One-stage revision versus debridement, antibiotics, and implant retention (DAIR) for acute prosthetic knee infection: an exploratory cohort study.

INTRODUCTION: Studies have shown that debridement, antibiotics, and implant retention (DAIR) is an effective procedure for acute infection of total knee arthroplasty (TKA). This study aimed to explore DAIR and one-stage revision for homogenous cohorts with acute postoperative and acute hematogenous infection of TKA, without compelling indications to perform a staged revision. MATERIALS AND METHODS: This study was an exploratory analysis that used retrospective data from Queensland Health, Australia, for DAIR and one-stage revision of TKA between June 2010 and May 2017 (3-year average follow-up). The re-revision burden, mortality rate, and the cost of the interventions were explored. Costs were expressed in 2020 Australian dollars. RESULTS: There were 15 (DAIR) and 142 (one-stage) patients with homogenous characteristics in the sample. The re-revision burden for DAIR was 20%, while for one-stage revision it was 12.68%. Two deaths were associated with a one-stage revision and no death was associated with DAIR. The total cost since the index revision of DAIR, $162,939, was higher than for one-stage revision $130,924 (p value = 0.501), due to higher re-revision burden. CONCLUSIONS: This study would suggest the use of one-stage revision over DAIR for acute postoperative and acute hematogenous infection of TKA. It suggests that there could be other potential criteria which have not been ascertained that need to be considered for optimal DAIR selection. The study indicates the need for more research and, of note, high-quality randomized controlled trials to provide a well-defined treatment protocol with high level of evidence to guide patient selection for DAIR.

Identifying risk groups of infectious spondylitis in patients with end-stage renal disease under hemodialysis: a propensity score-matched case-control study.

BACKGROUND: Patients with end-stage renal disease (ESRD) under hemodialysis (HD) are at greater risks of infectious spondylitis (IS), but there is no reliable predictor that facilitate early detection of this relatively rare and insidious disease. METHODS: A retrospective review of the medical records from patients with ESRD under HD over a 12-year period was performed at a tertiary teaching hospital, and those with a first-time diagnosis of IS were identified. A 1:4 propensity score-matched case-control study was carried out, and baseline characteristics, underlying diseases, and laboratory data were compared between the study group and the control group, one month before the date of diagnosis or the index date respectively. RESULTS: A total of 16 patients with IS were compared with 64 controls. After adjustment, recent access operation (odds ratio [OR], 13.27; 95% confidence interval [CI], 3.53 to 49.91; p <  0.001), degenerative spinal disease (OR, 12.87; 95% CI, 1.89 to 87.41; p = 0.009), HD through a tunneled cuffed catheter (OR, 6.75; 95% CI, 1.74 to 26.14; p = 0.006), low serum levels of hemoglobin, albumin, as well as high levels of red blood cell volume distribution width (RDW), alkaline phosphatase (ALP), and high sensitivity C-reactive protein were significant predictors for a IS diagnosis one month later. Receiver operating characteristic curves for hemoglobin, RDW, ALP, and albumin all showed good discrimination. The further multivariate models identified both high serum ALP levels and low serum RDW levels following a recent access intervention in patients with relatively short HD vintages may be indicative of the development of IS. CONCLUSION: Patients under HD with relatively short HD vintages showing either elevated ALP levels or low RDW levels following a recent access intervention should prompt clinical awareness about IS for timely diagnosis.

Management of acute or late hematogenous infection after shoulder arthroplasty with irrigation, débridement, and component retention.

BACKGROUND: Irrigation and débridement (I&D) with component retention is an appealing alternative to both patients and surgeons for the management of acute or late hematogenous deep periprosthetic shoulder infection (PSI). However, the success rate and results of I&D are poorly documented. This study reports the outcomes and complications of this treatment strategy for acute and delayed-onset acute hematogenous PSI. METHODS: Between 1980 and 2010, 10 shoulders (9 patients) underwent I&D with component retention for the management on an acute or delayed-onset acute hematogenous PSI at a single institution. Outcome data, including pain, range of motion, need for chronic oral antibiotic suppression therapy, eradication of infection, and need for further surgery were retrospectively collected. RESULTS: Deep infection recurred in 3 shoulders, which were eventually treated with resection arthroplasty. Of the remaining 6 patients (7 shoulders), 5 were prescribed chronic antibiotic suppression. At the most recent follow-up, pain was graded as none in 3 shoulders, mild in 1, moderate with activity in 3, moderate in 2, and severe in 1. Among shoulders with retained components, forward elevation was greater than 110° in 6 (median, 140°; range, 30°-160°), and external rotation was greater than 40° in all shoulders (median, 50°; range, 40°-90°). CONCLUSION: I&D allowed component retention in 70% of shoulders presenting with an acute or delayed-onset acute hematogenous infection. Most patients were prescribed chronic antibiotic suppression, and reasonable motion was maintained.

A Standardized Regimen for the Treatment of Acute Postoperative Infections and Acute Hematogenous Infections Associated With Hip and Knee Arthroplasties.

BACKGROUND: Papers concerning the treatment of periprosthetic infections and acute hematogenous infections often concern inhomogeneous treatment concepts or low numbers of patients; this results in inconsistent rates of treatment success. METHODS: Thirty-nine patients with early periprosthetic infections and 28 patients with acute hematogenous infections were treated with a homogeneous concept and followed with a mean period of 41.8 (24-132) months in order to investigate the success rate and influencing factors. All patients were treated with open surgical debridement, a revision of all removable components and irrigation with an antiseptic solution (octinedine). All patients received a systemic vancomycin/rifampicin antibiotic therapy until the microorganism causing the infection could be identified; a specific antibiotic therapy then followed until the end of the sixth week. RESULTS: This unified treatment regimen resulted in an overall success rate of 71.6%, an 82.1% success for early infections and 57.1% for acute hematogenous infections. Variables that influenced the recurrence of an infection were the timespan between revision and first appearance of symptoms (<2 days), the number of previous operations, the American Society of Anesthesiologists classification, and nicotine abuse. CONCLUSION: It appears that, in cases of early postoperative infection, a reproducibly high rate of success in retaining an implant can be achieved with this specific therapy regime if surgical intervention can be carried out within 2 days of first symptoms.

Incidence, functional outcomes and cure rate of hematogenous infection in a 2,498 Total Knee Arthroplasties cohort.

PURPOSE: The primary aim of the present study is to report the late acute hematogenous (LAH) prosthetic joint infection (PJI) cure rate following Total knee arthroplasty (TKA) treated by means of debridement, antibiotics, and implant retention (DAIR) in a long-term follow-up. The secondary purpose is to report the functional outcomes at that follow-up and to compare them with a non-infected group. MATERIAL AND METHODS: This study cohort consists of 2,498 TKA performed from September 2005 to April 2010 that had a minimum follow-up of 10 years. The diagnosis of PJI and classification into LAH was done in accordance with the Zimmerli criteria. The primary outcome was the failure rate, defined as death before the end of antibiotic treatment, a further surgical intervention for treatment of infection, life-long antibiotic suppressive treatment or chronic infection. The Knee Society Score (KSS) was used to evaluate clinical outcomes. RESULTS: Ten patients were diagnosed with acute hematogenous PJI during the study period (0.4%). All of them were managed with DAIR, which was performed by a knee surgeon and/or PJI surgeon. The failure rate was 0% at the 8.5-year (SD, 2.4) follow-up mark. The KSS score was 82.1 vs. 84.1 (p n.s.) at final follow-up. CONCLUSION: Although the literature suggests that TKA DAIR for LAH periprosthetic joint infection is associated with high rates of failure, the results presented here suggest a high cure rate with good functional outcomes. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Hematogenous septic arthritis of a non-prosthetic shoulder caused by Capnocytophaga canimorsus: A case report and review of the literature.

Capnocytophaga canimorsus, oral inhabitants of dogs and cats is a cause of zoonotic infections. It is transmitted to humans by bites, scratches, licks, or close exposure to these animals. Infections due to Capnocytophaga canimorsus have a wide range of severity and can sometimes be fatal. We report the case of an 89-years-old man who suffered from a sudden swollen native right shoulder. The blood test revealed an inflammatory syndrome and cytologic evaluation of joint aspiration showed an elevated nucleated cells count suspicious of infection. A Gram-negative bacillus grew after 48 h in the arthrocentesis and was identified as Capnocytophaga canimorsus. After 4 days, blood culture also grew Capnocytophaga canimorsus leading to the diagnosis of hematogenous septic arthritis of a non-prosthetic right shoulder. Antimicrobial therapy was empirically started with cefuroxime then switched to doxycycline for seven weeks with good clinical outcomes. It is important to inquire about patients' environment including their proximity to animals as it can lead to zoonotic infections that can be of high severity. Moreover, hygiene rules must be applied when dog scratches or lick wounds occurred to avoid the spread of zoonotic germs. Prophylactic antibiotic therapy should be given for animal bites.

Debridement and implant retention in acute hematogenous periprosthetic joint infection after knee arthroplasty: a systematic review.

Debridement, antibiotic, and implant retention (DAIR) can be used as a first surgical procedure for acute infections in patients who have well-fixed components. However, its use in hematogenous or late acute infections is still debated. This systematic review of literature aims to clarify the effectiveness of DAIR procedure in the treatment of hematogenous periprosthetic knee infections. DAIR is an effective way to treat acute hematogenous PJIs of the knee and reaches its best efficacy when performed within one week from the onset of symptoms, modular components are exchanged, and a pathogen-oriented antibiotic therapy can be set. It is safe, economic, and effective technique, but has to be performed in a very narrow temporal window.

Worse outcome of debridement, antibiotics, and implant retention in acute hematogenous infections than in postsurgical infections after total knee arthroplasty: a multicenter study.

BACKGROUND: We sought to determine (1) the success rate of debridement, antibiotics, and implant retention (DAIR) for acute periprosthetic joint infection (PJI) of the knee in patients with acute postsurgical infection and in those with acute hematogenous infection via a multicenter study, (2) the factors related to the failure of DAIR for overall acute PJI and acute hematogenous PJI via subgroup analysis, and (3) whether the PJI recurrence patterns differed between the two groups over time after DAIR. METHODS: This retrospective multicenter study included 101 acute knee PJI. Acute postsurgical PJI was defined as PJI diagnosed < 3 months following initial knee arthroplasty surgery. DAIR was performed for 34 cases of acute postsurgical PJIs (postsurgical group) and 67 cases of acute hematogenous PJIs (hematogenous group). The success rates between groups were compared, and factors related to DAIR failure were analyzed. RESULTS: The overall success rate of DAIR was 77%. The success rate tended to be higher in the postsurgical group than in the hematogenous group (p = 0.060). However, there was no significant factor related to DAIR failure in the subgroup analysis of acute hematogenous PJIs. In the postsurgical group, the recurrence of PJI occurred until 3 months, whereas in the hematogenous group, recurrence occurred for up to 2 years. CONCLUSIONS: The failure rate tended to be higher in the acute hematogenous PJI group than in the acute postsurgical PJI group. Since acute hematogenous infections may recur for a longer period than postsurgical infections, careful follow-up is required after DAIR.

Successive new-pathogen prosthetic joint reinfections: Observational cohort study on 61 patients.

OBJECTIVES: Prosthetic joint infection (PJI) treatment failure may be due to relapsing infection (same microorganism) or new-pathogen reinfection (npPJI). The aim was to describe npPJI epidemiological, clinical and microbiological characteristics, their treatments and outcomes, and identify their risk factors. METHODS: This observational, single-center, cohort study was conducted in a French Referral Center for Bone-and-Joint Infections between September 2004 and December 2015. Patients treated for at least two successive hip or knee PJIs in the same joint with a different pathogen were identified in the prospective database. We compared each patient's first PJI and subsequent npPJI(s) to analyze the type and microbiological characteristics of npPJIs. To search for npPJI risk factors, we compared those cases to a random selection of 122 "unique-episode" PJIs treated during the study period. RESULTS: Among 990 PJIs, 79 (8%) npPJIs occurring in 61 patients were included. New-pathogen prosthetic joint infections (npPJIs) developed more frequently in knee (14%) than hip prostheses (5%). Median interval from the first PJI to the npPJI was 26 months. New-pathogen prosthetic joint reinfections (npPJIs) more frequently spread hematogenously (60% vs 33%) and were predominantly caused by Staphylococcus (36%) or Streptococcus (33%) species. Multivariate analysis identified two risk factors: chronic dermatitis (odds ratio: 6.23; P<0.05) and cardiovascular diseases (odds ratio: 2.71; P<0.01). A curative strategy was applied to 70%: DAIR (29%), one-stage (28%), two-stage exchange arthroplasty (7%) or other strategies (7%). The others received prolonged suppressive antibiotic therapy (30%). CONCLUSIONS: New-pathogen prosthetic joint infections (npPJIs) are complex infections requiring management by multidisciplinary teams that should be adapted to each clinical situation.

Late Acute Hematogenous Infections after Total Knee Arthroplasty: Results of Debridement, Antibiotics, and Implant Retention.

The frequency of late acute hematogenous infection (LAHI) following total knee arthroplasty (TKA) is between 0.2% and 0.5%. There is controversy over the results of patients treated for LAHIs by surgical debridement, antibiotics, and implant retention (DAIR). This narrative review of the literature aims to establish the role of DAIR in LAHIs after TKA. The published success rate (retention of the prosthesis) after DAIR is between 50% and 100%. The success rate is associated with a shorter duration of symptoms (5-14 days from the onset of symptoms). Factors associated with failure are an accompanying infection and the diagnosis of rheumatoid arthritis before the TKA is performed. It is not recommended to indicate a DAIR in patients with atrial fibrillation, chronic obstructive pulmonary disease, the presence of >15 cells per high-powered field, preoperative C-reactive protein >500 mg/L or methicillin-resistant S. aureus. In such patients, a two-stage revision arthroplasty should be recommended. Arthroscopic DAIR has a limited effect. It is most efficacious in the very early stage of acute presentations of infected TKA. It can be useful in patients with extreme frailty as an adjunct to suppressive antibiotic therapy. If carried out, high volumes of fluid should be utilized. The indications for an open DAIR are the following: duration of clinical signs and symptoms is less than 3 weeks; patients with a well-fixed implant; no abscess or sinus tract; low-virulence bacteria; elderly patients with multiple comorbidities; and nonimmunocompromised patients. Open DAIR should not be advised in cases with chronic infection (>4 weeks postoperatively, insidious beginning of symptoms).

Implant retention and high rate of treatment failure in hematogenous acute knee and hip prosthetic joint infections.

OBJECTIVES: Only few studies evaluated hematogenous prosthetic joint infections. We aimed to describe the characteristics of these infections and factors associated with management failure. METHODS: We selected hematogenously-acquired infections, defined by the occurrence of infectious symptoms more than a year after implantation among records of patients treated for hip and knee prosthetic joint infections at Montpellier University Hospital between January 2004 and May 2015. Failure was defined by death due to prosthesis-related infection, need for prosthesis removal in case of conservative treatment, or recurrence of infectious signs on a new prosthesis. RESULTS: Forty-seven patients with hematogenous prosthetic joint infection were included (33 knee infections and 14 hip infections). Infectious agents were streptococci (43%), Staphylococcus aureus (43%), Gram-negative bacilli (13%), and Listeria monocytogenes (2%). Thirty-one patients were initially treated with debridement and implant retention and 15 with prosthesis removal (three with one-stage surgery, 10 with two-stage surgery). The median duration of antibiotic therapy was 66.5 days. The overall failure rate was 52% (24/48), 71% (22/31) with implant retention strategy, 13% (2/15) with prosthesis removal, and 63% (12/19) in case of Staphylococcus aureus infection. Conservative treatment was appropriate (arthrotomy on a well-implanted prosthesis without sinus tract and symptom onset <21 days) in 13/31 patients (42%) with a failure rate still high at 69% (9/13). The only factor associated with failure was conservative surgical treatment. CONCLUSION: The high risk of failure of conservative treatment for hematogenous prosthetic joint infections should lead to considering prosthesis replacement as the optimal strategy, particularly with Staphylococcus aureus.

Gardnerella vaginalis, from the Vaginal Microbiota to Prosthetic Joint Infection.

We describe two cases of chronic Gardnerella vaginalis prosthetic hip infections, in an immunocompetent postmenopausal woman and a young immunocompromised woman. G. vaginalis was also isolated from the genital tract, suggesting hematogenous spread of the bacterium. Outcomes were favorable after one-stage exchange arthroplasty and prolonged antibiotic therapy.

Antibacterial Activity of Ag-Hydroxyapatite Coating Against Hematogenous Infection by Methicillin-Resistant Staphylococcus aureus in the Rat Femur.

Several antibacterial materials have been developed to prevent periprosthetic joint infection and thus prevent serious complications for patients and surgeons. However, no study has addressed the activity of antibacterial materials against hematogenous infection. The present study evaluated the antibacterial activity of a silver-containing hydroxyapatite-coated implant against methicillin-resistant Staphylococcus aureus (MRSA) hematogenous infection. Implants coated with hydroxyapatite and silver-hydroxyapatite were inserted into rats' right and left femurs, respectively, after which the animals were infected with S. aureus via a tail vessel. About 107 colony-forming units was the optimal bacterial number for the establishment of S. aureus hematogenous infection. Bacterial loads and C-reactive protein in the blood were measured to confirm bacteremia and inflammation. Fourteen days after the infection, bacterial loads were statistically lower in the femurs containing silver-hydroxyapatite-coated implants than in those with hydroxyapatite-coated implants (p = 0.022). Thus, silver-hydroxyapatite-coated implants might provide antibacterial activity against MRSA hematogenous infection in the postoperative period. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2655-2660, 2019.

Management of Acute Hematogenous Infection Following Total Knee Arthroplasty: A Case Series of 11 Patients.

OBJECTIVE: Acute hematogenous infection is a devastating complication that can occur after total knee arthroplasty (TKA). The best strategies for management of this infection remain controversial. Two-stage revision has been well described as the gold standard for the management of chronic late infections. However, there is a paucity of information presently available on the management and outcomes of patients treated for acute hematogenous infections. The purpose of the present study was to report the outcome of acute hematogenous infections following TKA with the treatment of irrigation, debridement, and retention of the prosthetic components. METHODS: Eleven patients who had been diagnosed with acute hematogenous infection of the knee following TKA underwent irrigation and debridement between 2002 and 2012. To improve the efficiency of irrigation, a vacuum constriction device was used and the most sensitive antibiotics were injected into the irrigation saline. The mean age of the 11 patients was 56.3 ± 11.8 years (range, 35-73 years), with 2 male patients (18.2%) and 9 female patients (81.8%). The diagnosis at primary operation was osteoarthritis in three cases, rheumatoid arthritis in seven and osteoarthritis (OA) secondary to fracture in 1. They had pain and swell with the acute onset of pain after a previously well-functioning TKA, and met the Musculoskeletal Infection Society (MSIS) criteria for prosthetic joint infection. Before the onset of symptoms in the operated knees, patients had a history of bacteriaemia, and blood culture was consistent with the culture result of local infection. Failure was defined as: (i) death before the end of antibiotic treatment; (ii) a further surgical intervention for treatment of infection was needed; and (iii) life-long antibiotic treatment, or chronic infection. The prosthesis survivorship, Knee Society Score (KSS) and the factors that may lead to the infection recurrence, such as type of bacteria, age, sex, rheumatoid arthritis, history of diabetes, and interval surgery time, were analyzed. RESULTS: Among the 11 patients, the most common infecting organisms were staphylococcal and streptococcus species. The 2 staphylococcal species cases included: Staphylococcus epidermidis (1) and Staphylococcus aureus (1); The 7 Streptococcus species cases included: Streptococcus agalactiae (1), ß-Hemolytic Streptococcus (1), Streptococcus pneumonia (3), Streptococcus dysgalactiae (1), Viridans streptococci (1) and Enterobacter cloacae (1). The survivorship at the endpoint was 9 in 2 years. The survival rate for patients with a staphylococcal infection was 0%, and 100% for patients infected with non-staphylococcus species, with a mean KSS of 72.6 points. The duration of symptoms prior to operation and the type of pathogen affected the outcome (P = 0.00). CONCLUSIONS: Patients who developed an acute hematogenous infection with non-staphylococcus species following operative debridement and continuous irrigation with prosthetic retention had satisfactory outcomes, but patients infected with staphylococcal had poor results. To improve the success rate of treatment, patients should be treated as soon as possible and individually according to the bacterial culture results.