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Prevention of Infections of Prosthetic Joints
Ilker UçkayInfection Control ProgrammeGeneva University Hospitals
Hôpitaux Universitaires de Genève
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Relative risks of SSI
Northern France 1998-2000, 67 wards, 26,094 patients
Rioux et al, ICHE 2006
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Clean orthopaedic surgery
Primary arthroplasties
0.8% Norwegian Arthroplasty Register (73,000 arthroplasties)
0.5% Deep arthroplasty infection Norway (22,170)
0.9% Finland (4628 arthroplasties)
0.5% Geneva (6101 arthroplasties)
Havelin et al, Acta Orthop Scand 2000
Engesaeter et al, ACS 2003
Paavolainen et al, Acta Orthop Scand 1991
Uçkay et al, J Infect 2009
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Clean orthopaedic surgery
3.9% Femoral osteosynthesis3.6% Elbow arthroplasties1.2% Hand surgery1.6% Foot & ankle surgery 0.8% Primary arthroplasties0.1% Arthroscopies4-11% PIN care1.3% Hallux valgus - Lapidus
Kleinert et al, JBJS Am ‘97
Zgonis et al, J FSAS 2004
Uçkay et al, J Infect ‘09
Müller-Rath et al, Arthroskopie 2008
Merrer et al, ICHE ‘07
Celli et al, JBJS Am 2009
Reigstad et al, Knee Surg Traum Arthrosc ‘06
Popelka et al, Acta Chir orthop Traumatol Cech 2008
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1. Diagnosis and treatment
2. Prevention of SSI, general aspects
3. Particularities in orthopedic surgery
Structure of the presentation
1700 /μl
65%sens. 94%spec. 88% sens. 97%
spec. 98%
total leuc count
neutrophils
Diagnostics in low-grade infections
Sonication Mass spectrometry
Microcalorimetry Molecular methods 7
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Zimmerli et al. N Engl J Med 2004
Microbiology of 578 prosthetic joint infections seen at Mayo Clinic between 1992-1997
Microorganism %Coagulase-negative staphylococci 30 %S. aureus 23 %Polymicrobial 12 %Unknown 11 %Streptococci 9 %Gram-negative bacilli 6 %Anaerobes 4 %Enterococci 3 %Other 2 %
Steckelberg et al. Prosthetic Joint Infections, Infections Associated with Indwelling Medical Devices, 3rd edition, ASM Press, 2000
Zimmerli et al, JAMA 1998
• linzolide • quinopristine-dalfopristine• pristinamycine• daptomycin, • tigecyclin, • minocyclin,• New quinolones,
Studies of equivalencenot superior to « old combinations »
Uçkay, Lew. MRSA bone infections. Nova Science 2009.
New molecules
If implant removedclindamycine 3 x 600 mg, ciprofloxacine 2 x 750 mg
Combinationsciprofloxacine 2 x 500 mg - rifampicine 1 x 600 mgacide fusidique 3 x 500 mg - rifampicine 1 x 600 mgcotrimoxazole 2-3 x forte - rifampicine 1 x 600 mg
Antibiotics in Geneva
Uçkay, Lew. In Karchmer. Osteomyelitis 2010
No studies. Experts‘ opinion
As a principle 6-12 weeksindependently of bone or bacteria
Exceptions:Special pathogens: Tbc, actinomyces, fungi, etc.
Duration of antibiotic therapy
Lew, Waldvogel, Lancet 2004Zimmerli, Tampuz et al, various publications
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Multivariate analysis for outcome Cure
•Retention with debridement (OR 0.3, 0.1-1.1) •Two-stage exchange (OR 1.1, 0.2-4.8) •Number of surgical debridements (OR 0.9, 0.4-1.9) •6 weeks’ antibiotic treatment (OR 2.0, 0.9-7.8) •Duration of i.v. antibiotic course (OR 1.0, 1.0-1.0)
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1. Diagnosis and treatment
2. Prevention of SSI, general aspects
3. Particularities in orthopedic surgery
Structure of the presentation
Uçkay, Pittet et al, Ann Med 2009
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24Uçkay et al, J Infect 2009
Haematogenous infections
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Risk factors for SSI (selection)
Diabetes mellitus OR 4.5, 2.4-9.3
Obesity >30 BMI OR 4.1, 1.1-19.0
Change of surgeon OR 2.9, 2.0-4.0
Wound class OR 2.6, 2.2-3.0
Infect. prior surgery OR 2.4, 1.6-3.7
Hyperglycaemia OR 2.3, 1.3-4.0
Drains >3 days OR 2.2, 1.4-3.4
Trussel, Am J Surg 2008
Lübbeke et al, Arthrit Rheum 08
Park et al, Transplantation 2009
Rioux et al, ICHE 2006
Petrosillo et al, BMC Infect Dis 08
Beldi et al, Am J Surg 2009
Haridas et al, Surgery 2008
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Risk factors for SSI (selection)
ASA-Score >2 pts OR 1.9, 1.6-2.2
Loud noise OR 1.9, 1.3-2.6
Hectic movements OR 1.8, 1.1-3.0
Duration surg >75% OR 1.8, 1.2-2.8
Emergency surgery OR 1.7, 1.2-2.4
Age >65 years OR 1.3, 1.1-1.5
Rioux et al, ICHE 2006
Rioux et al, ICHE 2006
Beldi et al, Am J Surg 2009
Beldi et al, Am J Surg 2009
Haridas et al, Surgery 2008
Petrosillo et al, BMC Infect Dis 08
For orthopaedics
•Polyarthritis •Revision
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4 cornerstones
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Antibiotic prophylaxis …
• No benefit >24 h• No benefit of continuous vs. intermittent
infusion
• No threshold for routine vancomycine prophylaxis in settings with endemicity for methicillin-resistant staphylococci.
• No evidence that vancomycin is superior to cephalosporins.
McDonald et al, Aust N Z J Surg 1998
Suffoletta et al, Pharmacotherapy 2008
Prokuski, J Am Acad Orthop Surg 2008
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Timing
Steinberg et al. Ann Surg 2009
33Prokuski. J Am Acad Orthop Surg 2008
Choice of antibiotic agents
Postponing in case of remote infections ?
Experience of surgeons ?
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Does it matter ?
maybe ….38
Screening for S. aureus
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Walz et al, Arch Surg 2006Kurz et al, NEJM 1996
Intraoperative normoglycaemia (<200mg/dL)SSI 20% vs. 52%, while Hb A1c and diabetes mellitus were not associated
Park et al, Transplantation 2009
Ambiru et al, J Hosp Infect 2008
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Active surveillance
Courtesy: Astagneau, SFHH 2007
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Rioux et al, J Hosp Infect 2007
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Multimodal approachTimely antibiotic prophylaxis, strict glycaemia control, no shaving SSI 1.5% vs. 3.5% in controls
100k lives campaign(antibiotic prophylaxis, glycaemia control, normothermia)SSI from 2.3% to 1.7% (-27%)
SCIP project & Safety Checklist
100k lives campaign
Trussel et al, Am J Surg 2008
Things that do matter ?
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Before surgery
Disinfection in circles vs. back-and forthNo difference.
Preoperative bathing and showering.Cochrane review, 6 trials, 10,000 participantsNo evidence vs. placebo RR 0.9, 0.8-1.1.
Haïr removal. Meta-analysis of 4 trials.Inconclusive. Immediately before operation.
Stonecypher. Crit Care Nurs Q 2009
Webster et al, Cochrane Database of Systematic Reviews 2007
Niël-Weise et al. ICHE 2005Mangram et al, ICHE 1999
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During and afterLaparoscopy vs. laparotomy. No evidence
Double-gloving 26 trials. Inconclusive
Staples vs. sutures. No difference
Use of drains. No evidence
Pin site care. 6 trials, 349 patients.No regimen (daily vs. weekly, cleansing vs. no cleansing) is superior to others
Anderson et al. UpToDate 2009
Mullen et al, Can J Cardiol 1999Chughtai et al, Can J Cardiol 2000
Tanner et al, Cochrane Database of Systematic Reviews 2006
Gaines et al. Orthopedics 2008
Lethaby et al. Cochrane Database of Systematic Reviews 2008
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Laminar airflow
Laminar airflow reduces bacterial burden in the air
Retrospective analysis in KISS system(63 hospitals, 100,000 procedures).
No reduction of SSI with laminar airflow vs. no laminar airflow. OR 1.63, 1.06-2.52.No information about individual antibiotic prophylaxis, normothermia, obesity etc.
Brandt et al, Ann Surg 2008
Whyte et al, J Hosp Infect 1982
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Public reportingMandatory or planned in several US states
CDC reviewNo studies have investigated SSI reduction as outcome. None compared costs.
HICPAC recommends possible public reporting of antibiotic prophylaxis-related parameters, and SSI of selected operations.Key questionsMotivation for HCW or hospitals ?What to do with unexpected consequences ?
McKibben et al, Am J Infect Control 2005
Humphreys et al, Clin Microbiol Infect 2008
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Sparse literature
Most SSI are believed to be acquired during surgery ?- SSI diminution in operating room- airborne (opinion 1970s)
Charnley. Clin Orthop Relat Res 1972
Lidwell et al, BMJ 1982Lindberg. Lakartidningen 1979
The proportion of SSI acquired in the operating theatre vs. acquired afterwards, is unknown
Ayliffe. Rev Infect Dis 1991
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Author Harbarth, JAMA 2008
Robicsek, Annals 2008
Jeyaratnam, BMJ 2008
Keshtgar, Br J Surg 2008
Country Switzerland USA UK UK
Setting Surgery Hospital-wide Geriatrics, oncology, surgery
Surgery
Design Cross-over Before-after Cross-over Before-after
Control group Yes No Yes No
Admission MRSA prevalence
5.1% 6.3% 6.7% 4.5%
CONCLUSION Screening did not reduceMRSA infections
Admission screening reducedMRSA disease
Universal MRSA screening is not recommended
MRSA screening reduced staphyloc. BSI
Harbarth et al. J Am Coll Surg 2008
MRSA screening on admisson
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3.4
7.7
1.1
4.9
0
5
10
Intervention Placebo
SA in
fect
ion
rate
(%)
All S.aureus NI Deep SSI
S. aureus screening & decolonization
Bode et al NEJM 2010
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Nasal mupirocin
8 RCTs included
Effect of mupirocin nasal ointment on S. aureus infections
Significant reduction of the S. aureusinfection rate
RR 0.6, 95% CI 0.43-0.70
Van Rijen et al, Cochrane Database Syst Rev. 2008
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Nasal mupirocin ?
• Reduced MSSA carriage in 615 orthopaedic patients, but not SSI (not even due to MSSA !)
• No benefit in general surgery
• Meta-analysis in general surgeryMupirocin vs. no mupirocin; SSI 8.4% vs. 8.1%
Kalmeijer et al, CID 2002
Kallen et al, ICHE 2005
Perl et al, NEJM 2002
Single centresHistorical controls (before-after studies)
Screening & decolonisation (mupirocin, chlorhexidin) or (mupirocin, triclosan)
significantly beneficiary for MRSA, not MSSA
Caveat: No case-mix ajustements57
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Single centreProspective- two groups
Screening & decolonisation (mupirocin, 5d chlorhexidin)vs.no intervention
Results: no vs. 12 SSI due to S. aureusEconomic gain of $230,000 for the hospital
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In our case
No revision, no polyarthritisMassive early PJIAcquired in operating theatreExperienced surgeonsCorrect antibiotic prophylaxis
…..?63
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Thank you very much for your attention
AcknowledgmentsParham Sendi, Stephan Harbarth, Hazel Morse, Hugo Sax, Didier Pittet
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