The Right Time to Safely Re-Evaluate Empirical Antimicrobial Treatment of Hip or Knee Prosthetic Joint Infections

Abstract

Currently, no guideline provides recommendations on the duration of empirical antimicrobial treatment (EAT) in prosthetic joint infection (PJI). The aim of our study was to describe the time to growth of bacteria involved in PJI, rendering possible decreased duration of EAT. Based on a French multicentre prospective cohort study, culture data from patients with confirmed hip or knee PJI were analysed. For each patient, five samples were processed. Time to positivity was defined as the first positive medium in at least one sample for virulent pathogens and as the first positive medium in at least two samples for commensals. Definitive diagnosis of polymicrobial infections was considered the day the last bacteria were identified. Among the 183 PJIs, including 28 polymicrobial infections, microbiological diagnosis was carried out between Day 1 (D1) and D5 for 96.7% of cases. There was no difference in the average time to positivity between acute and chronic PJI (p = 0.8871). Microbiological diagnosis was given earlier for monomicrobial than for polymicrobial infections (p = 0.0034). When an optimized culture of peroperative samples was carried out, almost all cases of PJI were diagnosed within five days, including polymicrobial infections. EAT can be re-evaluated at D5 according to microbiological documentation.

Antibiotic Stewardship in Treatment of Osteoarticular Infections Based on Local Epidemiology and Bacterial Growth Times

“…As mentioned above, the Gram-positive bacteria growing after day 5 were C. acnes, followed by CoNS and Streptococcus spp. Similar findings were reported previously, e.g., in a French study aiming at estimating the right time to reevaluate EAT in hip and knee prosthetic joint infections, where more than 96% of the OAI-causing organisms were identified by day 5 and where the bacteria identified after 5 days were only Gram-positive bacteria, with only one case of Enterobacterales (20). Therefore, we propose adapting EAT by continuing daptomycin as monotherapy in order to reduce patient exposure to broad-spectrum antibiotics as well as to their individual and collective side effects.…”

“…Polymicrobial OAI, which represent 42% of OAI in our setting, were documented later than monomicrobial OAI. However, as in other studies, only Gram-positive bacteria grew after 5 days (20)(21)(22) in both mono-and polymicrobial OAI. Only three GNB grew after the first 2 days, but still within 5 days after sampling.…”

A Short-Course Antibiotic Prophylaxis Is Associated with Limited Antibiotic Resistance Emergence in Post-Operative Infection of Pelvic Primary Bone Tumor Resection

“…In terms of resistance patterns, most of the microorganisms involved in the SSIs in this study were susceptible to conventional antibiotics for bone and joint infections [40]. For the remaining microorganisms, we found that only 2.8% were MRSE and 3.2% were multidrug-resistant MRSE, for which conventional per os therapeutic options can be used such as cotrimoxazole, linezolid, and fusidic acid.…”

“…In our practice, an aggressive DAIR is performed at the slightest suspicion of infection, with replacement of the mobile implants whenever possible. We associate an intravenous probabilistic antibiotic treatment, using the association piperacillin-tazobactam + linezolid [40,45], after performing bacteriological sampling secondarily tailored to the microorganisms detected intraoperatively (Supplementary Table S1). This probabilistic approach aims to provide early infection treatment so as to limit delayed or chronic infections of any material implanted for reconstruction [46].…”

Prosthetic Joint Infection: Updates on Prevention, Diagnosis and Therapy

“…The two final studies of this issue are related to the treatment of PJI. Firstly, Deroche et al examined the optimal time for the safe re-evaluation of the empirical antibiotic choice during the operative treatment of hip and knee PJI [14]. The authors analysed data from 183 confirmed PJIs and concluded that almost 97% of all positive cultures were available within five days after the surgery when the culture protocol was optimised.…”