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Prosthetic-Joint Infections — NEJM

nic Osteomyelitis: Chronic osteomyelitis with usually occurs when acute osteomyelitis is not recognized early or is inadequately treated. Infection can be low-grade or remain dormant for years and then flare up to clinically resemble acute osteomyelitis. Surgery is usually required to remove necrotic bone and occasionally for diagnosis. Prolonged antibiotic therapy is recommended. Although the optimum duration of antibiotic therapy has never been established, most authors recommend therapy for 6 weeks to 6 months (). Management of this condition is particularly suited to outpatient intravenous therapy (), although direct comparisons between this mode of delivery and oral therapy is lacking. Combination therapy with and was studied in chronic osteomyelitis but appears to offer no additional benefit to nafcillin alone (). Vancomycin is associated with a higher risk of recurrence compared to antistaphylococcal penicillins and first generation cephalosporins (, ), and therefore should not be used if the strain is methicillin-susceptible.

 17. Sculco TP. The economic impact of infected joint arthroplasty.  1995;18:871-3

Essential for sufficient treatment of acute septic arthritis is the fast and aggressive therapy with the combined application of antimicrobial medication and joint lavage. Regarding the duration of treatment, there are no controlled studies. The recommendations vary for native joint infections between 2-3 weeks and 6 weeks in the presence of accompanied osteomyelitis and / or if the clinical response is only moderate. For initial therapy in the presence of clustered gram positive cocci in microscopic examination and, therefore, most likely an infection with is the intravenous therapy with a penicillinase-resistant penicillin. For gram positive chainlike cocci, thus highly suspicious for a streptococcal infection, penicillin G is empirically given. Most of the gram negative rods have their effective therapy initially with a quinolone or a second or third generation cephalosporin. In the case of a negative gram stain, first or second generation cephalosporines (e.g. Cefazolin, Cefuroxime), possibly in combination with an anti-staphylococcal penicillin (e.g. Flucloxacillin), are a calculated approach. If, after culture results and / or availability of antibiograms the first selected antibiotic regime has to be adjusted, then it has to be carried out immediately.

Patient education: Joint infection (Beyond the Basics)

. Green N, Edwards K. Bone and joint infections in children. Orthop Clin North Am 1987; 18:555-76.

may be alternatives in patients who are allergic to beta-lactam agents and vancomycin. However, the experience with these agents in the treatment of prosthetic joint infections has not yet been reported.

oral regimen consisting of the combination of (200 mg t.i.d.) and rifampin (900 mg. q.d.) has been studied in a non- comparative trial for S. aureus prosthetic joint infections of the hip (n=10) and knee (n=7) (). Patients with hip infections received oral therapy for five months preoperatively and one month postoperatively with removal of the infected joint. The cure rate was 70% (7/10). Patients with knee infections received oral therapy for six months preoperatively and three months postoperatively with removal of the infected joint. The cure rate was 71% (5/7). Failures with emergence of resistant occurred in 1 patient from each group. In another study of prosthetic joint infections caused by staphylococcal species, patients were randomized to oral (750 mg every 12 hours) plus placebo or ciprofloxacin plus rifampin (450 mg every 12 hours), after receiving an initial two weeks of intravenous therapy following debridement surgery (). This group was a select group limited to patients with stable orthopedic implants and short duration of symptoms (). In an open trial comparing oral rifampin with either or ofloxacin for implant infections, a cure rate of 56% (14/25) was found in both groups, four of whom had the device removed. Two out of eight failures in the rifampin/fusidic acid group were due to , one of which was resistant to rifampin but susceptible to fusidic acid and ofloxacin. Similarly, two out of eight failures in the rifampin/ofloxacin group were due to , both of which were resistant to rifampin (). This experience contrasts with the previous study in which rifampin resistance was not encountered when the combination of rifampin plus ciprofloxacin was given ().

Infection Associated with Prosthetic Joints — NEJM

20. Zimmerli W, Ochsner PE. Management of infections associated with prosthetic joints.  2003;31:99-108

Joint replacement surgery increases the risk of infections due to intraoperative bacterial wound contamination, leading to an early onset of the typical symptoms. The material of the joint prosthesis is also covered by host proteins such as fibrinogen and fibronectin, which in turn facilitates bacterial colonization, leading to a delayed type of PJI. The foreign material allows not only a surface colonization; it is also responsible for a reduction of the local defense mechanisms. Among others, it leads to an apoptosis of phagocytes surrounding the joint prosthesis; a mechanism described as frustrane phagocytosis [].

In reactive arthritis the cultural detection of pathogens is often not possible. This makes serological analysis to a method principally necessary to detect antibodies against the causing bacteria. The antibody detection has a great diagnostic value also due to the reduced sensitivity of bacterial culture in joint infections caused by Borrelia or Brucella. For a medically and economically adequate evaluation in serologic diagnosis the sensitivity and specificity of the various methods must be considered. An overview of the bacteria that most commonly trigger reactive arthritis is listed in Table .

. Frank AL, Marcinak JF, Mangat PD et al. Clindamycin treatment of methicillin-resistant  in children. Pediatr Infect Dis J 2002;21:530-534.
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of Medicine — Infection Associated with Prosthetic Joints

It is believed that approximately 60% of the prosthesis-related infections are caused by direct contamination during the operative procedures. Bacteria come from the patient’s skin, and/or the staff in the operating theater, or airborne pathogens in the operating environment. It is, therefore, important to disinfect the skin of the operating field thoroughly, pay attention to the sterile performance, and prevent any direct contamination from the operating staff. To minimize the possibility of implant and wound infections, it is helpful to use broad-spectrum β-lactam antibiotic prophylaxis intravenously before, during and after surgery. In our orthopedic surgical procedures, cefuroxime 1.5 g is given before and after the operation, and local application of gentamicin solution around the implant before closing the incision is routine practice. Use of orthopedic cement containing antibiotics in joint replacement surgery is one of the prophylaxis measures. In a long-term Norwegian study involving 22,170 THA patients, systemic antibiotic (cephalosporin or semisynthetic penicillinaseresistant penicillin) prophylaxis combined with cement containing gentamicin gave the lowest risk of revision, aseptic loosening and infection, compared to those patients who received only systemic antibiotic prophylaxis, indicating the importance of cement with antibiotic. In addition, on the basis of antibiotic- cement application, systemic antibiotic prophylaxis given 4 times on the day of surgery showed significantly lower rates for revision, aseptic loosening and infection compared to antibiotic prophylaxis given 1, 2 and 3 times on the day of surgery. Longer antibiotic prophylaxis did not show better results. Based on the clinical evidence, application of antibiotic embedded cement in combination with intravenous antibiotic prophylaxis of cefuroxime (1.5 g, q.i.d.) or in case of bβ-lactam allergy, vancomycin (1 g, t.i.d.) is recommended for orthopedic surgery with joint replacement if patient renal function is normal. The systemic antibiotic prophylaxis is recommended for the day of surgery only.

prosthetic joint infections treated with prosthesis ..

As foreign bodies, the implanted prostheses are easily colonized by bacteria. The presence of a foreign body decreases more than 100,000- fold the minimal infecting dose of S. aureus leading to a permanent abscess. Animal study demonstrated that 108 colony-forming units (CFU) of S. aureus could not produce any abscesses in the absence of foreign material, whereas 102 CFU was sufficient to infect 95% of the subcutaneous implants. The host neutrophils could not effectively clear the bacteria that attached to an implant due to the biofilm mode of growth of the bacteria., The application of antibiotic cements and the antibioticcoated implants partly down-regulate the risk of prosthetic-related infection due to the slow release of antibiotics from the cements and the formation of a relatively high antibiotic concentration locally., Animal studies demonstrated that application of antimicrobial-coated devices in a short time significantly reduced biofilm formation and the risk of implant-correlated infection against Staphylococcus aureus. However, this is not sufficient to solve the problem, and long-term application of antibiotics can also lead to serious problems of antibiotic resistance. To better protect orthopedic prostheses from infections, new materials or techniques with anti-microbe properties for the manufacture of orthopedic prostheses are needed.

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