Management of prosthetic joint infections in France: a national audit to identify key situations requiring innovation and homogenization

Abstract

Background Prosthetic joint infections (PJI) are one of the most serious complication of arthroplasty. The management of PJI needs a multidisciplinary collaboration between orthopaedic surgeon, infectious disease specialist and microbiologist. In France, the management of PJI is organized around reference centres (CRIOACs). Our main objective was to perform an audit through a questionnaire survey based on clinical cases, to evaluate how French physicians manage PJI. Eligible participants were all physicians involved in care of patients presenting a PJI. Physicians could answer individually, or collectively during a multidisciplinary team meeting dedicated to PJI. The survey consisted as three questionnaires organized in a total of six clinical cases. Results Answers from the CRIOACs to the three questionnaires were 92, 77, and 53%. Between 32 and 39% of respondents did not administer antibiotic prophylaxis despite positive S. aureus pre-operative documentation. One-stage exchange strategy was widely preferred in all clinical cases, with no difference between CRIOACs and other centres. Rifampicin was prescribed for S. aureus PJI, in a situation with (90–92%) or without any prosthesis (70%). There was no consensus for the total antibiotic regimen duration, with prescriptions from six to 12 weeks for a majority of respondents. Conclusions Surgical strategy for the management of PJI was homogenous with a preference for a one-stage exchange strategy. Medical management was more heterogenous, which reflects the heterogeneity of those infections and difficulties to perform studies with strong conclusions.

Antibiotic Therapy for Prosthetic Joint Infections: An Overview

“…More generally, in their experience, clindamycin-combination therapy appeared to be effective against erythromycin-resistant, lincosamide-susceptible staphylococcal BJIs [69]. According to a 2019 French national audit on the management of PJIs, clindamycin was a frequent choice, when fluoroquinolones or rifampicin were not available [70]. Other oral rifampicin combination partners include co-trimoxazole, minocycline or doxycycline [5] and linezolid.…”

“…Despite its high bioavailability and in vitro efficacy against methicillin-resistant staphylococci [78], linezolid was the last choice to treat staphylococcal PJIs in a French national audit, probably because of its safety profile and the restricting nonuse beyond 4 weeks [71,[78][79][80][81][82]. Study results showed increased tolerability of prolonged tedizolid administration [70,83], but data for broader use are lacking [84].…”

“…Antibiotic prophylaxis against PJI is still controversial [70,126]. In 2019, 30-39% of the teams included in a recent French national audit did not use it for PJI patients [70].…”

“…In our cohort of 157 chronic PJIs treated with one-stage exchange arthroplasty, median preoperative therapy lasted 7 (IQR 4-11) days [56]. According to the recent French national audit, 12% of the teams started preoperative antibiotic therapy for late hematogenous S. agalactiae PJIs, based on joint aspiration-culture results [70].…”