Efficacy of Single-stage Revision with Aggressive Debridement Using Intra-articular Antibiotics in the Treatment of Infected Joint Prosthesis

Abstract

Prosthetic joint infections (PJI) of the hip and knee are uncommon, but result in significant morbidity and mortality when they do occur. Current management consists of a combination of either single- or two-stage exchange of the prosthesis and/or exchange of polymer components with intravenous (IV) antibiotics (4–6 weeks) and intraoperative debridement of the joint prior to reimplantation. However, failure rate, morbidity, and expense associated with current management are high, especially if the infection involves resistant pathogens and/or osteomyelitis. Also, the current use of systemic antibiotics does not allow for high local concentrations of the drug and biofilm penetration of the infected prosthesis. To overcome these difficulties, we examined the outcomes of aggressive operative debridement of the infected prosthesis. This was achieved through the use of a single-stage revision and administration of high concentrations of local intra-articular antibiotics via Hickman catheters. We present 57 patients with PJI who were treated with intra-articular antibiotics and single-stage revisions. Minimal systemic toxicity was observed along with a 100% microbiologic cure rate and 89% without relapse at 11-month follow-up despite isolation of multidrug resistant pathogens. This is the largest study to date using this method in the treatment of PJI.

Treatment Options and Outcomes of Vancomycin-Resistant Enterococcus in prosthetic joint infections: Case Report and Potential Implications for Military Cases

“…High levels of antibiotic may overcome the resistance mechanisms of the bacteria, and thus the minimum inhibitory concentration, without causing systemic toxicity (3,20,21). The concentrations in adjacent bone are also higher via intraarticular antibiotics as compared to intravenous administration (9,20,21).…”

“…This allows for localized delivery of antibiotics, thereby increasing penetration into the joint space (3,9). A one-stage revision with placement of Hickman catheters allows for higher rates of microbiologic cure, characterized by negative follow-up synovial fluid cultures in patients with susceptible pathogens (3). Most significantly, the use of catheters supplying intraarticular antibiotics allows possible improvement of arthroplasty salvage rates and less limb loss, as compared to more traditional twostage revision (3,(19)(20)(21).…”

“…This allows for localized delivery of antibiotics, thereby increasing penetration into the joint space (3,9). A one-stage revision with placement of Hickman catheters allows for higher rates of microbiologic cure, characterized by negative follow-up synovial fluid cultures in patients with susceptible pathogens (3).…”

“…From 2000 to 2009, rates of knee replacement in the United States nearly doubled, increasing from about 120 to 215 per 100,000 people (1). Infection, however, poses one of the greatest risks of failure, found in 0.5% to 3% of patients (1)(2)(3). Within the veterans health administration, 43% of readmissions in the year post hip or knee arthroplasty are caused by infection (4).…”

Use of Intra-Articular Clindamycin in the Treatment of Prosthetic Joint Infections With Bacteroides fragilis in a Patient with Sickle Cell Disease

“…However, previous publications from this group and others have used a variety of intra-articular antibiotics to treat PJI with other pathogens such as methicillin-sensitive and methicillin-resistant Staphylococcus, a variety of gram-negative pathogens but not anaerobes. 9,10 Because of the patient's age and history of previous surgeries and underlying disease processes and the need to return to her active lifestyle and school, we elected to try to treat her with intra-articular clindamycin. She tolerated the antibiotics with no adverse reactions at all.…”