Osteo-articular infections (OAI) on material (prosthesis, implant, osteosynthesis) Pr M Dupon CHU Bordeaux, France

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Osteo-articular infections (OAI) on material
(prosthesis, implant, osteosynthesis)Pr M Dupon
CHU Bordeaux, France
Recommendations for the clinical practice

• Organized by the SPILF (Society of Infectious
  Pathology of French Language) with the
  cooperation of the following learned societies
• CMIT (College of the Academics of Infectious and
  tropical Diseases)
• GPIP (Group of Pediatric Infectious Pathology)
• SFAR (French Society of Anaesthetics and
  Intensive Care)
• SFHH (French Society of Hospital Hygiene)
• SFM (French Society of Microbiology)
• SFMN (French Society of Nuclear Medicine)
• SOFCOT (French Society of Orthopaedic Surgery)
• SOFMER (French Society of Physical Medicine and
  Rehabilitation)
• SFR (French Society of Radiology)
• SFR (French Society) of Rheumatology)

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• Rédaction V3 complète
• Réunions téléphoniques

• RPC are medical and professional recommendations
  which can be used to establish medical
  references, that is " standards of practice "
  determining what it is suited and\or
  inappropriate to make, during the implementation
  of preventive, diagnostic and\or therapeutic
  strategies in given clinical situations ". These
  standards can be used for
• Improve the quality of the professional practices
  
• establish a reference table of a clinical audit
• be at the origin of tools of regulation in a
  conventional frame(executive).
• A rigorous and explicit approach must be applied
  to prepare " medical and professional valid and
  credible recommendations.

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Recommandation gradation
Scientific level of proof provided by the literature Rank of the recommendations
Niveau 1 Comparative randomized studies with high power - Meta-analyse of randomized comparative studies - Decision analysis based on well led studies A Evidence based
Niveau 2 - Randomized comparative studies with low power - Well undertaken non-randomized comparative studies - Cohort studies B Scientific presumption
Niveau 3 Case-witness studies Niveau 4 - Comparative studies with important bias - Retrospective studies - Series of cases C Weak level of proof

• French High Authority of Health (HAS) gradation
• This gradation of the recommendations based on
  the scientific level of proof of the literature
  does not suppose obligatorily a degree of force
  of these recommendations. It can exist
  recommendations of rank C or founded on a
  professional agreement nevertheless strong in
  spite of the absence of a scientific support.

• OAI Variable levels of proof, mostly weak
• In the absence of precision, the suggested
  recommendations correspond with
• a professional agreement
• The expression of a professional agreement must
  translate a professional consensus obtained by a
  formalized method (vote, Delphi method)

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PLAN

• How to classify the various osteo-articular
  infections on material?
• How to assert the diagnosis of osteo-articular
  infections on material?
• What are the modalities of the therapeutic care?
• What are prerequisites to minimize this type of
  infections?
• What medico-legal repair for the consequences of
  the postoperative ostéo-articular infections on
  material?

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Question 1
How to classify the various osteo-articular
infections on material?
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Determining factors of a classification

• Definition of the type of material
• Material of osteosynthesis
• Material (affixed to the bone plate,
  intramedullary nail
• rachis inter-somatic stems, screws, grafts,
  cages, artificial ligaments)
• External fixing
• Prostheses
• Osseous substitutes and allografts
• Length of infection evolution
• Ambiguity of acute or chronic infection terms
  (clinician?microbiologist?surgeon)
• Time of diagnosis after the material
  implantation
• early infection lt1 mois
• delayed infection 2 to 6 months
• late infection gt 6 months
• No universal classification

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Determining factors of a classification

• To take account of 7 fundamental points
• Mode of contamination (direct, hematogen, by
  contiguity)
• Chronology, allowing to make difference between
  post-operative infection and hematogenous
  infection) (symptom-free period, time of
  contamination,delay before management)
• Infectious state (knowledge of microorganisms,
  repercussion of the infection)
• Mechanical state of the infected site (loosened
  prosthesis or not, consolidated fracture or not,
  material present or not, explantable or not)
• Localization of the infection (peripheral bone,
  joint, spinal column)
• State of skin and soft tissues
• State of the patient (functional and general,
  immune status, underlying ground)

Beginning of medical care
Infectious signs at prosthesis level
Prosthesis implantation
Remote infectious site
Free interval
Delay before manage-ment
Time of contamination
temps
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Surgical Site Infection risk factors (1)

• Opened fractures, significant risks
• tibial localization
• severity of the soft tissue lesions evaluated by
  classification of Gustilo (level 2)
• Closed fractures of the long bones
• Diabetes factor of difficulty of cicatrization
  after osteosynthesis of ankle or the foot (level
  2)
• Orthopedic Surgery
• significant increase of the SSI risk
• age gt65 years, existence of another infectious
  site, preoperative stay exceeding 4 days (level
  2)
• weak increase of the SSI risk
• obesity, corticosteroid therapy, recent
  radiotherapy on operational site, healing delay,
  hematoma occurence (level 2), rheumatoid
  polyarthritis (opinion of expert)
• Spine
• diabetes
• perioperative plasma glucose level rise (level 3)

• Rheumatoid polyarthritis
• no stop of the corticosteroid therapy (risk of
  acute suprarenal incapacity)
• Methotrexate continuation does not increase the
  risk of SSI (level 1)
• Anti-TNF (HAS recommendations)
• Stop of the anti-TNF 2 -5 half-lives before the
  intervention and until complete cutaneous healing.

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Microbial epidemiology

• Microorganisms Frequency
  ()
• Total Osteosynthesis prosthesis matérial
  
• Coagulase lt0 Staph. 30 à 43 22
• Staphylococcus aureus 12 à 23 30
• Streptococcus sp 9 à 10 1
• Enterococcus sp 3 à 7 3
• Gram négative bacilli 3 à 6 10
• Anaerobic (P acnes) 2 à 4 5
• Polymicrobial 10 à 12 27
• No bacteria 10 à 11 2
• Others Candida, Corynebacteria, ..

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Question 2
How to assert diagnosis of osteo-articular
infections on material?
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Clinical signs

• Fistula infection (level 3)
• In the month following material implantation
  (level3)
• Pain of abnormal intensity
• Purulent discharge
• Scar disunity or necrosis
• At a distance of the implementation (rank C)
• Pain
• After a long free interval, in front of local
  signs, look for a hematogenic infection (rank B)
• Absence of inflammatory sign do not eliminate an
  infection (level 2)

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Biological signs

• No biological parameter is specific
• Leucocytose low VPP or VPN (level 2)
• A normal value of VS and of CRP does not
  eliminate an infection (expert opinion)
• In the month after the implantation (rank C)
• Interest of CRP follow-up
• SR no diagnostic value
• After 3 months, suspicion of infection if (rank
  B)
• SR gt 22 - 30 mm, 82-93 , Sp 84
• CRP gt 10-13,5 mg / l, Se 91-97 , Sp 86-92
• if no confusing factors

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Radiological signs

• Need for producing a standard plain radio even if
  normal in 50 of the cases (rank B)
• Signs to be sought (level 2)
• Sequestration
• Bone loosening (border width gt2mm during 1 year)
• Blurred osteolytic lesions
• Periosteal reaction
• Presence of intra-articular gas
• Mobilisation or fracture of the
• material
• Se 14 Spe 70

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Computed tomography and ultrasonography signs

• Computed tomography (CT)
• It is recommended to produce a scanner with
  injection of contrast product (rank B)
• Peripheral bone structure osseous, soft tissues
  
• Interferences in the vicinity
• of metal implants
• Signs to be sought (level 2)
• Periosteal reactions
• Blurred osteolytic lesions
• Soft tissue abnormalities
• and collections

• Ultrasonography
• Signs (level 2)
• Intraarticular fluid accumulation or around the
  implant
• Soft tissues thickening

• Absence of intra-articular effusion strong NPV

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MRI, arthrographic signs

• Arthrography (iodine contrast)
• Sinus tract, para-articular collection,
• can be used to guide joint aspiration and
  drainage procedures.
• (level 2)

• Magnetic resonance imaging (MRI)
• artifacts making interpretation difficult
  (material, immediate post-operative period)-
• Injection of Gadolinium
• Signs (level 2)
• Oedema of soft tissues (hypersignal T2)
• Intra-osseous or soft tissues collection
• Sinus tract (hypersignal T2)
• Articular effusion (hypersignal T2)
• Osseous sequestration (hyposignal)

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Nuclear imaging

• Bone scintigraphy with HDP-Tc99m abnormal
  fixation in the 3 phases (level 2) Se 90-100
  Sp 30-40VPN 100
• Labelled leukocyte scan (or scan with
  anti-granulocyte antibodies) with late images at
  24h (level 2) improved Spe
• Hybrid imaging single photon emission
  tomography/ computed tomography (SPET/CT)
  increased spatial resolution
• Se 81-97 Sp 89-100
• But persistence of increased uptake between 6-12
  months after a surgery (perform
  sulfo-colloids-Tc99m medullar scintigraphy to
  look for absence of congruence)
• For the spine, scintigraphy with
• Gallium 67 (level 2)
• Positron Emission
• Tomography/CT imaging with
• F-18 fluorodeoxyglucose is
• under evaluation
• (for chronic infection)

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Imaging strategy

• Early (lt1 month) or hematogenous infection
• restricted contribution
• puncture of a collection, with surgical asepsis,
  under control echo or TDM if nonaccessible
  clinically (rank C)
• Delayed or late Infection (gt1 month)
• Radio operator standard (simplicity,
  reproducibility, low cost)(rank B)
• TDM with injection (rank B)
• puncture of a collection, with surgical asepsis,
  under echo or TDM or arthroscanner if clinically
  non-accessible (rank C)
• Imaging with radioisotopes (bone scintigraphy
  associated to scintigraphy with tagged PNM) (rank
  C)
• Rachis
• MRI (early or late infection)
• Scintigraphy with Ga67 (delayed or late
  infection)(rank B)

• Absence of intra-articular effusion strong NPV

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Question 2
How to assert diagnosis of osteo-articular
infections on material?

• 2.4 What is the contribution of the microbiology
  and the anatomo-pathology?

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How should diagnostic microbiological sampling be
performed? (1)

• General principles
• wait a minimum of 15 days after any
  antibiotherapy before any test, to decrease the
  rate of false negative samples (except in case of
  sepsis and after evaluating the risk for
  disseminated infection)(expert advice).
• Pre-operative sampling
• It is strongly recommended
• not to sample with a swab on the scar, even if it
  is not healed.
• to perform pre-operative sampling with surgical
  asepsis if diagnosis doubt
• It is recommended
• to perform hemocultures and pre-operative
  sampling (puncture of a joint or of an abscess)
  to rapidly initiate probabilistic antibiotherapy
  if general signs of sepsis
• not to perform sampling from the outlet of a
  fistula
• to carry out hemocultures and a preoperative
  puncture in order to begin a probabilistic
  antibiotherapy quickly if sepsis with general
  signs
• to carry out a puncture (vpp 67-100, vpn 95)
  in case of intra-articular effusion or abscess
  if not liquid, tissue biopsy with the true-cut
  (rank B)
• to collect part of the liquid in a hermetically
  closed sterile syringe and to inoculate
  hémoculture vials for aerobes and anaerobes with
  the other part

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How should diagnostic microbiological sampling be
performed? (2)

• Per-operative sampling
• It is recommended
• to sample at the beginning of surgery, without
  any antibiotherapy, and before any
  antibioprophylaxis.
• to perform 5 samplings at the level of
  macroscopically pathological areas (grade B).
  These samplings may be liquid (pus, articular
  fluid) or solid (granulomatous tissue, bone
  tissue, interposition tissue, and any suspicious
  tissue).
• to change sampling tools between each sampled
  site.
• Post-operative sampling
• In case of septic surgery, the positivity (with
  the same bacterium or another) of cultured drain
  fluids seems to be linked with a higher risk of
  infection relapse (level 2).
• In case of infection on external fixator pin, it
  is recommended to perform sampling along the pin
  (level 2)

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Microbiological techniques at the laboratory (1)

• It is recommended to maintain incubation of
  culture media for at least 14 days (expert
  advice).
• Pre-operative samplings articular fluid
• It is recommended to perform a cytological test
  (count and formula) in the 2 h following
  sampling.
• gt1,700 leucocytes/mm3 (Se 94, Spe 88) and gt65
  of PMN neutrophils are strongly suggestive of
  infection on prosthesis in articular fluid (level
  2).
• It is recommended to seed the articular fluid on
  enriched agars to be incubated in aerobic
  condition, under 5 of CO2 and in anaerobic
  condition, and to inoculate hemoculture vials for
  aerobics and anaerobes.

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Microbiological techniques at the laboratory (2)

• Per-operative sampling
• It is recommended
• to crush solid samples
• to seed on solid and liquid enriched media and
  eventually on a medium for mycobacteria
• to perform direct examination to screen for PMN
  neutrophils and bacteria (Gram staining)(Se 6,
  Spe 100).
• to freeze a part of samples (-80C) for specific
  screening (fungus, mycobacteria) and eventually
  for molecular biological techniques.
• It is recommended
• to identify all the different colonies,
  especially staphylococci slow culture( small
  colony variants )
• to perform an antibiogram on the various types of
  colonies
• isolated. It is necessary to asses glycopeptide
  MICs
• on staphylococci and to check, if possible, the
  susceptibility
• to oxacillin by screening for the mecA gene. It
  is necessary to
• assess MICs of beta-lactams on the non-groupable
  streptococci.
• New methods under evaluation sonication,
  broad-range PCR (16S RNA)

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Question 2
How to assert diagnosis of osteo-articular
infections on material?

• 2.5 What are the arguments in favour of the
  diagnosis? Definite infection and probably
  excluded or not detectable infection

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What data suggests the diagnosis (proved
infection, and non detectable or no infection)?

• The working group, with an exploratory objective,
  has judged useful to propose a binary
  classification (proved infection /infection
  probably excluded or not detectable) by
  considering that between the two, there are
  several situations of possible infection for
  which specific criteria cannot be defined
• Consider that the initial clinical, biological,
  and/or imaging approach, has allowed to suspect
  infection.
• Consider that 5 samplings at least were performed

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What data suggests the diagnosis (proved
infection, and non detectable or no infection)?
Infection Fistula Pus in joint or in contact with prosthesis gt0 per-op samplings Culture bacteria of the skin flora gt0 per-op samplings Culture bacteria not belonging to the skin flora Histology gt5PN / field In 5 fields x40 Joint fluid gt65 PN
definite 3 per-op or 2 per-op samplings and 1 joint punct. 1 per-op sampling or 1 joint punct. or 1 hemoc
infection probably excluded or not detectable - - - - -
infection probably excluded or not detectable 1 per op - - -
ou
or
or
or
ou
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Question 3
What are the modalities of therapeutic management?
What are the specificities of surgical treatment?
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What is the rational for the  therapeutic
strategy? Biofilm and biomaterials

• The oxides contained in the material are
  responsible
• for a secondary binding interaction surface for
  bacteria.
• This process begins by a phenomenon of
  attraction-adhesion
• during which bacteria are reversibly adsorbed on
  the material.
• Then, the bacteria irreversibly colonize the
  material.
• Bacteria develop a survival strategy within a
  dynamic entity defined as the biofilm, made of a
  polysaccharidic substance secreted by bacteria
  called  slime  which permits the definitive
  adherence of bacteria on the material.
• The bacteria in the biofilm are organized in
  micro-colonies ( small colony variant ) under
  the influence of inter-cellular communications
  leading to a stationary growth phase due to the
  absence of ATP production. This has for
  consequence
• to limit the activity of some antibiotics which
  diffuse badly in the biofilm,
• the prolonged persistence of S. aureus in
  osteoblasts,
• escaping the immune defense mechanism.
• This biofilm spreads to all the material surface
  in a few days explaining
• why a late surgical lavage is inefficient beyond
  15 days
• the need to remove the prosthetic material, most
  of the time

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Conservation of the prosthesis 

• It is recommended to use synovectomy and lavage
  (debridement) with implant retention in the
  case of very recent infection (post-operative
  until D15, recent secondary infection without
  loosening) (grade C).
• It is not recommended to perform arthroscopic
  synovectomy at the knee level but open arthrotomy
  (grade C) .
• It is recommended to initiate antibiotherapy as
  soon as bacteriological samplings have been made,
  first in a probabilistic way, then adapted to
  documentation. The recommended course length is 6
  weeks. It is useless to prolong beyond this.

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Removal of implants

• Hip
• Use the previous surgical approach provided it
  can be extended
• Femoral implants can be extracted by endo-femoral
  route or by femorotomy. It is recommended to
  perform femorotomy with large vascularized bone
  fragment to improve the removal of cement, to
  carefully close the femorotomy, and to
  osteosynthesize it with strong cerclage.
• In case of intra-pelvic implant dislocation, of
  protrusion without bone barrier, or intra-pelvic
  foreign bodies, it is strongly recommended to
  asses cases with vascular risk (expert advice)
• Knee and other joints
• Same principle Removal of infected implants does
  not present any specific problem.

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One or two stage surgical revision ?

• The majority of the authors recommends revision
  with 2 separate procedures even if the analysis
  of the litterature does not objectively define
  indications for 1 or 2 stages.
• What can be the choice criteria?
• The certitude to have identified the bacterium 
  choose a single procedure
• The bacterial profile
• Bacteria for which antibiotherapy is limited
  (multi-resistant bacterium, Pseudomonas
  aeruginosa), a mycobacterium, a fungus are
  indications for surgery with two procedures.
• Knowledge of the terrain 
• it seems that a patient with a long history of
  prosthesis infection is not a good candidate for
  surgery in one procedure.
• Problems with anesthesia 
• If the patient cannot undergo 2 procedures, a
  single surgery should be chosen after discussion
  with the anesthesiologist, the surgeon, and the
  patient (or his family).

t
Follow-up
antibiotherapy 6/8 w-6 m
One -stage explantation réimplantation
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Modalities surgery in the two procedures

• What is the ideal delay for replacement?
• There is no answer in the literature.
• In case of 2 short steps, the recommended delay
  is between 4 and 6 weeks during which
  antibiotherapy is given without interruption. If
  bacteriological samplings are negative after 15 d
  of culture, treatment may be interrupted.

t
suivi
antibiotherapy ? 6/8 w
reimplantation
explantation
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Modalities surgery in the two procedures

• What is the ideal delay for replacement?
• In case of 2 long steps, the delay range from 3
  to 6 months knowing that after 3 months the
  functionnal result will be less good. The
  antibiotherapy must be interrupted for 15 days
  before replacement. The usefulness of performing
  a puncture before reimplantation is not
  confirmed. The antibiotherapy will be resumed
  post-operatively and stopped if the culture is
  negative (after 15 days). (expert advice)
• Using a spacer recommended with an essentially
  mechanical aim so as to facilitate replacement of
  the prosthesis

reimplantation
Antibiotic window
antibiotherapy
Follow-up
culture
t
explantation
Additionnal histological and microbiological
samplings
puncture
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Question 3
What are the modalities of therapeutic management?

• What are the specificities of anti-infectious
  treatment?

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What is the contribution of local antibiotherapy?

• Strong doses of antibiotics may need to be used
  for therapy.
• These types of cement is prepared by the surgeon
  extemporaneously in the operating room
  (high-loaded) and are only recommended
  temporarily in 2 presentations
• cement beads used to fill a cavity.
• spacer with cement impregnated with antibiotics,
  with the objective on one hand to maintain
  the space after removing the implant and, on
  the other hand, to obtain local antibiotherapy
• The kinetics of antibiotic release includes two
  phases an immediate phase during 7 days, with a
  high concentration and a secondary phase, for the
  years with much weaker doses (sub-inhibiting
  doses).
• The antibiotics used in cement are currently
  aminosides, vancomycin, and clindamycin.and need
  to be active against identified bacterium
• These cements must in no case dispense from a
  prescription of general antibiotherapy and differ
  from the licensed antibiotic cement used for
  prosthesis (re)implantation prophylaxis.

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General principles for sytemic antibiotherapy (1)

• Rules for optimal antibiotherapy (grade C)
• based on culture results (in case of sepsis,
  probabilistic antibiotherapy must be initiated
  after microbiological sampling),
• antibiotherapy initiated as a combination
• achieving adequate plasmatic concentrations
• using molecules with a good bone distribution in
  order to achieve high concentration in the
  tissue
• in case of infection due to staphylococci, never
  use monotherapy with rifampicin, fusidic acid,
  fluoroquinolones, and fosfomycin
• linezolid, daptomycin, tigecyclin do not have
  marketing authorisation for medicinal products in
  2009, for the treatment of bone and joint
  infections

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General principles for sytemic antibiotherapy (2)

• Mode of administration 
• It is recommended to administer the treatment
  initially intravenously. No study has validated
  the duration of parenteral antibiotherapy. It is
  usually 10 to 15 days long (expert advice).
• After this, it is recommended to switch to per os
  administration if antibiotics
• have a good bioavailability and a good bone
  distribution,
• have a good digestive tolerance
• have no negative interaction
• and if observance is good .
• If switching to oral treatment is impossible, it
  is mandatory to maintain parenteral
  antibiotherapy as long as necessary, either in
  hospital or in ambulatory treatment (grade C).
• In this case, it is recommended to insert a
  central catheter which may be changed if the
  planned duration of antibiotherapy lt6 weeks, or
  a totally implanted central venous access device
  (TICVAD) if the planned duration of
  antibiotherapy gt6 weeks

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General principles for sytemic antibiotherapy (4)

• Duration of antibiotic treatment (expert advice)
• minimum of 6 weeks.
• usual length reported in litterature 6 to 12
  weeks.
• maintaining antibiotherapy gt12 weeks should be
  discussed
• variation according to surgical management
• Surveillance of antibiotherapy
• effectiveness assessed first on clinical data
  then on biological parameters (CRP). It is
  recommended to dose antibiotics with high
  inter-individual variations of blood
  concentrations. It is recommended to dose
  aminosides (peak) and glycopeptides. If
  rifampicin used, check that the antibiotic to
  which it is combined is not under dosed.
• tolerance assessed on clinical and on biological
  parameters (CBC/platelets, hepatic parameters,
  renal function). It is also necessary to measure
  blood concentrations of some antibiotics such as
  aminosides (trough level).

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3.3.2.2. Choosing antibiotic meticillin
resistant staphylococci
Initial IV antibiotherapy (2 weeks) (vancomyci or teicoplanin) rifampicin or (vancomycin or teicoplanin)  fusidic acid. or (vancomycin or teicoplanin) fosfomycin or (vancomycin or teicoplanin) doxycyclin or (vancomycin or teicoplanin) linezolid or clindamycin (if the strain is susceptible to erythromycin) gentamicin then clindamycin rifampicin
Switching to oral route if the bacterium susceptibility allows it rifampicin fusidic acid or rifampicin clindamycin6 (if the strain is susceptible to erythromycin) or rifampicin cotrimoxazole or rifampicin (minocyclin8 or doxycyclin) or rifampicin linezolid
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doses and ways of administration of antibiotics
(for a normal renal and hepatic function)
Antibiotics (DCI) Dose/24h Regimen
amoxicillin 100-200 mg/kg 4-6 injections IVL 3-4 oral intakes
cloxacillin oxacillin 100-200 mg/kg (doses superior to approval expert advice) 4-6 injections IVL
amoxicillin- clavulanic acid 100 mg/kg 4-6 injections IVL 3-4 oral intakes
cefazolin 60-80 mg/kg 4-6 injections IVL or Infusion pump1
cefotaxime 100-150 mg/kg 3 injections IVL
ceftriaxone 30-35 mg/kg 1-2 injection(s) IVL
ceftazidime 100 mg/kg Infusion pump1 or 3-4 injections IVL
imipenem 2 à 3 g 3 to 4 administrations IV or IM
meropenem 3 à 6 g 3 administrations IV
vancomycin2 40-60 mg/kg Infusion pump1
teicoplanin2 12 mg/kg/12h for 3-5 days then 12 mg/kg IVL, IM or s/c
gentamicin3 3-4 mg/kg 1 administration IV 30 minutes
amikacin3 15 mg/kg 1 administration IV 30 minutes
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Empirical antibiotherapy

• Antibiotic scheme before obtaining per operative
  bacteriological results when there is no reliable
  documentation in the patients history, when
  there are general signs indicating the emergency
  of treatment (sepsis), or for culture negative
  infection.
• suggested associations by order of preference,
  must be adapted according to the microbial
  ecology of each institution (expert advice)
• ureidopenicillin/ beta-lactamase inhibitor
  vancomycin
• 3rd generation cephalosporin vancomycin
• carbapenem (except ertapenem) vancomycin
• 3rd generation cephalosporin fosfomycin.

41
Suppressive antibiotherapy

• (grade C)
• indefinite long term oral antibiotics (1 year),
• palliative but not curing the infection,
• only with well-tolerated molecules and easy
  administration (per os)
• in the minority of patients in whom surgery is
  precluded or declined,
• available bacterial target

42
Follow-up of patients organization and structures

• optimal management requires
• an accurate clinical evaluation
• a microbiological diagnosis requiring validated
  techniques both for sampling and for
  identification of micro-organisms
• a therapeutic strategy defined during
  multidisciplinary staff meetings
• implementing specific treatments especially for
  surgical and anti-infectious goals in the short
  term
• a global continuous and clear management until
  coming back home, with a healthcare file
  including all the detail care
• continuous information of the patient
• interregional reference centers for the
  management of complex bone and joint infections
• Is cure possible? 
• the infectious and functional criteria should be
  taken into account.
• there is no criterion defining infection cure. It
  is recommended to follow-up patient between 1-2
  years after the end of antibiotherapy
• the functional result is obtained by assessing
  mobility, pain, strength, balance, and walking
  (specific score for joints).

43
Question 4
What are the pre-requisites to pour minimize
these types of infection?
44
What are the standards in terms of healthcare
environment control?  Hygiene  procedures?
Environmental surveillance?

• No formal proof of so-called septic units
  effectiveness on the prevention of SSI
• The procedures to be applied are the same that
  those described during the non-septic surgery
• They concern
• Management of potential portals of entry during
  care giving
• Air treatment efficiency, (expert recommendations
  by the French Society for Hospital Hygiène
  Société Française dHygiène Hospitalière SFHH-
  2004,
• Healthcare personnel discipline,
• Effectiveness of professional wear and operative
  sheets,
• Managing surgical instruments,
• Cleaning surfaces, 
• Surgical block architecture,
• Environmental  surveillance.

45
.What measures should be undertaken for the
preparation of the patient before surgery ? (1)

• These measures concern preparation for an
  orthopedic intervention as in a non-infected
  patient. (grade C)
• Specific risk factors a priori accessible to
  corrective treatment
• Length of pre-operative  hospitalization gt4 days
• Tobacoo, diabetes, obesity, denutrition
• Rheumatoid polyarthritis treatments
• No systematical screen for nasal carriage of S.
  aureus

• When Staphylococcus aureus SSI rates remain
  unusually high (gt2), it
• is recommended to perform nasal swabs of
  caregivers and patients.
• Nasal screening for methicillin resistant S
  aureus is recommended in patients who must
  undergo planned cardiac or orthopedic surgery,
  transferred from ICU, long and median stay
  structure, or in case of chronic cutaneous
  lesions.
• It is not recommended to use mupirocin
  systematically pour to prevent the onset of SSI
  in MRSA carriers.

46
What measures should be undertaken for the
preparation of the patient before surgery ?(2)

• Global prevention measures against infection in
  orthopedic and trauma surgery
• 1. Recommendations for skin care and preparation
  were specified in the french consensus conference
  pre-operative management of infectious risk
  (SFHH).
• 2. Systemic route antibioprophylaxis was codified
  by the 1992 french consensus conference
  antibioprophylaxis in surgical settings in the
  adult, and updated in 1999 (SFAR).
• 3. Per-operative normothermia is applicable to
  orthopedic and traumatological surgery.
• 4. Peri-operative hyperoxygenation could be used
  for orthopedic and traumatological surgery.
• 5. It is recommended to use local antibiotherapy
  for prophylaxis such as antibiotic impregnated
  cements for 1st intention arthroplasty
• 6. it is not necessary to carry out
  antibioprophylaxis in a septic patient in order
  to avoid false negativity of the microbiology
  sample

47
What measures are undertaken to fight the risk of
cross transmission when managing a patient
infected in an orthopedic surgical block? ?

• Should there be a chronological order for
  surgery?
• There is no need to impose a specific order of
  passage if hygiene precautions are observed
  (grade C).
• What precautions should be taken in the surgical
  block after operating a septic patient?
• It is recommended to perform the usual cleaning
  program and to respect the time needed for
  particle decontamination of the operating room
  between two interventions
• In case of Multi Resistant Bacteria, there are no
  supplementary precautions to take for the
  cleaning of the rooms but complementary
  precautions of the contact type must be
  respected (grade C).
• No septic operating room is necessary if
  cleaning procedures between two interventions
  with various contamination are observed and if
  rooms are equipped with efficient ventilation
  systems (grade C)
• There is no need to have separate post surgery
  surveillance rooms for patients having undergone
  different surgeries,

48
Thanks
RPC are available at www. infectiologie.com and
will be published in Médecine et Maladies
Infectieuses (Elsevier)
49
RPC are available at www. infectiologie.com and
will be published in Médecine et Maladies
Infectieuses (Elsevier)