periprosthetic joint infection “pji” - bvikm symposium/jan g… · periprosthetic joint...
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Titel Datum voordracht
Periprosthetic Joint infection
“PJI”
J. Geurts
Dept. Orthopaedic Surgery, MUMC+, the Netherlands
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DISCLOSURE
17-11-2017
No disclosures relevant to this presentation
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The bionic society
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Quality of life!!
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Overview
17-11-2017
• Definition
• Management
• Biofilm = enemy
• Challenges
• Future trends
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• Deep PJI is one of the most common causes for implant failure and revisions, with dramatic medical andsocioeconomic implications.
17-11-2017
• PJI is a tremendous burden for individual patients
as well as global health care
• Appropriate recognition and management are critical to
preserve/restore function and prevent exces morbidity.
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Titel Datum voordracht17-11-2017
primary revision
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By 2030 over 60% of all total joint revisions will be because of PJI
Swedish Hip registry 2016
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Definition by MSIS
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Definite PJI exists when:
Major
• There is a sinus tract communication with the prosthesis; or
• A pathogen is isolated by culture from at least 2 separate tissue or fluid samples, obtained from the
affected prosthetic joint; or
Minor
• 4 of following 6 criteria exist:
1. Elevated ESR and CRP concentration,
2. Elevated synovial leucocyte count,
3. Elevated synovial neutrophil percentage (PMN%),
4. Presence of purulence in the affected joint,
5. Isolation of a microorganism in 1 culture of periprosthetic tissue or fluid,
6. >5 neutrophils per HPF in 5 HPF’s observed from histologic analysis op periprosthetic tissue at x400
Clin Orthop Relat Res. 2011 Nov; 469(11): 2992–2994
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0–2 months 3–24 months Any time
Early postoperative
Delayed (low grade)
Late
S. aureus Streptococci Enterococci
S. aureusE. coli
Perioperative Haematogenous
Time
Type
Route
Cause
Signs Persistent pain, device loosening,
fistula
Coagulase-negative staphylococci
P. acnes
Fever, effusion,warmth, drainage
Acute orsubacute
Three types of implant infection
Zimmerli W NEJM 2004 Trampuz A Injury2006
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Definition
17-11-2017
Superficial
Deep
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Treatment strategies
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• In situ treatment : DAIR : debridement, antibiotics & implant retention
• One-step exchange
• Two-step exchange
• Definitive removal : Girdlestone / arthrodesis
• Long-term suppressive antibiotic therapy
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Debridement and retention
One stage
Two stage(short interval)
Two stage (long interval)
Treatment infected TJA
Onset ofinfection
2–4 weeksi.v.
8–10 weeksp.o.
Explantation and implantation
Explantation Implantation
6 weeksi.v.
Zimmerli W et al. N Engl J Med 2004 Borens O et al. Rev Med Suisse 2009
Explantation Implantation
(2 weeks)
“Biofilm treatment”
(with rifampin)
“Osteomyelitis treatment” (no
rifampin)
Debridement
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Titel Datum voordracht17-11-2017
Treatment concept:Surgery and Antibiotics
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J Bone Joint Surg Br 1986; Bengtson et al. Acta Orhop Scand1991
50
0
100
150
Johnson, 1986 Bengtson, 1991
Patients treated with antibiotics only
Cured
250 Cure rate 8% Cure rate 9%
200
Error: antibiotic treatment without
surgery
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What are we fighting? BIOFILM!
17-11-2017
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What are we fighting? BIOFILM!
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• Dynamic concept
• Reduced antimicrobial susceptibility
• Low growth rate
• “persisters”
• Micro-environent that impairs
antimicrobial activity
• Bacteriae also protected from
host immune system
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Biofilm: The race for the surface
3 days1 day1 min 3 h 12 h
Gristina AG. Biomaterial-centered infection: microbial adhesion versus tissue integration. Science
1987;237:1588-95
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Biofilm: The race for the surface
Microbial adhesion and biofilm formation compete with tissue integration of
host
Tissue cells win infection risk <
Bacteria win formation biofilm on implant
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Biofilm: The race for the surface
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Biofilm: The race for the surface
Bacteria attached to biomaterials are securely anchored and hardly
reachable for immune response cells and antibiotics
Biomaterials infections are hard treat
Eventually implant removal may be necessary
Polymers predeposition for st.epidermidis
Metals predeposition for st.aureus
Relative risk CrCo > stainless steel > titanium
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Biofilm Challenges
17-11-2017
Diagnostics
• With joint aspiration/swabs/tissue
cultures we find planktonic bacteria
• We cannot remove biofilm bacteria
• Sensitivity is not high enough!
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Biofilm Challenges
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Diagnostics
• Sonication
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Results of sonication study
p <0.001
Microbiologic testAseptic cases
(n = 675)
Infected cases
(n = 171)
Tissue culture 26 (4%) 126 (74%)
Sonicate culture 30 (5%) 152 (89%)
846 implants
(367 joint prostheses + 479 fracture fixation devices)
Trampuz N Engl J Med 2007
Problem : still high numbers of false positive and false negative
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Biofilm Challenges
17-11-2017
Diagnostics
• Sonication
Problems
• Risk of contamination : multi-step procedure
• Operator dependent procedures
1. Harvesting of samples in operation
2. Transport of harvested samples to lab
3. Inserting physiological solution in container
4. Sonicating the samples
5. Collecting the fluid after sonication
6. Centrifuging the fluid
7. Culturing bacteria pellet in solid media or broth
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Biofilm Challenges
17-11-2017
Diagnostics
• Sonication
Problems
Gram -
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Biofilm Challenges
17-11-2017
Diagnostics
• Dislodging of biofilm
DTT : dithiotreitol to dissolve the polysaccharide matrix
of the biofilm and detach the bacteriae
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Biofilm Challenges
17-11-2017
Diagnostics
• DTT
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Biofilm Challenges
17-11-2017
Diagnostics
• PCR
• MALDI-TOF
• Calorimetry
Pathogen identification <24h
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Biofilm Challenges
17-11-2017
Treatment
• GOAL =
• Reduce bacterial load
• Breakdown of biofilm in order to force bacteriae
in planktonic state and make them susceptible
• Ways to do this =
• Do it early
• Change all modular parts
• Mechanically disrupt biofilm
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Biofilm Challenges
17-11-2017
Treatment
• DAIR : time is running and biofilm is coming fast
• Succes-rate DAIR ↓
• With time (4w : 90%, 8w : 80%, > 8w : 50%)• Deterioration of soft tissue• “difficult-to-treat” bacteria : resistance / high MIC
eg. Enterococcus : never DAIR
• After revision
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Biofilm Challenges
17-11-2017
Treatment
• DAIR
CHANGE THE MODULAR PARTS!
Polyethylene Insert Exchange Is Crucial in
Debridement for Acute Periprosthetic Infections
following Total Knee Arthroplasty
J Knee Surg 2017;30:36–41.
Cure rate 93% versus 30% (p=0,0001)
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Biofilm Challenges
17-11-2017
Treatment : CHANGE THE MODULAR PARTS!
Oxford study• Exchange modular parts : 10y survival 86% vs 68% (p=0.02)
• Combi:• Early + exchange : 90% (78-100%)• Early + no exchange : 81% (67-95%)• Late + exchange : 79% (60-98%)• Late + no exchange : 52% (31-73%)
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Biofilm Challenges
17-11-2017
Treatment : DISRUPTION OF BIOFILM
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Biofilm Challenges
17-11-2017
Treatment
DISRUPTION OF BIOFILM
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Other Challenges ; Cultures
17-11-2017
• Instruct your orthopaedic surgeon!
• Obtain ≥ 3 tissue specimens
• No swabs, no sinus tract cultures
• No-touch technique
• Separate instruments
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Other Challenges ; Antibiotics
17-11-2017
• AB’s are not anti-inflammatory drugs should not be given to combat erythema
• Never give AB unless infection is confirmed and adequate work-up performed
• Systemic AB
• AB in the wrong way (oral monotherapy with AB with low bio-availability ;
penicillin,…)
• Rifampicin : no rifa / rifa monotherapy /…
• AB too long / too short
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Other Challenges ; Antibiotics
17-11-2017
Drug Oral bioavailability Bone penetration
Amoxicillin/clavulanic acid or ampicillin/sulbactam
15% (AUC 6x lower with PO dose)
7%
Cefuroxim, cefadroxil 10% (AUC 10x lowerwith PO dose)
12%
Ciprofloxacin 70% 48%
Levofloxacin 100% 77%
Rifampin 80% 51%
Co-trimoxazole 85% 55%
Clindamycin 90% 45%
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Other Challenges ; Antibiotics
17-11-2017
Risk factors for rifampicin resistance
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Other Challenges ; Soft tissue management
17-11-2017
If you don’t solve the problem…
• Iatrogenic fistula
• Longterm VAC treatment
Inadequate soft tissue management will lead to
• Superinfection
• Multiresistent pathogens
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Other Challenges ; Soft tissue management
17-11-2017
Probably no
indication for use
of VAC
in bone/implant
infections
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Other Challenges ; Spacer contamination
17-11-2017
• Over time : biofilm can & wil form on spacers
• Possibly induction of resistent strains
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Future trends
17-11-2017
Anti-infection coatings
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Future trends
17-11-2017
Anti-infection coatings
• Au, Ag,…
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Future trends
17-11-2017
Anti-infection coatings
• Biomolecular coatings
• cfr Hydrogel : hyaluronic acid + polylactic acid (DAC®)
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Future trends
17-11-2017
Not adressed in this talk :
• Prevention
• Diagnostics
• Imaging
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Titel Datum voordracht
So let’s join forces and battle this challenge together
17-11-2017
microbiology ortho