joint surgery have been developed to prevent
infection3 and by and large these work well. Among the strategies
that are employed are screening patients pre-operatively for
staphylococcal carriage, pre-operative antiseptic baths, skin anti-
sepsis at operation, antibiotic prophylaxis, laminar air flow in the
operating theatre, skilled and aseptic surgical technique, minimiz-
ing blood loss and maintaining body temperature.
Trends in the epidemiology of PJI in the UK are reported by
Lamagni.4,5 Infection rates are generally low and voluntary
reporting in the UK to Public Health England (formerly the HPA)
gives national figures for surgical site infection (SSI) and PJI.4,5
Approximately 1 in 100 patients undergoing hip prosthesis surgery
and 1 in 200 undergoing knee prosthesis surgery developed an SSI.
Of these infections, just over half affected the deeper tissue or joint.
The risk of SSI was highest in repair of neck of femur procedures,
where 1 in 60 patients developed an SSI. Rates of SSI increased
with patient age and the number of risk factors for infection pre-
sent at the time of operation. Inclusion of post-discharge surveil-
lance data (readmissions) has increased the number of SSIs
detected. Post-discharge infections comprised 41% of SSIs overall
and 58% in knee prosthesis during 2009/10. In 485194 procedures
in the UK over 5 years (2005 – 10), there were 3496 (0.72%)
reported SSIs. European and international PJI rates are similar.2,3
The diagnosis of PJI remains difficult. In addition to con-
ventional diagnosis, novel techniques in molecular diagnosis
and assessment of novel inflammatory markers are reviewed.
Saeed6 reports a wide range of existing and experimental diag-
nostic techniques and Hartley 7 comments on highly sensitive
molecular diagnosis, which may also provide greater insights
into the aetiology of PJI. Diagnostic investigations often involve
complex collaboration between the orthopaedic surgeon, radiolo-
gist and microbiologist/infection specialist. The main challenge is
often establishing the depth of infection and whether the pros-
thesis is actually involved. As highlighted by Barrett and Atkins8
in their article on clinical presentation, the diagnosis of PJI can
be a challenge and has major consequences for the patient.
Conventional microbiology remains relatively straightforward.
Staphylococcus aureus remains the most common pathogen
and is reported as causing 40% of SSIs. In knee prostheses,
the most common organisms reported for inpatient SSIs were
coagulase-negative staphylococci (30%). The second most com-
mon organisms were Enterobacteriaceae for inpatient SSIs.

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Dryden
However, the proportion of infections associated with these
pathogens was higher in recent years. The proportion of S. aureus
isolates resistant to methicillin (MRSA) was lower than the propor-
tion of methicillin-susceptible S. aureus (MSSA). MRSA and MSSA
now account for 16% and 22% of all inpatient SSIs, respectively,
with MSSA now the most common cause of all inpatient SSIs. The
data suggest that in the UK at least, the proportion of MRSA caus-
ing SSI is falling.
The surveillance of the microbial aetiology is important because
guidelines for treatment, reviewed by Minassian et al.9 in this
Supplement, will need to be reviewed as the epidemiology changes
and in relation to geographical differences. The specific challenges
of biofilms in PJI and antibiotic penetration are reviewed by
Jaqueline and Caillon10 while other authors discuss their experi-
ences or review the roles of newer antibiotics, singly or in combin-
ation, in the treatment of PJI in two European centres.11,12
Preventing infection is a critically important aspect of joint
replacement. However, when complications arise, infection, if pre-
sent, must be accurately diagnosed. If infection is present, suc-
cessful treatment of confirmed PJI requires close collaboration
between the surgeon and infection specialist. No two patients
are the same and treatment strategies often need to be individu-
ally tailor-made involving antimicrobial treatment, soft tissue
care, removal of prostheses and early or late revision. All of
these have a place, as occasionally does long-term antibiotic sup-
pressive therapy for those patients who are medically unfit or
mechanically unsuitable for further surgery.
Transparency declaration
This article is part of a Supplement sponsored by the BSAC and supported
by an unrestricted educational grant from Pfizer. The author has no con-
flict of interest to declare.
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