Title: MRSA infection in joint replacement
1MRSA infection in joint replacement
Assoc Prof. Keerati C.Vanich Orthopaedic
department Siriraj faculty of medicine Mahidol
university
2Introduction
- Prosthetic Joint Infection is important
complication of joint replacement surgery - This may result
- - increase morbidity.
- - increase revision operations.
- - increased antibiotic use.
3Introduction
- 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.
4Introduction
- 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.
5Microbacterial
- 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.
6Staphylococcus aureus
- Common cause of musculoskeletal infections
- early postoperative infection
- late chronic infection
- acute hematogenous infection at the site of a
prosthetic joint
7Staphylococcus aureus
- Susceptibility to methicillin treated most
effectively with - antistaphylococcal penicillin (e.g., nafcillinor
oxacillin) - first-generation cephalosporin.
8MRSA
- 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.
9MRSA
10MRSA
- 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.
11MRSA
- 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.
12MRSA
- 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.
13MRSA
- 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
14MRSA
- Rapeepat Narkbunnam, Retrospective study
- Knee revision arthroplasties at Siriraj hospital
2002-2008 - 189 case 59 case cause from infection
15Infected 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
16Treatment
17Treatment 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.
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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
22Result of treatment in MRSA infection
23MRSA
- 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.
24Antibiotic for treatment
- Systemic antibiotic
- Local antibiotic
25Antibiotic
- Nalinee Aswapokee study at Siriraj hospital
2002-2004 - In vitro study MRSA for ATB susceptible
- 113 clinical isolated MRSA
26MRSA Antibiotic
27Local Delivery of Antibiotics
- Antibiotic cemen bead/spacer
- local levels of antibiotics that far exceed those
attained with systemic antibiotic therapy.
28Local Delivery of Antibiotics
- Antibiotic bead
- - difficulty in removing after
implantation. - Antibioticimpregnated spacers
- - minimizes limb-shortening
- - limits scar formation
- - facilitates reimplantation
29Antibiotic for cement spacer
- Microbial Sensitivity
- Bactericidal
- Heat stable
- Powder form
30Antibiotic 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
31MRSA
- 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
32Our mobile spacer technique
33Prosthesis removal
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35Removal of debris and cement
36Cement spacer molding
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38Insertion with a pack of cement
39Final implantation
40Postoperative x- ray
41Treatment 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.
42Treatment 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.
43Treatment 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.
44Alternate 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
45MRSA 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.
46Antibiotic 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
47Inhibition zone excess diameter in each replicate
of each antibiotic cement on each day of the
experiment
48Fosfomycin
- 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
49Fosfomycin
- 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
50Fosfomycin
- 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.
51Fosfomycin
- 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
52Fosfomycin
- 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.
53Fosfomycin
54Fosfomycin
55On 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
57Primary 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
58Infrared thermometer Fluke TiR
59Conclusions
- Prevension
- Adequate surgical debridement
- Staged revision
- Adequate Susceptibility antibiotic
60Thank you
61Infection 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