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Evaluation of the standard procedure for the treatment of periprosthetic joint infections (PJI) in Germany - results of a survey within the EndoCert initiative.

ABSTRACT: BACKGROUND:The periprosthetic joint infection (PJI) is a severe complication in the field of arthroplasty. Despite the rising number of primary joint replacements, no unified therapeutic standard has been established for the treatment of PJI yet. METHODS:A survey on the principles of treatment of PJI in Germany was conducted. A total of 515 EndoProthetikZentren (EPZ) were included, resulting in a response rate of 100%. RESULTS:For early infections 97.6% of the centers use prosthesis-preserving procedures (DAIR). A one-stage exchange was implemented by less than 50% of the centers. If implemented, this treatment entails a prior selection of patients for a successful treatment. The two-stage exchange is performed in all centers, and most centers proceed with the implantation of a cemented spacer between stages. 75% of the centers proceed with a center-based concept for the treatment of PJI. CONCLUSION:The aim of a uniform PJI standard at the centers has not yet been fully achieved. Further improvements within the certification were initiated. The most relevant treatment options in Germany are displayed. The two-stage revision with a cemented spacer is the most widely implemented treatment. This exposition of principles could help for the further development of standardized treatment guidelines and definitions.

SUBMITTER: Rimke C

PROVIDER: S-EPMC7574524 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Evaluation of the standard procedure for the treatment of periprosthetic joint infections (PJI) in Germany - results of a survey within the EndoCert initiative.

Rimke Christina C Enz Andreas A Bail Hermann Josef HJ Heppt Peter P Kladny Bernd B von Lewinski Gabriela G Lohmann Christoph H CH Osmanski-Zenk Katrin K Haas Holger H Mittelmeier Wolfram W

BMC musculoskeletal disorders 20201019 1

<h4>Background</h4>The periprosthetic joint infection (PJI) is a severe complication in the field of arthroplasty. Despite the rising number of primary joint replacements, no unified therapeutic standard has been established for the treatment of PJI yet.<h4>Methods</h4>A survey on the principles of treatment of PJI in Germany was conducted. A total of 515 EndoProthetikZentren (EPZ) were included, resulting in a response rate of 100%.<h4>Results</h4>For early infections 97.6% of the centers use p ...[more]

PMID: 33076900

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Project description:Controversy exists regarding the optimal treatment of periprosthetic joint infection (PJI), considering control of infection, functional results as well as quality of life. Difficulties in treatment derive from the formation of biofilms within a few days after infection. Biofilms are tolerant to systemically applied antibiotics, requiring extreme concentrations for a prolonged period. Minimum biofilm eradicating concentrations (MBEC) are only feasible by the local application of antibiotics. One established approach is the use of allograft bone as a carrier, granting a sustained release of antibiotics in very high concentrations after appropriate impregnation. The purpose of this study was to determine the rate of reinfection after a one-stage revision of infected hip or knee prostheses, using antibiotic-impregnated allograft bone as the carrier and avoiding cement. Between 1 January 2004 and 31 January 2018, 87 patients with PJI, according to MSIS, underwent a one-stage revision with antibiotic-impregnated cancellous allograft bone. An amount of 17 patients had insufficient follow-ups. There were 70 remaining patients (34 male, 36 female) with a mean follow-up of 5.6 years (range 2-15.6) and with a mean age of 68.2 years (range 31.5-86.9). An amount of 38 hips and 11 knees were implanted without any cement; and 21 knees were implanted with moderate cementing at the articular surface with stems always being uncemented. Within 2 years after surgery, 6 out of 70 patients (8.6%, CI 2-15.1) showed reinfection and after more than 2 years, an additional 6 patients showed late-onset infection. Within 2 years after surgery, 11 out of 70 patients (15.7%, CI 7.2-24.2) had an implant failure for any reason (including infection) and after more than 2 years, an additional 7 patients had an implant failure. Using Kaplan-Meier analysis for all 87 patients, the estimated survival for reinfection was 93.9% (CI 88.8-99.1) at 1 year, 89.9% (CI 83.2-96.6) at 2 years and 81.5% (CI 72.1-90.9) at 5 years. The estimated survival for implant failure for any reason was 90.4% (CI 84.1-96.7) at 1 year, 80.9% (CI 72.2-89.7) at 2 years and 71.1% (CI 60.3-81.8) at 5 years. One-stage revision with antibiotic-impregnated cancellous allograft bone grants comparable results regarding infection control as with multiple stages, while shortening rehabilitation, improving quality of life for the patients and reducing costs for the health care system.

Project description:Current laboratory protocols for periprosthetic joint infections (PJIs) involve a standard 10- to 14-day incubation period. However, recent evidence indicates considerable variability in the time to diagnosis (TTD) between acute and chronic PJIs. TTD is also influenced by the employed culture media and sample types. Enriched liquid media, such as broths and blood culture bottles, along with sonication fluid culture, are commonly used, though their incremental benefit for PJI diagnosis remains debated. We retrospectively analyzed 187 confirmed hip and knee PJIs, each with at least three intraoperative samples. Comparison of TTD among early acute (n = 68), late acute (n = 52), and late chronic (n = 67) PJIs revealed a significant difference, particularly between late acute and late chronic infections (P < 0.004). Early acute and late acute PJIs were diagnosed within 5 days in 97.1% and 98.1% of cases, respectively, contrasting with 14 days required for 97.1% of late chronic PJIs. Enriched liquid media significantly improved species detection, especially in polymicrobial and anaerobic infections. Pediatric and anaerobic blood culture bottles demonstrated superior efficacy over thioglycolate broths for diagnostic confirmation. Sonication fluid culture was essential for confirming diagnoses in 17.6% of cases. Our findings highlight that clinical presentation, rather than time since primary arthroplasty, should guide incubation duration: both early acute and late acute PJIs can be diagnosed within 5 days. Medical microbiology laboratories should consider shorter incubation times for acute PJIs to optimize diagnostic efficiency. The use of blood culture bottles and sonication fluid culture proves invaluable for accurate PJI diagnosis.ImportanceWhile molecular techniques are becoming increasingly employed, culture remains the gold standard for diagnosing periprosthetic joint infections. However, guidance for laboratory protocols is limited and highly variable. This article aims to increase diagnostic efficiency by providing concrete recommendations for medical microbiology laboratories.

Dataset Information

Evaluation of the standard procedure for the treatment of periprosthetic joint infections (PJI) in Germany - results of a survey within the EndoCert initiative.

Publications

Evaluation of the standard procedure for the treatment of periprosthetic joint infections (PJI) in Germany - results of a survey within the EndoCert initiative.

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