Preventing periprosthetic joint infections: how to lower infection rates


As the number of joint replacements being performed around the world grows every year, so do the number of periprosthetic joint infections (PJI). The troublesome rise in antibiotic resistance as well as the antibiotic tolerance of biofilms, presents risk to patients and limited and shrinking treatment options for clinicians. What measures can you and your surgical team take prior to, during, and after joint replacement that will help lower the risk of PJI?

The frequency of joint replacement is forecast to continue its upward trend in all countries. A study in 2019 by Ackerman et al predicted that Australia could expect total knee (TKR) and hip (THR) replacements to increase by 276% and 208%, respectively, by 2030 [1]. Whether or not joint replacement growth estimates take into account a country’s changing demographics, body mass index (BMI), and gender factors [2], it is agreed that joint arthroplasty will only become more common [3–5]. As the number of implantations and cumulative number of joints in place increases, so too will the number of reported complications, including related infections [6, 7].


Did you miss AO Recon’s webinar on periprosthetic joint infection (PJI)?

In June 2019, AO Recon gathered an online community of close to 200 surgeons for an interactive information session and Q&A led by Olivier Borens, Head of Septic Surgery and Head of Traumatology at the Centre Hospitalier Universitaire Vaudois (Lausanne, Switzerland) and chat moderator Andrej Trampuz, Infectious Diseases Consultant in Septic Surgery at Charité–Universitätsmedizin (Berlin, Germany) on the topic of infection after joint arthroplasty.



Economic burden of infection

Despite the evolution and adoption of more stringent infection control protocols, infection is a very serious problem throughout the world’s hospitals. It carries both a psychological and economic burden for both patients and their families, the health care team, as well as the health care system. With a wider consideration of costs to society, health care-associated infection costs in the US have been estimated to exceed $200 billion annually [8].

Periprosthetic joint infection (PJI) is a complication that is both “serious and complex” [9]. As orthopedic surgeons, you will have had patients that were impacted by PJI, with some cases responding to treatment more readily than others [10]. Treating PJI can increase procedure costs by up to 24 times compared with cases without PJI [12]. The longer treatment takes and the more surgical intervention that is required (such as two-stage revisions), the higher the costs [6, 12, 13].


Antimicrobial resistance

However, the persistence of infection encountered in some patients, despite antibiotic treatment, highlights a global problem that has been brewing since antibiotics came into use. Antimicrobial resistance is developing to the antibiotics and fungicides that even 50 years ago were effective and rapid treatments. Methicillin-resistant Staphylococcus aureus (MRSA) is estimated to cause at least 20,000 annual in-hospital deaths in the US alone [11].


Tackling antimicrobial resistance

There are numerous organizations with the aim of funding, conducting, and/or dispersing research into antimicrobial resistance as well as providing education on its prevention and treatment. Here are a few:


Biofilms: a complex, persistent neighborhood

However, PJI’s are difficult to treat because pathogen microorganisms colonize the prosthesis, growing in biofilms [12]. Biofilms are “structurally complex” which gives them the emergent property of an evolved protection against the body’s immune response as well as against antibiotics, and even physical debridement [13]. A biofilm is more persistent than its parts as it is structured in a layered matrix—a community that alters its metabolic function and even communicates with itself via quorum sensing [14, 15].


How does bacteria form a biofilm?

A short animation from the Centre for Microbial Innovation, at the University of Auckland, New Zealand, illustrates the process. Created by Andrew Dopheide.

Ciofu et al point out that biofilm-associated antimicrobial tolerance is “fundamentally different from antimicrobial resistance” and attribute this to the following multi-factorial causes [16]:

  • Antimicrobial tolerance increases with biofilm age (maturation)
  • Biofilm matrices restrict antimicrobial penetration
  • Bacterial metabolic activity varies within the layers of biofilm
  • Specific gene expression unique to biofilms can provide enhanced tolerance
  • Persister cells divide slowly or not at all, inhibiting antibiotic pathways
  • The in vivo environment may have low oxygen tension, limiting the effectiveness of antibiotics dependent on the presence of oxygen for uptake, such as fluoroquinolones, beta‐lactams, and aminoglycosides

It has been observed that biofilm-associated infections are diversifying and the impact of this may be underestimated [17]. The persistent characteristics of biofilm and the role it plays in PJI highlights the importance of correct use of biofilm active antibiotics in implant-associated infections.

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  • PJI rates differ for joints
  • Prevention of PJI needs a cross-disciplinary approach
  • PREOPERATIVE infection prevention strategies
    • Identification and management of risk factor comorbidities
    • Nasal screening
    • Skin preparation
    • Immunosuppressive therapy
    • Glycemic control
    • New device coatings to battle microorganisms
  • INTRAOPERATIVE infection prevention strategies
    • Prophylactic antibiotics
    • Reducing operating room traffic
    • Dressed for success
    • A (clean) tool for the job?
  • POSTOPERATIVE infection prevention strategies
    • Prophylactic antibiotics for certain procedures
    • Blood transfusion
    • Wound care
    • Timeline for prevention
  • Conclusion
  • References
Additional Resources

Additional AO resources on this topic

Access videos, tools, and other assets to learn more about this topic.

 

Contributing experts

This series of articles was created with the support of the following specialists (in alphabetical order):


Olivier Borens

University Hospital Lausanne, Switzerland

Nora Renz

Inselspital, University Hospital
Bern, Switzerland

Andrej Trampuz

Charité - University Medicine
Berlin, Germany

This issue was created by Word+Vision Media Productions, Switzerland.

References

 

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