MRSA infection in joint replacement

1
MRSA infection in joint replacement
Assoc Prof. Keerati C.Vanich Orthopaedic
department Siriraj faculty of medicine Mahidol
university
2
Introduction

• Prosthetic Joint Infection is important
  complication of joint replacement surgery
• This may result
• - increase morbidity.
• - increase revision operations.
• - increased antibiotic use.

3
Introduction

• Prosthetic joint infections infrequent
  complication
• Range rate of infection
• THA 0.3 - 1.3 1
• TKA 1 - 2 2

1.Hanssen AD. Evaluation and treatment of
infection at the site of a total hip or knee
arthroplasty. Instr Course Lect. 1999481122.
2.Lidgren L.A. Infection and arthritis.Infection
of prosthetic joints. Best Pract Res Clin
Rheumatol.200317209218.
4
Introduction

• Risk Factors for Infected Arthroplasty
• Prior surgery
• Surgery time gt2.5 hours
• Compromised immune status
• Poor nutrition
• Diabetes mellitus
• Obesity
• Smoking

Peersman G. Infection in total knee replacement
a retrospective review of 6489 total knee
replacements. Clin Orthop. 200139215-23.
5
Microbacterial

• Majority of infections Staphylococci
• Acute hematogenous infections
• -Staphylococcus aureus
• -Beta-hemolytic streptococci
• -Enterococcus species
• Gram-negative bacilli and anaerobes are also seen
  in chronic infections but uncommon..

1. Abudu A, Sivardeen KA, Grimer RJ, Pynsent PB,
Noy M. The outcome of perioperative wound
infection after total hip and knee arthroplasty.
Int Orthop.20022640-3. 2. Bengtson S, Blomgren
G, Knutson K, Wigren A, Lidgren L.
Hematogenous infection after knee arthroplasty.
Acta Orthop Scand. 198758529-34.
6
Staphylococcus aureus

• Common cause of musculoskeletal infections
• early postoperative infection
• late chronic infection
• acute hematogenous infection at the site of a
  prosthetic joint

7
Staphylococcus aureus

• Susceptibility to methicillin treated most
  effectively with
• antistaphylococcal penicillin (e.g., nafcillinor
  oxacillin)
• first-generation cephalosporin.

8
MRSA

• Methicillin-resistant Staphylococcus aureus
  (MRSA)
• first described in 1961
• extra penicillin-binding protein (PBP2a) which
  results in a low affinity for beta-lactam
  antibiotics such as the penicillins and
  cephalosporins

1. Garvin KL, Hinrichs SH, Urban JA.Emerging
antibiotic-resistant bacteria their treatment in
total joint arthroplasty.Clin Orthop1999369110-2
3.
9
MRSA
10
MRSA

• MRSA
• poor clinical outcome because of the limited
  effectiveness of antibiotics.
• Increase cost for treatment

1. Garvin KL, Hinrichs SH, Urban JA.Emerging
antibiotic-resistant bacteria their treatment in
total joint arthroplasty.Clin Orthop1999369110-2
3.
11
MRSA

• Increasing trend in MRSA infection
• Staphylococcus aureus (MRSA) from the nosocomial
  setting and its emergence as a
• cause of community-acquired infection.

Chambers HF. The changing epidemiology of
Staphylococcus aureus? Emerg Infect Dis.
20017178-82.
12
MRSA

• Ridgeway report multicentre study of 102
  hospitals in England.
• - Rate of surgical site infection after
  total hip replacement 2.2
• - MRSA infecting organism 24.3.

Ridgeway S, Wilson J, Charlet A, et al.Infection
of the surgical site after arthroplasty of the
hip.J Bone Joint Surg Br200587-B844-50.
13
MRSA

• D Ip, SK Yam retrospectively review causative
• organisms isolated from 36 infected hip and knee
• replacements requiring revision.
• - positive culture in revision hip
  patients was 59, 46 of MRSA.

D Ip, SK Yam, CK Chen.Implications of the
changing pattern of bacterial infections
following total joint replacements ,Journal of
Orthopaedic Surgery 200513(2)125-130
14
MRSA

• Rapeepat Narkbunnam, Retrospective study
• Knee revision arthroplasties at Siriraj hospital
  2002-2008
• 189 case 59 case cause from infection

15
Infected cases
From 59 Infected cases Positive culture 24
cases (41)
Organism Number
MRSA 14 (23.7)
Enterococcus Spp. 6
cons 5
Fungus - Candida 2
M.Tuberculosis 2
Others 5
16
Treatment
17
Treatment of prosthetic infection

• long-term antibiotic suppression
• surgical débridement with retention of the
  prosthesis
• resection arthroplasty
• Arthrodesis
• One-stage reimplantation procedure
• Two-stage reimplantation procedures

Hanssen AD, Rand JA. Evaluation and treatment of
infection at the site of a total hip or knee
arthroplasty. J Bone Joint Surg Am.
199880910-22.
18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21

• Two-stage reconstruction is the standard practice
  for treating patients with infected total joint
  arthroplasty.
• The success rate of two-stage reimplantation has
  ranged from 80-100

CP Duncan and CP Beauchamp, A temporary
antibiotic loaded joint replacement system for
management of complex infections involving the
hip. Orthop Clin North Am 24 (1993), p. 751. I
Ivarsson, O Wahlstrom, K Djerf and SA Jacobsson,
Revision of infected hip replacement Two-stage
procedure with a temporary gentamicin spacer.
Acta Orthop Scand 65 (1994), p. 7 TK Fehring,
TF Calton and WL Griffin, Cementless fixation in
2-stage reimplantation for periprosthetic sepsis.
J Arthroplasty 14 (1999), p. 175
22
Result of treatment in MRSA infection

23
MRSA

• Yogesh Mittal retrospective cohort study
• 37 TKA patients with MRSA or MRSE infection
• Two stage revision success rate 76 at median
  duration of follow-up was 51 months (range,
  twentyfour to 111 months).

Mittal Y, Fehring TK.Two-stage reimplantation
for periprosthetic knee infection involving
resistant organisms. 2007,JBJS Am.89(6)1227-31.
24
Antibiotic for treatment

• Systemic antibiotic
• Local antibiotic

25
Antibiotic

• Nalinee Aswapokee study at Siriraj hospital
  2002-2004
• In vitro study MRSA for ATB susceptible
• 113 clinical isolated MRSA

26
MRSA Antibiotic
27
Local Delivery of Antibiotics

• Antibiotic cemen bead/spacer
• local levels of antibiotics that far exceed those
  attained with systemic antibiotic therapy.

28
Local Delivery of Antibiotics

• Antibiotic bead
• - difficulty in removing after
  implantation.
• Antibioticimpregnated spacers
• - minimizes limb-shortening
• - limits scar formation
• - facilitates reimplantation

29
Antibiotic for cement spacer

• Microbial Sensitivity
• Bactericidal
• Heat stable
• Powder form

30
Antibiotic for cement spacer

• Gentamycin
• Tobramycin
• Vancomycin
• Fosfomycin

Hanssen AD, Spangehl MJ. Practical applications
of antibioticloaded bone cement for treatment of
infected joint replacements. Clin Orthop 2004 1
7985. Boonsin Buranapanithit.Home-made local
antibiotic cement for chronic osteomyelitis
caused by resistant organism.The journal of the
asean orthopaedic association.2000, 13.53-56
31
MRSA

• Vancomycin is first choice in MRSA
• Vancomycin bead/cement space
• Intravenous vancomycin

Juan J. Picazo.Activity of daptomycin against
staphylococci collected from bloodstream
infections in Spanish medical centers.Diagnostic
Microbiology and Infectious Disease.200964
,448451
32
Our mobile spacer technique
33
Prosthesis removal
34
(No Transcript)
35
Removal of debris and cement
36
Cement spacer molding
37
(No Transcript)
38
Insertion with a pack of cement
39
Final implantation
40
Postoperative x- ray
41
Treatment MRSA

• Yu-Ping Su prospectively 15 TKA cases
• 12/15 case MRSA
• Vancomycin spacer Vancomycin IV 4wk Fusidic
  oral 4-12 wk ? 12 revision TKA , 1 arthrodesis
  (poor control infection due to DM)
• None of the patients had recurrent infection
  after revision
• TKA.follow-up period of 47.5 months (range,
  3761 months).

Su YP.A facile technique to make articulating
spacers for infected total knee arthroplasty.J
Chin Med Assoc. 2009 72(3)138-45.
42
Treatment MRSA

• Yamamoto report 3 MRSA infected THA
• All case success control infection after revision
  with Vancomycin spacer and IV ATB at follow up
  53-62 month

• Yamamoto K.Cement spacer loaded with antibiotics
  for infected implants of the hip joint.J
  Arthroplasty. 2009 24(1)83-9.

43
Treatment MRSA

• Takahira report 2 MRSA infected THA
• 1 case (Vancomycin spacer) ? good control
  infection after revision ATB at follow up
  37.5month
• 1 case (Gentamycin spacer) ?
• recurrence infection at 4 month

Takahira N.Treatment outcome of two-stage
revision total hip arthroplasty for infected hip
arthroplasty using antibiotic-impregnated cement
spacer.J Orthop Sci. 20038(1)26-31.
44
Alternate antibiotic

• Allergy to Vancomycin
• Pathogen resistance to Vancomycin
• increase reports of decreasing
  susceptibility of S. aureus to vancomycin

Juan J. Picazo.Activity of daptomycin against
staphylococci collected from bloodstream
infections in Spanish medical centers.Diagnostic
Microbiology and Infectious Disease.200964
,448451
45
MRSA sensitivity

• Possible alternatives
• Teicoplanin
• Daptomycin
• Leinazolid
• Fosfomycin

Picazo JJ, Betriu C.Activity of daptomycin
against staphylococci collected from bloodstream
infections in Spanish medical centers.Diagn
Microbiol Infect Dis. 2009 64(4)448-51. Schintl
er MV,High fosfomycin concentrations in bone and
peripheral soft tissue in diabetic patients
presenting with bacterial foot infection. J
Antimicrob Chemother. 2009 Jul 3.
46
Antibiotic cement in MRSA

• Boonsin Buranapanithit in vitro study
• Gentamycin , Cefalexin bead cannot inhibit MRSA
• Vancomycin , Fosfomycin bead effectively inhibit
  growth of MRSA

Boonsin Buranapanitkit.In vitro Elution
Characteristics of Antibiotic Cement on MRSA
organism.The journal of the asean orthopaedic
association.2000, 13.33-36
47
Inhibition zone excess diameter in each replicate
of each antibiotic cement on each day of the
experiment
48
Fosfomycin

• A synthetic broad spectrum antibiotic
• Bactericidal antibiotic
• Heat stable
• High concentration in bone

Boselli E, Allaouchiche B.Diffusion in bone
tissue of antibiotics.Presse Med. 1999
,28(40)2265-76
49
Fosfomycin

• F.Baquero study 20 patient THR
• 2 study group
• A FOSMICIN 4 g. preoperation 1 hr (
  10 patient )
• B FOSMICIN 4 g. preoperation 2 hr (
  10 patient )
• Mean Bone penetration
• Cancellous bone 23.7
• Cortical bone 22.9

F.Baquero,E.Bergogne,D.Hoffler.Fosmicin
Penetration into Non-infected human bone. 13th
International Congress of Chemotherapy.Vienna.
28th Aug 1983
50
Fosfomycin

• Schintler Study fosfomycin concentrations in
  bone in 9 patients with DM foot with
  osteomyelitis
• High concentration in bone.
• Effective for treatment of deep-seated diabetic
  foot infections with osseous matrix involvement.

Schintler MV.High fosfomycin concentrations in
bone and peripheral soft tissue in diabetic
patients presenting with bacterial foot
infection.J Antimicrob Chemother. 2009 Jul 3.
51
Fosfomycin

• Boonsin Buranapanithit report
• 15 case Chronic osteomyelitis(8 MRSA)
• Combine Fosfomycin bead and systemic antibiotic
• 80 success rate

Boonsin Buranapanithit.Home-made local antibiotic
cement for chronic osteomyelitis caused by
resistant organism.The journal of the asean
orthopaedic association.2000, 13.53-56
52
Fosfomycin

• Boonsin Buranapanithit in vitro study
• PMMA bead
• Vancomycin group exerted inhibition to MRSA 3
  months
• Fosfomycin group exerted inhibition to MRSA 8 week

Boonsin Buranapanitkit,The Efficacy of a
Hydroxyapatite Composite as a Biodegradable
Antibiotic Delivery System Clin Orthop Relat Res.
2004 (424)244-52.
53
Fosfomycin
54
Fosfomycin
55
On going study

• A control trial between fosfomycin and
  cefuroxime as the antibiotic prophylaxis in knee
  arthroplasty
• Siriraj hospital
• Double blind method
• 112 patients, 56 patients per group

56

• First group
• fosfomycin sodium 2 g. iv drip
  before operation then 2 g. iv drip after 12 hrs.
  
• Second group receive
• cefuroxime injection 1.5 g. before
  operation then 0.75 g. iv after 8 and 16 hrs.
  respectively

57
Primary outcome

• Pain
• Skin temperature outside and inside knee are
  difference over 5 c by Infrared thermometer Fluke
  TiR
• C- reactive protein , ESR
• Synovial fluid culture

58
Infrared thermometer Fluke TiR
59
Conclusions

• Prevension
• Adequate surgical debridement
• Staged revision
• Adequate Susceptibility antibiotic

60
Thank you
61
Infection criteria in Rapeepat study

• Infection
• 1. The presence of an abscess or sinus tract that
  was found to be communicating with the joint
  space
• 2. A positive preoperative culture of aspirate on
  solid medium
• 3. Two or more positive intraoperative cultures
  of the same organism
• 4. Presence of gross intracapsular purulence or
  abnormal histological findings.
• 5. Received treatment as infected TKA such as
  prolond ATB, stage revision