A Multicenter Study of Irrigation and Debridement in Total Knee Arthroplasty Periprosthetic Joint Infection: Treatment Failure Is High

Urish, Ken; Bullock, Andrew G; Kreger, Alexander M.; Shah, Neel; Jeong, Kwonho; Rothenberger, Scott D.; Irrgang, James J.; Klatt, Brian A.; Hamlin, Brian R.

doi:10.1016/j.arth.2017.11.029

Cited by 123 publications

(86 citation statements)

References 31 publications

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“…Similarly, the type of cement and dosage of antibiotic in two-stage revisions was not standardized, nor were the diagnostic criteria for confirming eradication and clearance for reimplantation. Although the lack of treatment standardization in PJI is not unique to our study [29][30][31][32] , we acknowledge that this makes interpretation of a single variable (the intravenous antibiotic) difficult to interpret with regard to treatment outcome. The formalization of PJI consensus criteria has improved treatment standardization in our institution over the past year and we plan to re-evaluate daptomycin performance on more recent cases treated by a smaller group of high volume revision surgeons.…”

Section: Discussionmentioning

confidence: 99%

Assessing the Role of Daptomycin as Antibiotic Therapy for Staphylococcal Prosthetic Joint Infection

Carli

Miller

Kapadia

et al. 2020

J. Bone Joint Infect.

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Background: The role of daptomycin, a potent, safe, convenient anti-staphylococcal antibiotic, in treatment of prosthetic joint infection (PJI) is unclear. We evaluated our experience with the largest cohort of patients with staphylococcal PJI managed with daptomycin. Methods: A cohort of staphylococcal hip and knee PJI treated with daptomycin was identified by hospital records from 2009 to 2016. All cases met Musculoskeletal Infection Society International Consensus criteria for PJI. The primary endpoint was 2 year prosthesis retention. Univariate analyses and regression statistics were calculated. Results: 341 patients with staphylococcal PJI were analyzed. 154 two-stages (77%) and 74 DAIR procedures (52%) met criteria for treatment success at 2 years. 77 patients were treated with daptomycin, of which 34 two-stages (68%) and 15 DAIRs (56%) achieved treatment success. Pairwise and regression analysis found no association between treatment success and daptomycin use. Organism (DAIR only) and Charlson Comorbidity Index scores (DAIR and two-stage) were significantly associated with treatment outcome. Six daptomycin patients (7.8%) had adverse side effects. Discussion: Daptomycin fared no better or worse than comparable antibiotics in a retrospective cohort of staphylococcal hip and knee PJI patients, regardless of surgical strategy. Conclusion: The convenient dosing, safety, and potency of daptomycin make it an attractive antibiotic for staphylococcal PJI. However, these advantages must be weighed against higher costs and rare, but serious side effects.

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Section: Discussionmentioning

confidence: 99%

Assessing the Role of Daptomycin as Antibiotic Therapy for Staphylococcal Prosthetic Joint Infection

Carli

Miller

Kapadia

et al. 2020

J. Bone Joint Infect.

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“…Although there is a range of pathogenesis from simple, superficial abscesses to life threatening systemic sepsis, the outcomes of these disease processes resolve over a limited time period. An exception is surgical infection where chronic infections can develop over an extended period of time and biofilm formation plays an important physiologic role (5, 11). Regulation of growth, biofilm formation, and antibiotic tolerance could have important roles of bacteria physiology in this disease state.…”

Section: Discussionmentioning

confidence: 99%

“…Total knee arthroplasty is a common surgical procedure, and the most common reason for failure is infection, termed periprosthetic joint infection (3, 4). S. aureus periprosthetic joint infection can be culture negative for prolonged periods (5, 6), has high failure rates above 50% once treatment is initiated (5), and a 5-year mortality of 20% (7–9), higher than many common cancers (10). Similar to other surgical implant associated infections, the challenge in treating this disease involves the ability of S. aureus to develop a chronic biofilm associated infection tolerant to antibiotics (11, 12).…”

Section: Introductionmentioning

confidence: 99%

The Toxin Antitoxin MazEF DrivesStaphylococcus aureusChronic Infection

Mandell

Donegan

et al. 2019

Preprint

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48Staphylococcus aureus is the major organism responsible for surgical implant infections. 49Antimicrobial treatment of these infections often fails leading to expensive surgical intervention 50and increased risk of mortality to the patient. The challenge in treating these infections is 51 associated with the high tolerance of S. aureus biofilm to antibiotics. MazEF, a toxin-antitoxin 52 system, is thought to be an important regulator of this phenotype, but its physiological function 53 in S. aureus is controversial. Here, we examined the role of MazEF in developing chronic 54infections by comparing growth and antibiotic tolerance phenotypes in three S. aureus strains 55to their corresponding strains with disruption of mazF expression. Strains lacking mazF 56 production showed increased biofilm growth, and decreased biofilm antibiotic tolerance. 57Deletion of icaADBC in the mazF::tn background suppressed the growth phenotype observed 58with mazF-disrupted strains, suggesting the phenotype was ica-dependent. We confirmed 59 these phenotypes in our murine animal model. Loss of mazF resulted in increased bacterial 60 burden and decreased survival rate compared to its wild-type strain demonstrating that loss of 61the mazF gene caused an increase in S. aureus virulence. Although lack of mazF gene 62 expression increased S. aureus virulence, it was more susceptible to antibiotics in vivo. 63Combined, the ability of mazF to inhibit biofilm formation and promote biofilm antibiotic 64tolerance plays a critical role in transitioning from an acute to chronic infection that is difficult to 65 eradicate with antibiotics alone. 66 67Importance 68Surgical infections are one of the most common types of infections obtained in a hospital. 69Staphylococcus aureus is the most common pathogen associated with this infection. These 70infections are resilient and difficult to eradicate as the bacteria form a biofilm, a community of 71 bacteria held together by an extracellular matrix. Compared to bacteria floating in liquid, 72bacteria in a biofilm are more resistant to antibiotics. The mechanism behind how bacteria 73 develop this resistance and establish a chronic infection is unknown. We demonstrate that 74 mazEF, a toxin-antitoxin gene, inhibits biofilm formation and promotes biofilm antibiotic 75 tolerance which allows S. aureus to transition from an acute to chronic infection that cannot be 76 eradicated with antibiotics but is less virulent. This gene not only makes the bacteria more 77 tolerant to antibiotics but makes the bacteria more tolerant to the host. 78 79

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“…However, the success in controlling the infection varies from 31% to 100%. 13,[14][15][16][17] Although the term DAIR is not used in megaprosthesis infection papers, the outcome of debridement and implant retention in this group of patients has been very poor. Jeys et al reported that there were 68 patients of 136 patients treated with local debridement.…”

Section: Discussionmentioning

confidence: 99%

Antibiotic-laden cement wrap: A simple but effective way of treating patients with megaprosthesis infection

Lam

Yau

et al. 2019

J Orthop Surg (Hong Kong)

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Infection is one of the commonest causes for megaprosthesis failure. The current treatment includes antibiotics but no surgery, debridement, prosthesis removal and joint fusion, prosthesis revision or amputation. Success in controlling infection may be less than 50% in implant revision. The overall risk of amputation is more than 20%. We believe that repeated debridement with antibiotic-laden cement wrap (ALCW) may be a reliable alternative for managing the megaprosthesis infection. The purposes of this article are to identify whether ALCW is an effective way of eradicating the megaprosthesis infection, the associated complications and the functional outcome after management by ALCW. Methods: This was a retrospective study of patients with megaprosthesis infection. From January 2014 to June 2016, there were five patients with tumour megaprosthesis infection who had undergone the ALCW procedure. Ages ranged from 17 to 59 years of age. Male to female ratio was 4:1. The patients studied had humeral (1), proximal femoral (1), distal femoral (1) and proximal tibial (2) prostheses. All patients had follow-ups more than 1 year (21-52 months) after treatment. Results: All patients recovered from their implant infection and the implants were retained in all patients. There was no sign of infection in the most recent follow-up. One patient died of osteosarcoma recurrence. One patient had a large block of cement causing plastic insert dislodgement in the shoulder joint 1 year after surgery. Another patient with a dislocated hip cup had revision carried out in the final debridement. The most recent Musculoskeletal Tumor society (MSTS) scores ranged from 21 to 30. All patients were satisfied with their treatment. Conclusions: In this preliminary report of a small number of patients, ALCW has achieved 100% infection control. ALCW may be an easy and effective alternative for managing the megasprosthesis infection. The complications associated can be avoidable. The functional outcome is excellent.

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A Multicenter Study of Irrigation and Debridement in Total Knee Arthroplasty Periprosthetic Joint Infection: Treatment Failure Is High

Cited by 123 publications

References 31 publications

Assessing the Role of Daptomycin as Antibiotic Therapy for Staphylococcal Prosthetic Joint Infection

Assessing the Role of Daptomycin as Antibiotic Therapy for Staphylococcal Prosthetic Joint Infection

The Toxin Antitoxin MazEF DrivesStaphylococcus aureusChronic Infection

Antibiotic-laden cement wrap: A simple but effective way of treating patients with megaprosthesis infection

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