Osteo-articular infections (OAI) on material (prosthesis, implant, osteosynthesis)

Pr M Dupon CHU Bordeaux, France

Organized by the SPILF (Society of Infectious Pathology of French Language) with the cooperation of the following learned societies : •CMIT (College of the Academics of Infectious and tropical Diseases) •GPIP (Group of Pediatric Infectious Pathology) •SFAR (French Society of Anaesthetics and Intensive Care)•SFHH (French Society of Hospital Hygiene) •SFM (French Society of Microbiology) •SFMN (French Society of Nuclear Medicine) •SOFCOT (French Society of Orthopaedic Surgery) •SOFMER (French Society of Physical Medicine and Rehabilitation) •SFR (French Society of Radiology) •SFR (French Society) of Rheumatology)

Recommendations for the clinical practice

• Rédaction V3 complète• Réunions téléphoniques

RPC are medical and professional recommendations which can be used to establish medical references, that is " standards of practice " determining what it is suited and\or inappropriate to make, during the implementation of preventive, diagnostic and\or therapeutic strategies in given clinical situations ". These standards can be used for:

• Improve the quality of the professional practices • establish a reference table of a clinical audit • be at the origin of tools of regulation in a conventional

frame(executive).A rigorous and explicit approach must be applied to prepare "

medical and professional valid and credible recommendations.

Recommandation gradation

French High Authority of Health (HAS) gradationThis gradation of the recommendations based on the scientific level of proof of the literature does not suppose obligatorily a degree of force of these recommendations. It can exist recommendations of rank C or founded on a professional agreement nevertheless strong in spite of the absence of a scientific support.

Scientific level of proof provided by the literature

Rank of therecommendations

Niveau 1-Comparative randomized studies with high power - Meta-analyse of randomized comparative studies- Decision analysis based on well led studies

AEvidence based

Niveau 2- Randomized comparative studies withlow power- Well undertaken non-randomizedcomparative studies- Cohort studies

BScientific presumption

Niveau 3Case-witness studiesNiveau 4- Comparative studies with important bias- Retrospective studies- Series of cases

CWeak level of proof

OAI : Variable levels of proof, mostly weak In the absence of precision, the suggested recommendations correspond witha professional agreementThe expression of a professional agreement must translate a professional consensus obtained by a formalized method (vote, Delphi method…)

PLAN

1. How to classify the various osteo-articular infections on material?

2. How to assert the diagnosis of osteo-articular infections on material?

3. What are the modalities of the therapeutic care?4. What are prerequisites to minimize this type of

infections?5. What medico-legal repair for the consequences

of the postoperative ostéo-articular infections on material?

Question 1

How to classify the various osteo-articular infections on material?

Determining factors of a classification Definition of the type of material• Material of osteosynthesis

– Material (affixed to the bone: plate, intramedullary : nail; rachis: inter-somatic stems, screws, grafts, cages, artificial ligaments)– External fixing

• Prostheses• Osseous substitutes and allografts

Length of infection evolution• Ambiguity of acute or chronic infection terms

(clinician≠microbiologist≠surgeon)• Time of diagnosis after the material implantation :

– early infection: <1 mois– delayed infection: 2 to 6 months– late infection: > 6 months

No universal classification

Determining factors of a classificationTo take account of 7 fundamental points• Mode of contamination (direct, hematogen, by contiguity)• Chronology, allowing to make difference between post-operative infection and

hematogenous infection) (symptom-free period, time of contamination,delay before management)

• Infectious state (knowledge of microorganisms, repercussion of the infection)• Mechanical state of the infected site (loosened prosthesis or not, consolidated fracture or

not, material present or not, explantable or not)• Localization of the infection (peripheral bone, joint, spinal column)• State of skin and soft tissues • State of the patient (functional and general, immune status, underlying ground)

Prosthesis implantation

Remote infectious

site

Infectious signs at prosthesis

level

Beginning of medical

care

Free interval

Time of contamination

Delay before

manage-ment

temps

Surgical Site Infection risk factors (1)Opened fractures, significant risks• tibial localization • severity of the soft tissue lesions evaluated by classification of Gustilo (level 2)

Closed fractures of the long bones • Diabetes = factor of difficulty of cicatrization after osteosynthesis of ankle or the foot

(level 2)Orthopedic Surgery • significant increase of the SSI risk

– age >65 years, existence of another infectious site, preoperative stay exceeding 4 days (level 2)

• weak increase of the SSI risk– obesity, corticosteroid therapy, recent radiotherapy on operational site, healing

delay, hematoma occurence (level 2), rheumatoid polyarthritis (opinion of expert) Spine • diabetes • perioperative plasma glucose level rise (level 3)

• Rheumatoid polyarthritis no stop of the corticosteroid therapy (risk of acute suprarenal incapacity) Methotrexate continuation does not increase the risk of SSI (level 1) • Anti-TNF (HAS recommendations) Stop of the anti-TNF 2 -5 half-lives before the intervention and until complete cutaneous healing.

Microbial epidemiology

Microorganisms Frequency (%) Total Osteosynthesis

prosthesis matérial Coagulase <0 Staph. 30 à 43 22Staphylococcus aureus 12 à 23 30Streptococcus sp 9 à 10 1Enterococcus sp 3 à 7 3Gram négative bacilli 3 à 6 10Anaerobic (P acnes) 2 à 4 5Polymicrobial 10 à 12 27No bacteria 10 à 11 2Others: Candida, Corynebacteria, ..

Question 2

How to assert diagnosis of osteo-articular infections on material?

Clinical signs

Fistula = infection (level 3) In the month following material implantation (level3) •Pain of abnormal intensity•Purulent discharge•Scar disunity or necrosis

At a distance of the implementation (rank C) •Pain

After a long free interval, in front of local signs, look for a hematogenic infection (rank B) Absence of inflammatory sign: do not eliminate an infection (level 2)

Biological signs

No biological parameter is specific Leucocytose: low VPP or VPN (level 2) A normal value of VS and of CRP does not eliminate an infection (expert opinion) In the month after the implantation (rank C)• Interest of CRP follow-up• SR: no diagnostic value

After 3 months, suspicion of infection if: (rank B)• SR > 22 - 30 mm, = 82-93 %, Sp = 84 % • CRP > 10-13,5 mg / l, Se = 91-97 %, Sp = 86-92 % • if no confusing factors

Radiological signs

Need for producing a standard plain radio even if normal in 50% of the cases (rank B)

Signs to be sought (level 2):•Sequestration•Bone loosening (border width >2mm during 1 year)•Blurred osteolytic lesions•Periosteal reaction•Presence of intra-articular gas•Mobilisation or fracture of the

materialSe : 14%; Spe : 70%

Computed tomography and ultrasonography signs

Computed tomography (CT)

It is recommended to produce a scanner with injection of contrast product (rank B)

Peripheral bone structure osseous, soft tissues ++

Interferences in the vicinityof metal implants

Signs to be sought (level 2):• Periosteal reactions• Blurred osteolytic lesions• Soft tissue abnormalities

and collections

Ultrasonography

Signs : (level 2) :• Intraarticular fluid accumulation or

around the implant • Soft tissues thickening

• Absence of intra-articular effusion: strong NPVAbsence of intra-articular effusion: strong NPV

MRI, arthrographic signs

Magnetic resonance imaging (MRI)artifacts making interpretation difficult (material, immediate post-operative period)- Injection of Gadolinium ++ Signs: (level 2):•Oedema of soft tissues (hypersignal T2) •Intra-osseous or soft tissues collection •Sinus tract (hypersignal T2) •Articular effusion (hypersignal T2) •Osseous sequestration (hyposignal)

Arthrography (iodine contrast)

Sinus tract, para-articular collection, can be used to guide joint aspiration and drainage procedures.(level 2):

Nuclear imagingBone scintigraphy with HDP-Tc99m: abnormal fixation in the 3 phases (level 2): Se: 90-100%; Sp: 30-40%;VPN: 100%

Labelled leukocyte scan (or scan with anti-granulocyte antibodies) with late images at 24h (level 2) improved SpeHybrid imaging single photon emission tomography/ computed tomography (SPET/CT) increased spatial resolution• Se: 81-97%; Sp: 89-100%

But persistence of increased uptake between 6-12 months after a surgery (perform sulfo-colloids-Tc99m medullar scintigraphy to look for absence of congruence)

For the spine, scintigraphy with Gallium 67 (level 2)

Positron Emission Tomography/CT imaging with F-18 fluorodeoxyglucose is under evaluation (for chronic infection)

Imaging strategyEarly (<1 month) or hematogenous infection :• restricted contribution• puncture of a collection, with surgical asepsis, under control echo or TDM if nonaccessible clinically (rank C)

Delayed or late Infection (>1 month)1.Radio operator standard (simplicity, reproducibility, low cost)(rank B)2.TDM with injection (rank B)

puncture of a collection, with surgical asepsis, under echo or TDM or arthroscanner if clinically non-accessible (rank C)3.Imaging with radioisotopes (bone scintigraphy associated to scintigraphy with tagged PNM) (rank C)

Rachis •MRI (early or late infection)• Scintigraphy with Ga67 (delayed or late infection)(rank B)

• Absence of intra-articular effusion: strong NPV

Question 2

2.4 What is the contribution of the microbiology and the anatomo-pathology?

How to assert diagnosis of osteo-articular infections on material?

How should diagnostic microbiological sampling be performed? (1)

General principleswait a minimum of 15 days after any antibiotherapy before any test, to decrease the rate of false negative samples (except in case of sepsis and after evaluating the risk for disseminated infection)(expert advice).

Pre-operative sampling•It is strongly recommended

– not to sample with a swab on the scar, even if it is not healed. – to perform pre-operative sampling with surgical asepsis if diagnosis doubt

• It is recommended – to perform hemocultures and pre-operative sampling (puncture of a joint or of an abscess)

to rapidly initiate probabilistic antibiotherapy if general signs of sepsis– not to perform sampling from the outlet of a fistula;– to carry out hemocultures and a preoperative puncture in order to begin a probabilistic

antibiotherapy quickly if sepsis with general signs – to carry out a puncture (vpp: 67-100%, vpn: 95%) in case of intra-articular effusion or

abscess; if not liquid, tissue biopsy with the true-cut (rank B)

– to collect part of the liquid in a hermetically closed sterile syringe and to inoculate hémoculture vials for aerobes and anaerobes with the other part

Per-operative sampling• It is recommended

– to sample at the beginning of surgery, without any antibiotherapy, and before any antibioprophylaxis. – to perform 5 samplings at the level of macroscopically pathological areas (grade B). These samplings may be

liquid (pus, articular fluid) or solid (granulomatous tissue, bone tissue, interposition tissue, and any suspicious tissue).

– to change sampling tools between each sampled site.Post-operative sampling• In case of septic surgery, the positivity (with the same bacterium or another) of cultured drain fluids seems to be

linked with a higher risk of infection relapse (level 2). • In case of infection on external fixator pin, it is recommended to perform sampling along the pin (level 2)

How should diagnostic microbiological sampling be performed? (2)

Microbiological techniques at the laboratory (1)

It is recommended to maintain incubation of culture media for at least 14 days (expert advice).

Pre-operative samplings: articular fluid• It is recommended to perform a cytological test (count and formula) in

the 2 h following sampling. • >1,700 leucocytes/mm3 (Se 94%, Spe 88%) and >65% of PMN

neutrophils are strongly suggestive of infection on prosthesis in articular fluid (level 2).

• It is recommended to seed the articular fluid on enriched agars to be incubated in aerobic condition, under 5% of CO2 and in anaerobic condition, and to inoculate hemoculture vials for aerobics and anaerobes.

Per-operative sampling•It is recommended

– to crush solid samples– to seed on solid and liquid enriched media and eventually on a medium for

mycobacteria– to perform direct examination to screen for PMN neutrophils and bacteria (Gram

staining)(Se : 6%, Spe ~ 100%). – to freeze a part of samples (-80°C) for specific screening (fungus, mycobacteria)

and eventually for molecular biological techniques.•It is recommended

– to identify all the different colonies, especially staphylococci slow culture(« small colony variants »)

– to perform an antibiogram on the various types of colonies isolated. It is necessary to asses glycopeptide MICs on staphylococci and to check, if possible, the susceptibility to oxacillin by screening for the mecA gene. It is necessary to assess MICs of beta-lactams on the non-groupable streptococci.

New methods under evaluation : sonication, broad-range PCR (16S RNA)

Microbiological techniques at the laboratory (2)

Question 2

2.5 What are the arguments in favour of the diagnosis? Definite infection and probably excluded or not detectable infection

How to assert diagnosis of osteo-articular infections on material?

What data suggests the diagnosis (proved infection, and non detectable or no infection)?

The working group, with an exploratory objective, has judged useful to propose a binary classification (proved infection /infection probably excluded or not detectable) by considering that between the two, there are several situations of possible infection for which specific criteria cannot be definedConsider that the initial clinical, biological, and/or imaging approach, has allowed to suspect infection. Consider that 5 samplings at least were performed

What data suggests the diagnosis (proved infection, and non detectable or no infection)?

ou

ou

Infection

Fistula Pus in joint or in contact with prosthesis

>0 per-op samplings Culture : bacteria of the skin flora

>0 per-op samplings Culture :bacteria not belonging to the skin flora

Histology>5PN / fieldIn 5 fieldsx40

Joint fluid >65% PN

definite + + 3 per-op or 2 per-op samplings and 1 joint punct.

1 per-op sampling or 1 joint punct. or 1 hemoc

infection probably excluded or not detectable

- - - - -

1 per op - - -

or or or

Question 3

What are the modalities of therapeutic management?

What are the specificities of surgical treatment?

What is the rational for the  therapeutic strategy? Biofilm and biomaterials

The oxides contained in the material are responsible for a secondary binding interaction surface for bacteria.

1. This process begins by a phenomenon of attraction-adhesion during which bacteria are reversibly adsorbed on the material.

2. Then, the bacteria irreversibly colonize the material. 3. Bacteria develop a survival strategy within a dynamic entity defined as the biofilm,

made of a polysaccharidic substance secreted by bacteria called « slime » which permits the definitive adherence of bacteria on the material.

The bacteria in the biofilm are organized in micro-colonies (« small colony variant ») under the influence of inter-cellular communications leading to a stationary growth phase due to the absence of ATP production. This has for consequence:• to limit the activity of some antibiotics which diffuse badly in the biofilm, • the prolonged persistence of S. aureus in osteoblasts,• escaping the immune defense mechanism.

This biofilm spreads to all the material surface in a few days explaining • why a late surgical lavage is inefficient beyond 15 days • the need to remove the prosthetic material, most of the time

Conservation of the prosthesis 

It is recommended to use synovectomy and lavage («debridement») with implant retention in the case of very recent infection (post-operative until D15, recent secondary infection without loosening) (grade C).

It is not recommended to perform arthroscopic synovectomy at the knee level but open arthrotomy (grade C) .

It is recommended to initiate antibiotherapy as soon as bacteriological samplings have been made, first in a probabilistic way, then adapted to documentation. The recommended course length is 6 weeks. It is useless to prolong beyond this.

Removal of implants

Hip:• Use the previous surgical approach provided it can be extended• Femoral implants can be extracted by endo-femoral route or by

femorotomy. It is recommended to perform femorotomy with large vascularized bone fragment to improve the removal of cement, to carefully close the femorotomy, and to osteosynthesize it with strong cerclage.

• In case of intra-pelvic implant dislocation, of protrusion without bone barrier, or intra-pelvic foreign bodies, it is strongly recommended to asses cases with vascular risk (expert advice)

Knee and other joints:• Same principle Removal of infected implants does not present any

specific problem.

One or two stage surgical revision ? The majority of the authors recommends revision with 2 separate procedures even if the analysis of the litterature does not objectively define indications for 1 or 2 stages. What can be the choice criteria?

a.The certitude to have identified the bacterium : choose a single procedureb.The bacterial profile

Bacteria for which antibiotherapy is limited (multi-resistant bacterium, Pseudomonas aeruginosa), a mycobacterium, a fungus are indications for surgery with two procedures.

c.Knowledge of the terrain  it seems that a patient with a long history of prosthesis infection is not a good candidate for surgery in one procedure.

d.Problems with anesthesia If the patient cannot undergo 2 procedures, a single surgery should be chosen after discussion with the anesthesiologist, the surgeon, and the patient (or his family).

tFollow-up

One -stageOne -stage explantationexplantation

+ + réimplantatiréimplantati

onon

antibiotherapy [6/8 w-6 m[

Modalities surgery in the two procedures

What is the ideal delay for replacement? There is no answer in the literature. • In case of 2 short steps, the recommended delay is between 4 and 6 weeks during

which antibiotherapy is given without interruption. If bacteriological samplings are negative after 15 d of culture, treatment may be interrupted.

tsuivi

explantatioexplantationn

reimplantatireimplantationon

antibiotherapy 6/8 w

Modalities surgery in the two procedures

What is the ideal delay for replacement?

• In case of 2 long steps, the delay range from 3 to 6 months knowing that after 3 months the functionnal result will be less good. The antibiotherapy must be interrupted for 15 days before replacement. The usefulness of performing a puncture before reimplantation is not confirmed. The antibiotherapy will be resumed post-operatively and stopped if the culture is negative (after 15 days). (expert advice)

Using a spacer : recommended with an essentially mechanical aim so as to facilitate replacement of the prosthesis

tantibiotherapy Follow-

up

explantatioexplantationn

Antibiotic window culture

puncture Additionnal histological and microbiological samplings

reimplantation

Question 3

What are the specificities of anti-infectious treatment?

What are the modalities of therapeutic management?

What is the contribution of local antibiotherapy? Strong doses of antibiotics may need to be used for therapy. These types of cement is prepared by the surgeon extemporaneously in the operating room (high-loaded) and are only recommended temporarily in 2 presentations:•cement beads used to fill a cavity. •spacer with cement impregnated with antibiotics, with the objective on one hand to maintain the space after removing the implant and, on the other hand, to obtain local antibiotherapy

The kinetics of antibiotic release includes two phases: an immediate phase during 7 days, with a high concentration and a secondary phase, for the years with much weaker doses (sub-inhibiting doses).The antibiotics used in cement are currently aminosides, vancomycin, and clindamycin.and need to be active against identified bacteriumThese cements must in no case dispense from a prescription of general antibiotherapy and differ from the licensed antibiotic cement used for prosthesis (re)implantation prophylaxis.

General principles for sytemic antibiotherapy (1)

Rules for optimal antibiotherapy (grade C) :• based on culture results (in case of sepsis, probabilistic

antibiotherapy must be initiated after microbiological sampling),

• antibiotherapy initiated as a combination;• achieving adequate plasmatic concentrations;• using molecules with a good bone distribution in order to

achieve high concentration in the tissue;• in case of infection due to staphylococci, never use

monotherapy with rifampicin, fusidic acid, fluoroquinolones, and fosfomycin:• linezolid, daptomycin, tigecyclin do not have marketing

authorisation for medicinal products in 2009, for the treatment of bone and joint infections

General principles for sytemic antibiotherapy (2)

Mode of administration :• It is recommended to administer the treatment initially intravenously. No

study has validated the duration of parenteral antibiotherapy. It is usually 10 to 15 days long (expert advice). • After this, it is recommended to switch to per os administration if antibiotics :

– have a good bioavailability and a good bone distribution,– have a good digestive tolerance – have no negative interaction– and if observance is good .

• If switching to oral treatment is impossible, it is mandatory to maintain parenteral antibiotherapy as long as necessary, either in hospital or in ambulatory treatment (grade C). • In this case, it is recommended to insert a central catheter which may be

changed if the planned duration of antibiotherapy <6 weeks, or a totally implanted central venous access device (TICVAD) if the planned duration of antibiotherapy >6 weeks

Duration of antibiotic treatment: (expert advice)

• minimum of 6 weeks. • usual length reported in litterature : 6 to 12 weeks.• maintaining antibiotherapy >12 weeks should be discussed• variation according to surgical management

Surveillance of antibiotherapy :• effectiveness assessed first on clinical data then on biological

parameters (CRP). It is recommended to dose antibiotics with high inter-individual variations of blood concentrations. It is recommended to dose aminosides (peak) and glycopeptides. If rifampicin used, check that the antibiotic to which it is combined is not under dosed.

• tolerance assessed on clinical and on biological parameters (CBC/platelets, hepatic parameters, renal function). It is also necessary to measure blood concentrations of some antibiotics such as aminosides (trough level).

General principles for sytemic antibiotherapy (4)

3.3.2.2. Choosing antibiotic: meticillin resistant staphylococci Initial IV antibiotherapy

(2 weeks)(vancomyci or teicoplanin) + rifampicin

or(vancomycin or teicoplanin) + fusidic acid.

or(vancomycin or teicoplanin) + fosfomycin

or(vancomycin or teicoplanin) + doxycyclin

or(vancomycin or teicoplanin) + linezolid

orclindamycin (if the strain is susceptible to erythromycin)

+ gentamicin then

clindamycin + rifampicin

Switching to oral route if thebacterium susceptibility allows it

rifampicin + fusidic acidor

rifampicin + clindamycin6 (if the strain is susceptible to erythromycin)

orrifampicin + cotrimoxazole

orrifampicin + (minocyclin8 or doxycyclin)

orrifampicin + linezolid

Antibiotics (DCI) Dose/24h Regimen

amoxicillin 100-200 mg/kg 4-6 injections IVL3-4 oral intakes

cloxacillinoxacillin

100-200 mg/kg (doses superior to approval – expert advice)

4-6 injections IVL

amoxicillin- clavulanic acid

100 mg/kg 4-6 injections IVL3-4 oral intakes

cefazolin 60-80 mg/kg 4-6 injections IVL orInfusion pump1

cefotaxime 100-150 mg/kg 3 injections IVL

ceftriaxone 30-35 mg/kg 1-2 injection(s) IVL

ceftazidime 100 mg/kg Infusion pump1 or3-4 injections IVL

imipenem 2 à 3 g 3 to 4 administrations IV or IM

meropenem 3 à 6 g 3 administrations IV

vancomycin2 40-60 mg/kg Infusion pump1

teicoplanin2 12 mg/kg/12h for 3-5 daysthen 12 mg/kg

IVL, IM or s/c

gentamicin3 3-4 mg/kg 1 administration IV 30 minutes

amikacin3 15 mg/kg 1 administration IV 30 minutes

doses and ways of administration of antibiotics (for a normal renal and hepatic function)

Empirical antibiotherapy

Antibiotic scheme before obtaining per operative bacteriological results when there is no reliable documentation in the patient’s history, when there are general signs indicating the emergency of treatment (sepsis), or for culture negative infection.suggested associations by order of preference, must be adapted according to the microbial ecology of each institution

(expert advice): • ureidopenicillin/ beta-lactamase inhibitor + vancomycin • 3rd generation cephalosporin + vancomycin• carbapenem (except ertapenem) + vancomycin• 3rd generation cephalosporin + fosfomycin.

Suppressive antibiotherapy

(grade C)

indefinite long term oral antibiotics (≥1 year),

palliative but not curing the infection,

only with well-tolerated molecules and easy administration (per os)

in the minority of patients in whom surgery is precluded or declined,

available bacterial target

Follow-up of patients: organization and structures

optimal management requires :• an accurate clinical evaluation• a microbiological diagnosis requiring validated techniques both for

sampling and for identification of micro-organisms• a therapeutic strategy defined during multidisciplinary staff

meetings • implementing specific treatments especially for surgical and anti-

infectious goals in the short term• a global continuous and clear management until coming back home,

with a healthcare file including all the detail care• continuous information of the patient• interregional reference centers for the management of complex bone

and joint infections Is cure possible? • the infectious and functional criteria should be taken into account.• there is no criterion defining infection cure. It is recommended to

follow-up patient between 1-2 years after the end of antibiotherapy• the functional result is obtained by assessing mobility, pain, strength,

balance, and walking (specific score for joints).

Question 4

What are the pre-requisites to pour minimize these types of infection?

What are the standards in terms of healthcare environment control?  Hygiene  procedures? Environmental surveillance?

No formal proof of so-called “septic” units effectiveness on the prevention of SSI The procedures to be applied are the same that those described during the non-septic surgeryThey concern:• Management of potential portals of entry during care giving• Air treatment efficiency, (expert recommendations by the French Society for Hospital

Hygiène Société Française d’Hygiène Hospitalière –SFHH- 2004,

• Healthcare personnel discipline,

• Effectiveness of professional wear and operative sheets,

• Managing surgical instruments,

• Cleaning surfaces,  • Surgical block architecture, • Environmental  surveillance.

.What measures should be undertaken for the preparation of the patient before surgery ? (1)

These measures concern preparation for an orthopedic intervention as in a non-infected patient. (grade C) Specific risk factors a priori accessible to corrective treatment :• Length of pre-operative  hospitalization >4 days • Tobacoo, diabetes, obesity, denutrition• Rheumatoid polyarthritis treatments • No systematical screen for nasal carriage of S. aureus

• When When Staphylococcus aureusStaphylococcus aureus SSI rates remain unusually high (>2%), it SSI rates remain unusually high (>2%), itis recommended to perform nasal swabs of caregivers and patients.is recommended to perform nasal swabs of caregivers and patients.

• Nasal screening for methicillin resistant Nasal screening for methicillin resistant S aureusS aureus is recommended in patients who is recommended in patients who must undergo planned cardiac or orthopedic surgery, transferred from ICU, long must undergo planned cardiac or orthopedic surgery, transferred from ICU, long and median stay structure, or in case of chronic cutaneous lesions.and median stay structure, or in case of chronic cutaneous lesions.

• It is not recommended to use mupirocin systematically pour to prevent the onset It is not recommended to use mupirocin systematically pour to prevent the onset of SSI in MRSA carriers.of SSI in MRSA carriers.

What measures should be undertaken for the preparation of the patient before surgery ?(2)

Global prevention measures against infection in orthopedic and trauma surgery:• 1. Recommendations for skin care and preparation were specified in

the french consensus conference «pre-operative management of infectious risk» (SFHH).

• 2. Systemic route antibioprophylaxis was codified by the 1992 french consensus conference «antibioprophylaxis in surgical settings in the adult», and updated in 1999 (SFAR).

• 3. Per-operative normothermia is applicable to orthopedic and traumatological surgery.

• 4. Peri-operative hyperoxygenation could be used for orthopedic and traumatological surgery.

• 5. It is recommended to use local antibiotherapy for prophylaxis such as antibiotic impregnated cements for 1st intention arthroplasty

• 6. it is not necessary to carry out antibioprophylaxis in a septic patient in order to avoid false negativity of the microbiology sample

What measures are undertaken to fight the risk of cross transmission when managing a patient infected in an orthopedic surgical block? ?

Should there be a chronological order for surgery? • There is no need to impose a specific order of passage if hygiene

precautions are observed (grade C). What precautions should be taken in the surgical block after operating a septic patient? • It is recommended to perform the usual cleaning program and to

respect the time needed for particle decontamination of the operating room between two interventions • In case of Multi Resistant Bacteria, there are no supplementary

precautions to take for the cleaning of the rooms but complementary precautions of the «contact» type must be respected (grade C).• No «septic» operating room is necessary if cleaning procedures

between two interventions with various contamination are observed and if rooms are equipped with efficient ventilation systems (grade C)• There is no need to have separate post surgery surveillance rooms for

patients having undergone different surgeries,

Thanks

RPC are available at www. infectiologie.com and will be published in Médecine et Maladies Infectieuses (Elsevier)

RPC are available at www. infectiologie.com and will be published in Médecine et Maladies Infectieuses (Elsevier)