Can You Wait Several Months With a Chronic Infection in a Knee Protheseis
Paget: I am pleased today to present Dr. Barry Brause, an infectious disease specialist -- a specialty in the general expanse of internal medicine. Over the by 20 years, he has developed a item interest in prosthetic articulation infections, although he has a general approach to infections in this hospital and in the setting of musculoskeletal diseases.
Dr. Brause, nosotros do approximately 2,000 to 3,000 joint replacements here out of our xv,000 surgeries a year. What percentage of people might develop an infection in that joint?
Brause: The infection rate is less than 1% for the prosthetic articulation infections implanted at this infirmary, merely that just covers the initial three months post-operatively. There is a larger run a risk that goes forward from there--an infection of the joint past blood stream sources and from infections elsewhere in the body. Information technology is by and large thought that the infection rate varies between 1% and 4% over the form of the life of the prosthesis.
Paget: Has that infection rate changed since John Charnley developed the hip replacement in England in 1960?
Brause: Yes, the infection rate actually was as high equally 14% back when the prosthesis was first introduced, every bit John Charnley devised it. And then, every bit information technology was performed by a number of other surgeons, they all had to go through a learning process. As the learning curved progressed, the infection charge per unit came down. A number of preventive techniques were employed that helped that infection rate get down to the depression charge per unit it is at now.
Paget: And so let'due south talk about those points. A person comes to a doctor and has a articulatio genus or a hip pain, and eventually is diagnosed as having either osteoarthritis or rheumatoid arthritis, and it'due south deemed that a joint replacement is needed. What should that set up up both pre-operatively, simply post-operatively, and and so in the long term, equally far as a process to prevent these infections, considering they are and then horrible when they occur?
Brause: I call up the kickoff thing is that patients have to become knowledgeable about the fact that they are having a foreign body introduced permanently into their torso. As a foreign body, it cannot defend itself against infection the manner the rest of the tissue in the torso can. If other tissues in the trunk are exposed to bacteria, those tissues are likely to exist able to defend themselves. Just when those same bacteria are allowed access to tissues that are correct adjacent to the metal prosthesis, then there is an enhanced capacity to establish an infection, because our bodies cannot articulate the germs from those locations when there is a foreign body in the midst of the tissues. And then I think they need to know that that is the problem. Prostheses, as wonderful equally they are in terms of restoring role, do represent a substantial increase in gamble for infection at that site.
Then there are a number of bug that should be brought up to the patient prior to the implantation. There are three areas that are particularly prominent that all patients should be thinking almost forth with their physicians.
The first is that if they have whatever skin weather condition, they should be under very proficient command. If they accept a chronic dermatitis, similar psoriasis, it should exist very well controlled prior to the implantation. And and so they should be on a regimen, and a continuing cure protocol with the dermatologist, to continue it under command, considering the biggest defense nosotros take confronting infection is an intact skin. When they don't have an intact peel, when they have any skin condition that would permit a pigsty to develop in the pare surface that represents a take chances of infection, that can seed the blood stream and can wind upward infecting the prosthesis.
The second area is the teeth and the gums, an area that simply cannot exist neglected. It needs constant maintenance to exist certain that the ordinary bacteremia, the ordinary number of bacteria into the blood stream associated with chewing and brushing teeth, is minimal. If patients get worried about going to meet the dentist because they accept been told that seeing the dentist represents a risk for their prosthesis, which it may, some people reply by not going to the dentist, and that is the wrong arroyo.
And then showtime they demand to be encouraged to brand sure that they are upwardly to date with their dentist and that there is no unfinished business in their mouths. They should avert the idea that "Well, I'll accept care of this after my joint is replaced", because it is very important to have information technology taken care of before the joint is replaced. We should talk later about what should be done once the prosthesis is in to reduce the hazard of those dental visits, because dental cleaning is a significant cause of bacteremia and at that place are situations where the information has been adequately persuasive that rubber antibiotics are of utilise.
The third surface area would be urologic bug. In men who have an enlarging prostate and urinary bug, where they are already having bladder dysfunction, many of them will say, "Well, I'll accept my prostate taken care of subsequently my prosthesis is put in", and that is actually the wrong way. If the prostate is already at a point where it needs to exist operated upon, then that surgery should not be delayed until the prosthesis is put in.
It is preferable to have it done before the prosthesis is put in, so that the enlarged prostate, which represents a adventure of a urinary tract infection, will no longer be such a risk. And the risk of a urinary tract infection volition be largely reduced. So when the prosthesis is in place, it won't exist vulnerable to the potential bacteremia that such a urinary tract infection could represent, particularly in the perioperative menses. Mail-operatively, it is very common for these patients to crave bladder catheterization, which can be a particular upshot if your prostate is very big and you don't accept good bladder function.
In women, it is a different anatomic situation, but it is the same functional result, in that women who are predisposed to urinary tract infections need to bring that under control. We may not exist able to eliminate the cause of their predisposition, only we should be able to go through risk reduction in coordination with urologists and other specialists in the surface area. If they need to take a bladder resuspension, that shouldn't be put off if that is indicated. That would be a fairly rare intervention. I call back, more commonly, acidification of the urine, drugs like Methenamine Mandelate (Mandelamine) and other types of procedures that are going to exist specific for the individual should exist employed. The patient should be adequately knowledgeable about them. But taking advantage of the opportunity that the prosthesis represents, the physician can motivate them to keep that blazon of problem at the lowest adventure possible.
Paget: So nosotros have addressed the issue of what a patient should practise prior to even coming in for the surgery. What has scientific discipline and a hospital like Hospital for Special Surgery washed to decrease the incidence of infection while they are in the operating room and in the infirmary?
Brause: As I mentioned before, the biggest improvement in infection rates occurred as the techniques of surgery improved. The second biggest improvement is associated with using perioperative antibiotic therapy. That has been shown to substantially reduce the adventure of having a prosthetic articulation infection. I think that, universally, people are using prophylactic antibiotic therapy for well-nigh 24 hours, at the most 48 hours, post-operatively, starting immediately before the implant is inserted. I call up that continues to be an constructive deterrent and adventure reducer with regard to perioperative infection rates.
In add-on, some prostheses are cemented in identify, and some surgeons may cull to use antibiotics in the cement, which may represent an boosted accelerate in terms of risk reduction. Information technology is not clear that that actually represents a risk reduction in humans. So that is something that should be decided individually by the surgeon, related to the specific type of prosthesis that is put into which private. That is an option.
The third area that has been of some benefit is command of the air menstruation in the operating room, which is a very expensive investment by the infirmary, to create a arrangement in which the flow is all directed in a style to reduce the risk of infection. This is a very expensive outlay, and it does give a very small subtract in the infection rate. Information technology is the type of decrease in infection rate that is so small that nigh full general hospitals probably would not make that investment, but hospitals that specialize in putting in prostheses might accept made that investment, as we have hither at Hospital for Special Surgery.
Paget: And post-operatively, if there are wound infections or urinary tract infections, one needs to be ambitious in treating those and calming them downwardly. Then if somebody has had joint replacement, is home and kind of getting back to their lives once more, what other methods of infection prevention should exist carried out?
Brause: The outset thing that I tell patients is that they accept to become more skillful and responsive to their outset aid needs. Commonly, when nosotros are doing something and we cut ourselves, we stop the job then we say, "I'll take intendance of that cutting later." What happens later is that you forget about the cut because it doesn't hurt anymore. So it's non until the next day, when its festering, it'due south red and it gives yous a piddling pain that you start to do something about information technology. By that time, information technology may be too tardily to protect you from a potential risk that it represents to your prosthesis. And then if you go some injury while yous are doing something, you accept to stop what you are doing and take care of that injured pare area with some proper kickoff assistance -- using antiseptics and some Band-Aids -- and so go dorsum to stop the task. It is your attitude toward hazard that could represent a problem for your prosthesis.
In the aforementioned mode, if you go symptoms that you think are consistent with urinary tract infection, talk to your dr. well-nigh it. In the past, yous may take been able to drop your urine off, have information technology cultured and wait to encounter what the result was. Then, if the culture was positive, y'all would be treated for it. If you have a prosthetic joint and y'all have symptoms that are at all compatible with urinary tract infection, you should be treated for the urinary tract infection beginning and expect for the culture to come back. You lot tin stop the therapy if information technology turns out that you don't accept an infection. The adventure that that additional 24 or 48 hours represents while you are waiting for the urine civilisation to come back may be a critical menses of time. If the infection advances, it may become bacteremia during that period, and that may be something that could take been avoided if antibiotics had been started earlier.
Paget: And then close collaboration and partnership with the medico is obviously important. At present patients will commonly have procedures. They'll have a dental procedure. They may need a cystoscopy or a colonoscopy. Is there a specific blazon of prophylaxis that they should retrieve about and anticipate the need for in that case?
Brause: Aye, this has been in the past a very controversial area. I call back some aspects of it are still subject to controversy. Only the area that has received fairly universal agreement is that patients who are undergoing dental procedures that take an invasive nature to them -- that is a procedure that is associated with mucilage bleeding for case -- should receive prophylactic antibiotics prior to undergoing those procedures. The data that is based on is largely the ideas that are backside prevention of endocarditis. And some data shows that the patients, for about two years after the implant is put in, accept an increased incidence of dental bacteria causing their prosthetic joint infection.
It is thought that they are more prone to dental-origin infections at their prosthesis because of the enriched blood supply through the prosthesis during that 2-yr menses of time, when the bone and the surrounding tissues are still healing. Statistics show that the dental bacteremia probably represents a hazard all the time, just it is only enhanced vascularly during that two years. That's what the statistics show. It is on that basis that some parties who are non convinced that safe antibiotics would be of employ, have go convinced. Now there is a consensus that prophylactic antibiotics should be used starting most an hour before the invasive dental procedure. Just i cluster of pills is taken at that once without any follow-up antibiotics, unless the dentist finds something that he thinks the patient should receive longer grade of therapy for.
Paget: Are there specific types of antibiotics that you might mention, so the patients can talk to their physicians almost them?
Brause: Well, for patients who are not allergic to penicillin, I think the preferred agent is amoxicillin, and it's usually every bit 2 grams of amoxicillin, which would exist four 500 mg tablets taken one hour prior to the dental process. There are alternative drugs. Cephalexin (make named Keflex) has been an agreed upon alternative to amoxicillin. I think we take to comport in heed that cephalexin does not cover anaerobes every bit well as amoxicillin does.
An alternative amanuensis, for those who are allergic to penicillins and cephalosporins, would exist clindamycin (Cleocin), which covers well-nigh of the strep in the rima oris and anaerobes very well. That also should be taken one hour prior to the dental procedure and the dose is 600 mg, and that normally comes every bit 150 mg and 300 mg tablets and capsules.
Paget: What about other procedures like colonoscopy or cystoscopy -- do they need to be prophylaxed also?
Brause: We don't know the real answer for that. It is subject area to argue and probably it is going to be very difficult to become proficient numbers that would tell u.s.a. that information technology has to be washed. I think those decisions should be fabricated on an private basis between the patient and the person doing the process in consultation with a rheumatologist and even an orthopaedic surgeon, to make sure that the proper run a risk reduction is employed. And there should be a remainder to that approach, so that patients should not receive antibiotics unless it would be in their best interest.
Paget: Say a patient has a procedure and is doing well and and so there is a concern that there might be a joint infection in the prosthesis. How such patients present? How would they know that that is happening, so they tin can communicate with their physician?
Brause: The only really common symptom associated with prosthetic joint infection is pain. Somewhere betwixt 90% and 95% of patients with prosthetic joints nowadays with pain, but most of the people who have painful prostheses are not infected. Probably one in iv or i in five of patients who accept a chronically painful prosthesis is infected. And then a painful prosthesis is one symptom that the patient would go back to the orthopaedist or the rheumatologist to exist evaluated for. And one of the differential diagnoses to be entertained is whether that pain is due to infection.
The other types of presentations are things like fever, redness, swelling, and drainage from the incision. Those are all present in virtually 25% to 35% of cases, considering generally, prosthetic joint infections nowadays in 1 of two fashions. The virtually common type is where they nowadays with pain which slowly progresses over a menstruation of many months until it is so bad that the patient no longer tin tolerate it.
Paget: Then they will have a pain-complimentary menses between their surgery and when that new pain happens and it develops slowly?
Brause: That is exactly correct. Or, they will never accept the normal progression to painless airing that we expect. If they don't experience the benefits of the prosthesis, they may take a very early infection. But almost of them have been pain-gratuitous, with everything going well, and and so there is a disruption. Something goes wrong and nobody knows what that is, and ane of the possibilities is that it could be an infection.
Paget: So they are erring on the side of safety. They call their doctor. How exercise you brand the diagnosis?
Brause: The nigh straight manner is to put a needle into the articulation, using radiographic guidance when information technology is a hip prosthesis, because it is very hard to actually be confident that the needle is placed in the joint space when y'all have a total hip replacement in place. So we always really try to do that radiographically. We practise a picayune bit of an arthrogram, put the needle in place, and and then put some dye through the needle to confirm that the needle really is in the articulation space. So we brand an aspiration and apply that material for culture and for gram stain to decide whether an infection is nowadays.
If it is a genu prosthesis, that is also a very good way of going, simply because it is more superficially located, a number of orthopaedic surgeons and rheumatologists experience sufficiently comfortable with the anatomy to do an aspiration without using an imaging technique. The other types of diagnostic approaches, using imaging techniques such as centigraphy, iridium scans, gallium scans, and technetium scans, are really fraught with likewise much non-specificity to be helpful. At that place are too many fake positives and too many false negatives to actually carry the burden of making a diagnosis about whether prosthetic joint infection is present or absent.
Paget: And so how are these prosthetic joint infections treated?
Brause: In that location are three basic approaches. The archetype approach is one that was actually developed here at Hospital for Special Surgery. Although this approach has the highest success rate, it is also the one that is the hardest to perform -- the prosthesis is removed. The patient remains without a prosthesis in place for vi weeks while they receive antibiotics that are specific for the germ that is causing their infection. At the cease of the antibiotic therapy, they receive a nice new implant at that site. That takes six weeks plus the rehab at the other cease after the prosthesis is put back in. So the patient really is out of their normal functioning stride for most two months.
Another arroyo is to take the prosthesis out and to put another prosthesis in immediately, during that aforementioned operative procedure. That is an approach that was adult in Europe, and it has a substantially lower success rate than a 2-stage procedure. But it is used in those situations where the patient, for other reasons, usually other medical reasons, cannot have a period of fourth dimension with the prosthesis out. When the prosthesis is out, the patient is not normally convalescent, and if they can't handle that menstruation of relative bed rest or walking effectually with crutches and a walker, then it may be in their best interest to accept what is called an 'substitution process' which is that 1 operation.
Paget: And they become the half-dozen weeks of antibiotics as well on elevation of that?
Brause: That is the protocol. Nosotros use that protocol. In Europe, they actually do non do that, and that may exist i of the reasons why their success charge per unit was lower. Only even when you utilise the antibiotics subsequently the prosthesis has been exchanged, it should be expected that the persistent infection rate will be substantial considering you never really had the opportunity to treat the patient when the prosthesis was absent. As we said at the beginning of this talk, the main predisposition to the infection is the presence of the strange trunk. If you don't become a chance to treat the germ in the absence of the strange body, your success rate is going to be substantially lower.
Paget: And what is the third scenario?
Brause: The third scenario is reserved for people who cannot undergo surgical removal of the prosthesis, for medical or orthopaedic reasons, and where the prosthesis is not loose (so we still have a functional prosthesis), where the organism causing the infection is not causing the patient to exist systemically ill, where the organism is exquisitely sensitive to all agents, and where the patient tin can tolerate such antibiotics.
When those criteria are fulfilled, and then we will approach the patient with an idea to suppress the infection. That is where we acknowledge that we will not exist able to eradicate the infection, merely instead we endeavor to control the infection to such degree that the patient will never know that there is an infection going on.
That requires, oftentimes times, a surgical procedure at the beginning to drain out the fluids effectually the prosthesis, although there are cases where that is not included. That is followed past intravenous antibiotic therapy, ordinarily to get a head start on the infection, but there are besides cases where that has non been employed.
What is employed is protracting all antibiotic therapy, designed specifically on the basis of the germ that is causing the infection, using antibiotics that are well absorbed through the alimentary canal, so that we can get proficient tissue levels and maintain high-dose therapy, with very boring tapering of the dosage. The patient stays on antibiotic therapy for the life of the prosthesis, and this may not be for the patient's whole life, but information technology will be until the prosthesis needs to be replaced.
Information technology may well exist that the prosthesis will survive for the patient'due south normal life span, merely then it could loosen because of mechanical reasons. When the prosthesis needs to exist replaced, we should accept advantage of that opportunity to eradicate the infection completely.
Paget: Nosotros have come then far in 42 years. Are we going to come fifty-fifty farther in the side by side 42 years and, if and so, what will that entail?
Brause: I'm confident that we are going to make improvements, but I have no idea. I think that the innovations that are presently existence worked on, not just thought well-nigh, are innovations that go across antibiotic therapy. These are trying to devise techniques by which we make the prosthesis capable of repelling the organism. So the organism becomes incapable of attaching itself to the surface of the prosthesis. Those techniques are now in the laboratory, and we hope that they are going to exist useful in the hereafter.
Paget: And manifestly the responsibility is mine as a rheumatologist to prevent the joint problem in the beginning place, and finally, the issue of antibiotic resistance. We have just heard that some streps are now resistant to erythromycin, one of our mainstays. What can patients and their physicians exercise to try to avoid changing the flora of the world so that these bugs get our enemies and we can't get rid of them?
Brause: That is a very good topic to discuss at every forum, considering I think information technology is something that we need to accost as part of our club equally a whole. I think that this is a good opportunity to make a pitch for not using antibiotics unnecessarily. That is in the individual that we are talking virtually, who has a prosthesis, merely information technology is besides in order in general, because information technology is by the overuse of antibiotics in general that nosotros induce resistance. It is non merely the use of antibiotics in patients. It's the employ of antibiotics in cattle and other food producing livestock. Nosotros demand to encourage our government and representatives to encourage the people in that industry to reduce their use of antibiotics in livestock, because that is generating a whole host of resistant organisms.
In addition, more recently, patients have taken to using antibacterial soaps, which are not a good idea to utilize on a chronic basis. If at that place is an issue, or if their dermatologist, rheumatologist or somebody has said that for a curt flow of time using an antibacterial soap would exist an advantage to them, that is fine. But I think if they utilise information technology chronically, and then they volition be altering the organisms on their skin surface, and they will be colonized with resistant organisms. So if they ever get an infection from germs on the skin surface, it will exist harder to care for.
Updated: v/12/2016
Dr. Brause was interviewed by Dr. Stephen A. Paget, Physician-in-Chief, Infirmary for Special Surgery
Authors
Source: https://www.hss.edu/conditions_prevention-of-infection-joint-replacement.asp
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