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PIANO examine offers perception into profitable prosthetic joint an infection administration

September 23, 2022

5 min learn


Percival stories no related monetary disclosures.

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Prosthetic joint alternative surgical procedure adjustments the lives of tens of millions yearly, however issues, together with prosthetic joint an infection, happen in 1% to 2% of sufferers following giant joint alternative.

Prosthetic joint infections (PJIs) result in affected person morbidity and place a major monetary burden on the well being care system, with annual prices in the USA exceeding $1.6 billion in 2020. Specialists predict that there will probably be 4 million whole knee and hip arthroplasties yearly within the US by 2030. It’s vital to find out the most effective administration for optimum outcomes.

Kelly Percival

There are few randomized managed trials (RCTs) to direct finest surgical and antimicrobial administration, resulting in a poor proof base of the Infectious Illnesses Society of America 2012 PJI pointers. Most knowledge are from small retrospective research from facilities with specialised PJI experience, and registry knowledge typically underestimate the true incidence, particularly of late acute PJI. To handle this data hole, the Prosthetic Joint An infection in Australia and New Zealand commentary (PIANO) examine was performed.

The PIANO examine was a potential observational examine of PJI traits, etiology and preliminary administration from July 2014 via December 2017 in 27 hospitals all through Australia and New Zealand. The examine included 783 sufferers with PJI — 427 knee (54.5%), 323 hip (41.3%), 25 shoulder (3.2%), six elbow (0.8%) and two ankle (0.3%) joint infections — in an preliminary 90- day final result, categorized in response to PJI definitions, microbiological classification (monomicrobial, polymicrobial, or tradition adverse) and surgical administration technique.

Surgical methods included:

  • debridement, antibiotics, irrigation, implant retention (DAIR);
  • two-stage alternate arthroplasty;
  • single-stage alternate arthroplasty;
  • suppressive antibiotics alone;
  • excision arthroplasty; and
  • no plan recognized.

PJI definitions have been:

  • early PJI: 30 days or much less after authentic arthroplasty operation;
  • late acute PJI (LA-PJI): greater than 30 days from implantation however with period of signs of seven days or much less with no proof of sinus tract;
  • late indeterminate PJI: greater than 30 days from implantation and period of signs between 8 and 30 days with no proof of sinus tract; and
  • late persistent PJI: greater than 30 days from implantation and period of signs greater than 30 days or presence of sinus tract.

LA-PJI was the commonest kind, accounting for 44.8% of infections, adopted by early PJI (25%) and late persistent PJI (18.9%). LA-PJIs have been probably attributable to an contaminated knee prosthesis (71%), whereas hip infections have been extra prone to be early PJIs (59%), with related charges of persistent an infection in each. The most typical comorbidities have been diabetes (22.1%) and ischemic coronary heart illness (16.8%), with no affiliation discovered between comorbidities and kind of PJI.

Most infections have been monomicrobial, adopted by polymicrobial and tradition adverse. LA-PJIs have been extra prone to be monomicrobial (81.2%) in contrast with early PJIs (49.5%), with the bulk attributable to staphylococcus aureus, coagulase-negative staphylococci (CoNS), or beta-hemolytic streptococci. Early infections have been polymicrobial 41.3% of the time, with S. aureus and CoNS being most typical, and Enterobacteriaceae and enterococci current in 12.2% and 16.3%, respectively. In persistent infections, 70.3% have been monomicrobial and 19.6% have been polymicrobial, with CoNS accounting for one-third of organisms, adopted by S.aureus, Enterobacteriaceae and enterococci, every accounting for about 5%.

The most typical surgical technique utilized in 66.4% of instances was DAIR, then two-stage revision (18.6%), one-stage revision (4.6%), antibiotic suppression (6.7%) and excision arthroplasty (0.9%). DAIR was the deliberate main administration technique in 70% of LA-PJI, 81.6% of early PJI and 44.6% of persistent PJI, with most requiring just one debridement, typically with out liner alternate, arthroscopic debridement or elimination of all contaminated materials.

Empiric antibiotics have been began in 82% of instances, with vancomycin probably the most prescribed (45%), adopted by cefazolin (40%), flucloxacillin (32%), piperacillin-tazobactam (9.6%) and ceftriaxone (6%). The minority of sufferers obtained enough gram-negative protection of their empiric antibiotic routine typically attributable to AmpC organisms.

This 90-day final result examine confirmed LA-PJI is the commonest presentation and demonstrated heterogeneity in PJI presentation and administration. It was adopted by a 24-month final result evaluation of the PIANO cohort to look at relationships between follow variations and supplied a platform to construct interventional research.

The 653 sufferers who accomplished the 24-month follow-up as a part of the PIANO cohort have been evaluated to find out if remedy success was related to modifiable variables in surgical and antibiotic administration. The principle outcomes outlined have been medical treatment (alive, absence of medical or microbiological proof of an infection and never requiring ongoing antibiotics) and remedy success (medical treatment plus index prosthesis nonetheless in place).

Medical treatment was achieved in 69% of sufferers, and 54% had remedy success. DAIR was the commonest surgical technique and was most profitable in early PJIs (74%), with declining success in LA-PJI (49%) and persistent PJI (44%). Components related to remedy success within the univariate evaluation have been youthful age, hip as index joint, early an infection, greater baseline serum albumin and absence of persistent renal illness or malignancy. Success price was lowest for infections brought on by S. aureus (46%), Propionibacterium (Cutibacterium) species (46%) or gram-negative rods (46%), whereas different organisms had 56% to 58% success and tradition adverse had 71% success. The PIANO cohort had only a few MRSA infections—solely 23—however the success price was decrease with these infections, at 39%.

LA-PJIs have been much less possible to achieve success than early PJIs, however these managed with a two-stage revision had related success to these with early PJIs (72% vs. 79%). These LA-PJIs managed with DAIR have been profitable in solely 48% of instances. Therapy success was no completely different amongst these handled with rifampin vs. no rifampin (OR 1.15; 95% CI, 0.82-1.61), and this insignificance maintained, even when restricted to gram-positive or S. aureus infections solely.

Rifampin was utilized in 255 episodes, with 26% experiencing an hostile occasion. There must be a big RCT to find out if there’s a profit to the addition of rifampin in PJI administration.

Therapy success was decided by nonmodifiable variables, together with index joint, early vs. late PJI, causative organism, affected person age and absence of choose comorbidities, however surgical and antibiotic (modifiable) components weren’t related to success. Low success charges with DAIR recommend that revision arthroplasty (single or two stage) would be the preferable administration technique in these with LA-PJI, and DAIR for early PJI.

Empiric antibiotic remedy in PJI ought to goal the probably organisms whereas avoiding overly broad-spectrum exercise. Unnecessarily broad antibiotic remedy can result in growth of antibiotic resistance and will increase the danger for hostile occasions.

The PIANO cohort confirmed early PJIs have been extra prone to be polymicrobial in contrast with LA-PJIs. Proportion of sufferers based mostly on PJI kind was analyzed to find out empiric regimens that may adequately cowl recognized organism in 80% of sufferers with out sepsis and 90% with sepsis. Primarily based on these knowledge, the authors proposed empiric remedy based mostly on kind of PJI and indicators of sepsis (Desk).

Proposed empirical therapy table

The same examine performed in New Zealand evaluating 15 years of microbiological knowledge from knee PJIs concluded related empiric antibiotic remedy suggestions for PJIs. The advice ought to enhance empirical enough gram-negative protection from the 26% famous within the PIANO cohort. Cefazolin alone is advisable for LA-PJI, typically a monomicrobial gram-positive an infection, which is cheap for Australia and New Zealand as a result of the speed of MRSA was low in these cohorts however could must be modified to vancomycin monotherapy in areas with greater charges of MRSA.


The information from this massive cohort confirmed success of PJI remedy is usually influenced by nonmodifiable danger components in contrast with surgical and antibiotic methods, though the timing of the PJI from preliminary arthroplasty must be factored into preliminary surgical administration and empiric antibiotic remedy choice.

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