Outcome of hip and knee periprosthetic joint infections caused by pathogens resistant to biofilm-active antibiotics: results from a prospective cohort study
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Periprosthetic joint infections (PJI) caused by pathogens, for which no biofilm-active antibiotics are available, are often referred to as difficult-to-treat (DTT). However, it is unclear whether the outcome of DTT PJI is worse than those of non-DTT PJI. We evaluated the outcome of DTT and non-DTT PJI in a prospective cohort treated with a two-stage exchange according to a standardized algorithm.
Patients with hip and knee PJI from 2013 to 2015 were prospectively included and followed up for ≥ 2 years. DTT PJI was defined as growth of microorganism(s) resistant to all available biofilm-active antibiotics. The Kaplan–Meier survival analysis was used to compare the probability of infection-free survival between DTT and non-DTT PJI and the 95% confidence interval (95% CI) was calculated.
Among 163 PJI, 30 (18.4%) were classified as DTT and 133 (81.6%) as non-DTT. At a mean follow-up of 33 months (range 24–48 months), the overall treatment success was 82.8%. The infection-free survival rate at 2 years was 80% (95% CI 61–90%) for DTT PJI and 84% (95% CI 76–89%) for non-DTT PJI (p = 0.61). The following mean values were longer in DTT PJI than in non-DTT PJI: hospital stay (45 vs. 28 days; p < 0.001), prosthesis-free interval (89 vs. 58 days; p < 0.001) and duration of antimicrobial treatment (151 vs. 117 days; p = 0.003).
The outcome of DTT and non-DTT PJI was similar (80–84%), however, at the cost of longer hospital stay, longer prosthesis-free interval and longer antimicrobial treatment. It remains unclear whether patients undergoing two-stage exchange with a long interval need biofilm-active antibiotics. Further studies need to evaluate the outcome in patients treated with biofilm-active antibiotics undergoing short vs. long interval.
KeywordsPeriprosthetic joint infection Difficult-to-treat Outcome Biofilm-active antibiotics
Compliance with ethical standards
Conflict of interest
Authors DA, NR and AT declare that they have no conflict of interest. Author CP reports grants from Aesculap, personal fees from Zimmer, Smith & Nephew, Depuy/Synthes, Ceramtec and Link, outside the submitted work.
- 4.Bongartz T, Halligan CS, Osmon DR, Reinalda MS, Bamlet WR, Crowson CS, Hanssen AD, Matteson EL (2008) Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis. Arthritis Rheum 59(12):1713–1720. https://doi.org/10.1002/art.24060 CrossRefPubMedPubMedCentralGoogle Scholar
- 5.De Man FH, Sendi P, Zimmerli W, Maurer TB, Ochsner PE, Ilchmann T (2011) Infectiological, functional, and radiographic outcome after revision for prosthetic hip infection according to a strict algorithm. Acta Orthop 82(1):27–34. https://doi.org/10.3109/17453674.2010.548025 CrossRefPubMedPubMedCentralGoogle Scholar
- 13.Tzeng A, Tzeng TH, Vasdev S, Korth K, Healey T, Parvizi J, Saleh KJ (2015) Treating periprosthetic joint infections as biofilms: key diagnosis and management strategies. Diagn Microbiol Infect Dis 81(3):192–200. https://doi.org/10.1016/j.diagmicrobio.2014.08.018 CrossRefPubMedGoogle Scholar
- 18.Isiklar ZU, Darouiche RO, Landon GC, Beck T (1996) Efficacy of antibiotics alone for orthopaedic device related infections. Clin Orthop Relat Res (332):184–189Google Scholar
- 20.John AK, Baldoni D, Haschke M, Rentsch K, Schaerli P, Zimmerli W, Trampuz A (2009) Efficacy of daptomycin in implant-associated infection due to methicillin-resistant Staphylococcus aureus: importance of combination with rifampin. Antimicrob Agents Chemother 53(7):2719–2724. https://doi.org/10.1128/AAC.00047-09 CrossRefPubMedPubMedCentralGoogle Scholar
- 23.Reffuveille F, Fuente-Nunez Cde L, Fairfull-Smith KE, Hancock RE (2015) Potentiation of ciprofloxacin action against Gram-negative bacterial biofilms by a nitroxide. Pathog Dis 73 (5). https://doi.org/10.1093/femspd/ftv016
- 24.El Helou OC, Berbari EF, Lahr BD, Eckel-Passow JE, Razonable RR, Sia IG, Virk A, Walker RC, Steckelberg JM, Wilson WR, Hanssen AD, Osmon DR (2010) Efficacy and safety of rifampin containing regimen for staphylococcal prosthetic joint infections treated with debridement and retention. European journal of clinical microbiology & infectious diseases: official publication of the European Society. of Clinical Microbiology 29(8):961–967. https://doi.org/10.1007/s10096-010-0952-9 Google Scholar
- 31.Ochsner PEBO., Bodler PM, Broger I, Eich G, Hefti F, Maurer T, Nötzli H, Seiler S, Suva D, Trampuz A, Uckay I, Vogt M, Zimmerli W (2016) Infections of the musculoskeletal system. Basic principles, prevention, diagnosis and treatment. Swiss orthopaedics in-house publisher, GrandvauxGoogle Scholar
- 32.Akgun D, Trampuz A, Perka C, Renz N (2017) High failure rates in treatment of streptococcal periprosthetic joint infection: results from a seven-year retrospective cohort study. Bone Joint J 99-B(5):653–659. https://doi.org/10.1302/0301-620X.99B5.BJJ-2016-0851.R1 CrossRefPubMedGoogle Scholar
- 34.Krenn V, Morawietz L, Perino G, Kienapfel H, Ascherl R, Hassenpflug GJ, Thomsen M, Thomas P, Huber M, Kendoff D, Baumhoer D, Krukemeyer MG, Natu S, Boettner F, Zustin J, Kolbel B, Ruther W, Kretzer JP, Tiemann A, Trampuz A, Frommelt L, Tichilow R, Soder S, Muller S, Parvizi J, Illgner U, Gehrke T (2014) Revised histopathological consensus classification of joint implant related pathology. Pathol Res Pract 210(12):779–786. https://doi.org/10.1016/j.prp.2014.09.017 CrossRefPubMedGoogle Scholar
- 37.Akgun D, Muller M, Perka C, Winkler T (2017) A positive bacterial culture during re-implantation is associated with a poor outcome in two-stage exchange arthroplasty for deep infection. Bone Joint J 99-B(11):1490–1495. https://doi.org/10.1302/0301-620X.99B11.BJJ-2017-0243-R1 CrossRefPubMedGoogle Scholar
- 38.Achermann Y, Eigenmann K, Ledergerber B, Derksen L, Rafeiner P, Clauss M, Nuesch R, Zellweger C, Vogt M, Zimmerli W (2013) Factors associated with rifampin resistance in staphylococcal periprosthetic joint infections (PJI): a matched case-control study. Infection 41(2):431–437. https://doi.org/10.1007/s15010-012-0325-7 CrossRefPubMedGoogle Scholar
- 39.Hoell S, Moeller A, Gosheger G, Hardes J, Dieckmann R, Schulz D (2016) Two-stage revision arthroplasty for periprosthetic joint infections: what is the value of cultures and white cell count in synovial fluid and CRP in serum before second stage reimplantation? Arch Orthop Trauma Surg 136(4):447–452. https://doi.org/10.1007/s00402-015-2404-6 CrossRefPubMedGoogle Scholar
- 46.Zeller V, Lhotellier L, Marmor S, Leclerc P, Krain A, Graff W, Ducroquet F, Biau D, Leonard P, Desplaces N, Mamoudy P (2014) One-stage exchange arthroplasty for chronic periprosthetic hip infection: results of a large prospective cohort study. J Bone Joint Surg Am 96(1):e1. https://doi.org/10.2106/JBJS.L.01451 CrossRefPubMedGoogle Scholar
- 51.Baldoni D, Haschke M, Rajacic Z, Zimmerli W, Trampuz A (2009) Linezolid alone or combined with rifampin against methicillin-resistant Staphylococcus aureus in experimental foreign-body infection. Antimicrob Agents Chemother 53(3):1142–1148. https://doi.org/10.1128/AAC.00775-08 CrossRefPubMedGoogle Scholar
- 52.Trampuz A, Murphy CK, Rothstein DM, Widmer AF, Landmann R, Zimmerli W (2007) Efficacy of a novel rifamycin derivative, ABI-0043, against Staphylococcus aureus in an experimental model of foreign-body infection. Antimicrob Agents Chemother 51(7):2540–2545. https://doi.org/10.1128/AAC.00120-07 CrossRefPubMedPubMedCentralGoogle Scholar