1

Prevention of Infections of Prosthetic Joints

Ilker UçkayInfection Control ProgrammeGeneva University Hospitals

Hôpitaux Universitaires de Genève

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Relative risks of SSI

Northern France 1998-2000, 67 wards, 26,094 patients

Rioux et al, ICHE 2006

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Clean orthopaedic surgery

Primary arthroplasties

0.8% Norwegian Arthroplasty Register (73,000 arthroplasties)

0.5% Deep arthroplasty infection Norway (22,170)

0.9% Finland (4628 arthroplasties)

0.5% Geneva (6101 arthroplasties)

Havelin et al, Acta Orthop Scand 2000

Engesaeter et al, ACS 2003

Paavolainen et al, Acta Orthop Scand 1991

Uçkay et al, J Infect 2009

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Clean orthopaedic surgery

3.9% Femoral osteosynthesis3.6% Elbow arthroplasties1.2% Hand surgery1.6% Foot & ankle surgery 0.8% Primary arthroplasties0.1% Arthroscopies4-11% PIN care1.3% Hallux valgus - Lapidus

Kleinert et al, JBJS Am ‘97

Zgonis et al, J FSAS 2004

Uçkay et al, J Infect ‘09

Müller-Rath et al, Arthroskopie 2008

Merrer et al, ICHE ‘07

Celli et al, JBJS Am 2009

Reigstad et al, Knee Surg Traum Arthrosc ‘06

Popelka et al, Acta Chir orthop Traumatol Cech 2008

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1. Diagnosis and treatment

2. Prevention of SSI, general aspects

3. Particularities in orthopedic surgery

Structure of the presentation

1700 /μl

65%sens. 94%spec. 88% sens. 97%

spec. 98%

total leuc count

neutrophils

Diagnostics in low-grade infections

Sonication Mass spectrometry

Microcalorimetry Molecular methods 7

8

Zimmerli et al. N Engl J Med 2004

Microbiology of 578 prosthetic joint infections seen at Mayo Clinic between 1992-1997

Microorganism %Coagulase-negative staphylococci 30 %S. aureus 23 %Polymicrobial 12 %Unknown 11 %Streptococci 9 %Gram-negative bacilli 6 %Anaerobes 4 %Enterococci 3 %Other 2 %

Steckelberg et al. Prosthetic Joint Infections, Infections Associated with Indwelling Medical Devices, 3rd edition, ASM Press, 2000

Zimmerli et al, JAMA 1998

• linzolide • quinopristine-dalfopristine• pristinamycine• daptomycin, • tigecyclin, • minocyclin,• New quinolones,

Studies of equivalencenot superior to « old combinations »

Uçkay, Lew. MRSA bone infections. Nova Science 2009.

New molecules

If implant removedclindamycine 3 x 600 mg, ciprofloxacine 2 x 750 mg

Combinationsciprofloxacine 2 x 500 mg - rifampicine 1 x 600 mgacide fusidique 3 x 500 mg - rifampicine 1 x 600 mgcotrimoxazole 2-3 x forte - rifampicine 1 x 600 mg

Antibiotics in Geneva

Uçkay, Lew. In Karchmer. Osteomyelitis 2010

No studies. Experts‘ opinion

As a principle 6-12 weeksindependently of bone or bacteria

Exceptions:Special pathogens: Tbc, actinomyces, fungi, etc.

Duration of antibiotic therapy

Lew, Waldvogel, Lancet 2004Zimmerli, Tampuz et al, various publications

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Multivariate analysis for outcome Cure

•Retention with debridement (OR 0.3, 0.1-1.1) •Two-stage exchange (OR 1.1, 0.2-4.8) •Number of surgical debridements (OR 0.9, 0.4-1.9) •6 weeks’ antibiotic treatment (OR 2.0, 0.9-7.8) •Duration of i.v. antibiotic course (OR 1.0, 1.0-1.0)

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1. Diagnosis and treatment

2. Prevention of SSI, general aspects

3. Particularities in orthopedic surgery

Structure of the presentation

Uçkay, Pittet et al, Ann Med 2009

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24Uçkay et al, J Infect 2009

Haematogenous infections

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Risk factors for SSI (selection)

Diabetes mellitus OR 4.5, 2.4-9.3

Obesity >30 BMI OR 4.1, 1.1-19.0

Change of surgeon OR 2.9, 2.0-4.0

Wound class OR 2.6, 2.2-3.0

Infect. prior surgery OR 2.4, 1.6-3.7

Hyperglycaemia OR 2.3, 1.3-4.0

Drains >3 days OR 2.2, 1.4-3.4

Trussel, Am J Surg 2008

Lübbeke et al, Arthrit Rheum 08

Park et al, Transplantation 2009

Rioux et al, ICHE 2006

Petrosillo et al, BMC Infect Dis 08

Beldi et al, Am J Surg 2009

Haridas et al, Surgery 2008

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Risk factors for SSI (selection)

ASA-Score >2 pts OR 1.9, 1.6-2.2

Loud noise OR 1.9, 1.3-2.6

Hectic movements OR 1.8, 1.1-3.0

Duration surg >75% OR 1.8, 1.2-2.8

Emergency surgery OR 1.7, 1.2-2.4

Age >65 years OR 1.3, 1.1-1.5

Rioux et al, ICHE 2006

Rioux et al, ICHE 2006

Beldi et al, Am J Surg 2009

Beldi et al, Am J Surg 2009

Haridas et al, Surgery 2008

Petrosillo et al, BMC Infect Dis 08

For orthopaedics

•Polyarthritis •Revision

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4 cornerstones

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Antibiotic prophylaxis …

• No benefit >24 h• No benefit of continuous vs. intermittent

infusion

• No threshold for routine vancomycine prophylaxis in settings with endemicity for methicillin-resistant staphylococci.

• No evidence that vancomycin is superior to cephalosporins.

McDonald et al, Aust N Z J Surg 1998

Suffoletta et al, Pharmacotherapy 2008

Prokuski, J Am Acad Orthop Surg 2008

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Timing

Steinberg et al. Ann Surg 2009

33Prokuski. J Am Acad Orthop Surg 2008

Choice of antibiotic agents

Postponing in case of remote infections ?

Experience of surgeons ?

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Does it matter ?

maybe ….38

Screening for S. aureus

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Walz et al, Arch Surg 2006Kurz et al, NEJM 1996

Intraoperative normoglycaemia (<200mg/dL)SSI 20% vs. 52%, while Hb A1c and diabetes mellitus were not associated

Park et al, Transplantation 2009

Ambiru et al, J Hosp Infect 2008

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Active surveillance

Courtesy: Astagneau, SFHH 2007

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Rioux et al, J Hosp Infect 2007

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Multimodal approachTimely antibiotic prophylaxis, strict glycaemia control, no shaving SSI 1.5% vs. 3.5% in controls

100k lives campaign(antibiotic prophylaxis, glycaemia control, normothermia)SSI from 2.3% to 1.7% (-27%)

SCIP project & Safety Checklist

100k lives campaign

Trussel et al, Am J Surg 2008

Things that do matter ?

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Before surgery

Disinfection in circles vs. back-and forthNo difference.

Preoperative bathing and showering.Cochrane review, 6 trials, 10,000 participantsNo evidence vs. placebo RR 0.9, 0.8-1.1.

Haïr removal. Meta-analysis of 4 trials.Inconclusive. Immediately before operation.

Stonecypher. Crit Care Nurs Q 2009

Webster et al, Cochrane Database of Systematic Reviews 2007

Niël-Weise et al. ICHE 2005Mangram et al, ICHE 1999

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During and afterLaparoscopy vs. laparotomy. No evidence

Double-gloving 26 trials. Inconclusive

Staples vs. sutures. No difference

Use of drains. No evidence

Pin site care. 6 trials, 349 patients.No regimen (daily vs. weekly, cleansing vs. no cleansing) is superior to others

Anderson et al. UpToDate 2009

Mullen et al, Can J Cardiol 1999Chughtai et al, Can J Cardiol 2000

Tanner et al, Cochrane Database of Systematic Reviews 2006

Gaines et al. Orthopedics 2008

Lethaby et al. Cochrane Database of Systematic Reviews 2008

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Laminar airflow

Laminar airflow reduces bacterial burden in the air

Retrospective analysis in KISS system(63 hospitals, 100,000 procedures).

No reduction of SSI with laminar airflow vs. no laminar airflow. OR 1.63, 1.06-2.52.No information about individual antibiotic prophylaxis, normothermia, obesity etc.

Brandt et al, Ann Surg 2008

Whyte et al, J Hosp Infect 1982

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Public reportingMandatory or planned in several US states

CDC reviewNo studies have investigated SSI reduction as outcome. None compared costs.

HICPAC recommends possible public reporting of antibiotic prophylaxis-related parameters, and SSI of selected operations.Key questionsMotivation for HCW or hospitals ?What to do with unexpected consequences ?

McKibben et al, Am J Infect Control 2005

Humphreys et al, Clin Microbiol Infect 2008

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Sparse literature

Most SSI are believed to be acquired during surgery ?- SSI diminution in operating room- airborne (opinion 1970s)

Charnley. Clin Orthop Relat Res 1972

Lidwell et al, BMJ 1982Lindberg. Lakartidningen 1979

The proportion of SSI acquired in the operating theatre vs. acquired afterwards, is unknown

Ayliffe. Rev Infect Dis 1991

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Author Harbarth, JAMA 2008

Robicsek, Annals 2008

Jeyaratnam, BMJ 2008

Keshtgar, Br J Surg 2008

Country Switzerland USA UK UK

Setting Surgery Hospital-wide Geriatrics, oncology, surgery

Surgery

Design Cross-over Before-after Cross-over Before-after

Control group Yes No Yes No

Admission MRSA prevalence

5.1% 6.3% 6.7% 4.5%

CONCLUSION Screening did not reduceMRSA infections

Admission screening reducedMRSA disease

Universal MRSA screening is not recommended

MRSA screening reduced staphyloc. BSI

Harbarth et al. J Am Coll Surg 2008

MRSA screening on admisson

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3.4

7.7

1.1

4.9

0

5

10

Intervention Placebo

SA in

fect

ion

rate

(%)

All S.aureus NI Deep SSI

S. aureus screening & decolonization

Bode et al NEJM 2010

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Nasal mupirocin

8 RCTs included

Effect of mupirocin nasal ointment on S. aureus infections

Significant reduction of the S. aureusinfection rate

RR 0.6, 95% CI 0.43-0.70

Van Rijen et al, Cochrane Database Syst Rev. 2008

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Nasal mupirocin ?

• Reduced MSSA carriage in 615 orthopaedic patients, but not SSI (not even due to MSSA !)

• No benefit in general surgery

• Meta-analysis in general surgeryMupirocin vs. no mupirocin; SSI 8.4% vs. 8.1%

Kalmeijer et al, CID 2002

Kallen et al, ICHE 2005

Perl et al, NEJM 2002

Single centresHistorical controls (before-after studies)

Screening & decolonisation (mupirocin, chlorhexidin) or (mupirocin, triclosan)

significantly beneficiary for MRSA, not MSSA

Caveat: No case-mix ajustements57

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Single centreProspective- two groups

Screening & decolonisation (mupirocin, 5d chlorhexidin)vs.no intervention

Results: no vs. 12 SSI due to S. aureusEconomic gain of $230,000 for the hospital

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In our case

No revision, no polyarthritisMassive early PJIAcquired in operating theatreExperienced surgeonsCorrect antibiotic prophylaxis

…..?63

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Thank you very much for your attention

AcknowledgmentsParham Sendi, Stephan Harbarth, Hazel Morse, Hugo Sax, Didier Pittet