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 Table of Contents  
REVIEW ARTICLE
Year : 2015  |  Volume : 29  |  Issue : 3  |  Page : 120-128

Prosthetic joint infection: A microbiological review


Department of Microbiology, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, India

Date of Web Publication1-Dec-2015

Correspondence Address:
Ralte Lalremruata
Room No 36, PG Mens Hostel, Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-4958.170778

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  Abstract 

Joint replacement is a highly effective intervention that significantly improves patients' quality of life, providing symptom relief, restoration of joint function, improved mobility, and independence. Prosthetic joint infection (PJI) remains one of the most serious complications of prosthetic joint implantation. PJI positions a substantial burden on individuals, communities, and the health-care system, and thus early diagnosis and appropriate intervention are extremely important. Determining the various host and environmental factors that put an individual at risk for development of PJI may reduce the morbidity and cost of total joint arthroplasties. Microbial agents implicated in the causation of PJI range from Gram-positive to Gram-negative bacteria. PJI with fungi is commonly seen in immunocompromised patients. Numerous novel, uncultivable, and fastidious organisms have been identified as potential pathogens with the use of non-culture techniques. The majority of cases of PJI require surgical treatment, while the use of antimicrobials is essential when prosthetic removal is not possible or contraindicated. The microbiology and treatment of PJI in the light of improved culture and diagnostic methods are reviewed.

Keywords: Antibiotic sensitivity, Diagnosis, microbiology, Prosthetic joint infection (PJI), Therapy


How to cite this article:
Lalremruata R. Prosthetic joint infection: A microbiological review. J Med Soc 2015;29:120-8

How to cite this URL:
Lalremruata R. Prosthetic joint infection: A microbiological review. J Med Soc [serial online] 2015 [cited 2021 Dec 8];29:120-8. Available from: https://www.jmedsoc.org/text.asp?2015/29/3/120/170778


  Introduction Top


Joint replacement is a highly effective intervention that significantly improves patients' quality of life, providing symptom relief, restoration of joint function, improved mobility, and independence. Prosthetic joint infection (PJI) remains one of the most serious complications of prosthetic joint implantation. It presents as a sinus tract or persistent wound drainage over a joint prosthesis, acute onset of a painful prosthesis, or any chronic painful prosthesis at any time after prosthesis implantation, particularly in the absence of a painfree interval, in the first few years following implantation or if there is a history of prior wound-healing problems or superficial or deep infection. Blood cultures for aerobic and anaerobic organisms should be obtained if fever is present, if there is an acute onset of symptoms, or if the patient has a condition or suspected condition or concomitant infection or pathogen (e.g., Staphylococcus aureus) that would make the presence of a bloodstream infection more likely. [1] The management of PJI almost always necessitates surgical intervention and prolonged courses of intravenous or oral antimicrobial therapy. [2],[3] An essential component of the care of patients with PJI is strong collaboration among all involved medical and surgical specialists (e.g., orthopedic surgeons, plastic surgeons, infectious disease specialists, internists). It is anticipated that consideration of these guidelines can help reduce morbidity, mortality, and the costs associated with PJI. In this paper, current knowledge of the pathogenesis, diagnosis, and management of PJI is reviewed.


  Risk Factors Top


There are various factors that play a significant role in the development of PJI. It has been observed that PJI may either coexist with or result from bacteremia but remains undiagnosed until later. A study by Luessenhop et al. [4] noted that another infection (such as bacteremia, urinary tract infection, or infected decubitus ulcer) was present for a significantly greater percentage (i.e., 85%) of patients with multiple prosthetic infections after total joint arthroplasty, compared with patients with a single PJI. Polymicrobial PJIs are also associated with antibiotic prophylaxis spectra without activity against the subsequently isolated organisms, rheumatoid arthritis, and purulent wound discharge at presentation on univariate analysis. Rheumatoid arthritis and antibiotic prophylaxis spectra remain independent predictors of polymicrobial infections on multivariate analysis. [5]

Because the insertion of a large-sized device and injury at the site of surgical incision have been suggested as factors that predispose patients to hematogenous infection, [6] prosthetic joints may be particularly susceptible to hematogenous seeding, because of their large size as well as the greater likelihood of injury due to mobility. Surgical site infection (SSI) is another well-defined risk factor for PJI. [7],[8] An NNIS (National Nosocomial Infections Surveillance) System surgical patient risk index score of >1 is also an independent risk factor. [7] The NNIS System surgical patient risk index scores each operation by adding the number of risk factors among these three measurements. One point is given if the American Society of Anesthesiologists' preoperative assessment score is 3, 4, or 5; another point is given if the operation time is >3 h for prosthetic joint arthroplasty; a third point is given if the wound classification is 3 or 4. [9] Although studies performed by Wilson et al. [10] and Fitzgerald et al. [11] show that there is no association between the presence of malignancy and PJI, the case-control study conducted by Berbari et al. [7] noted their association. Possibilities for the association of malignancy and PJI include the immunosuppressive effects of treatment for malignancy that are unrelated to neutropenia or steroid therapy and simply unknown factors associated with the malignancy itself. [12] A history of joint arthroplasty on the index joint has been consistently recognized as a risk factor for PJI in various retrospective cohort studies. [13],[14] The risk of PJI increases with the number of previous joint arthroplasties. [14] Nonsurgical trauma to the prosthetic joint is shown to be associated with PJI, [8] whereas dental treatment does not increase the incidence of late PJIs. [15] Women are shown to have a lower risk of PJI than men. [16] Obesity is another independent risk factor for acute periprosthetic infection after primary hip arthroplasty. [17] Risk factors for the development of invasive candidal infections include immunosuppression, neutropenia, chronic or prolonged use of antibiotics, presence of indwelling intravenous catheters, parenteral hyperalimentation, malnutrition, diabetes mellitus, rheumatoid arthritis, cirrhosis, history of multiple abdominal surgeries, history of renal transplantation, severe burns, and injection drug use. [18],[19],[20],[21],[22],[23] Rheumatoid arthritis is also associated with PJI due to Gram-negative bacilli on univariate and multivariate models. Factors associated with PJI caused by methicillin-resistant Staphylococcus aureus (MRSA) on univariate analysis are nonglycopeptide antibiotic prophylaxis at the index arthroplasty, neck of femur fracture, and nursing home residence prior to arthroplasty. [5] The various risk factors are summarized in [Table 1].
Table 1: Risk factors for development of PJIs

Click here to view



  Causative Organisms Top


Microbial agents implicated in causation of PJI range from Gram-positive bacteria to Gram-negative bacteria. PJI with fungi is commonly seen in immunocompromised patients. The pathogens responsible for primary deep-space infections are usually distinct from normal commensal organisms on the skin, but it is precisely these commensal organisms on the skin that most commonly infect implantable biomedical devices. [24] PJIs have been classified as "early" and "late," although to these categories have been added the classifications of "acute hematogenous" and "positive intraoperative cultures," the latter indicating a group with positive cultures without prior suspicion of infections. [25] Early infections present acutely with overt wound infection; late infections present with worsening pain in the joint accompanied by loosening of the prosthesis at the bone-cement interface and sometimes by sinus tract formation with chronic discharge. The majority of PJIs reported are caused by a single organism, but Marculescu et al. [26] identified 19% of the PJIs in their study to be polymicrobial. In the study, MRSA and anaerobes were the most commonly isolated causative organisms of polymicrobial PJI; the presence of a soft-tissue defect/wound dehiscence, drainage, and age 65 years or older were the factors associated with polymicrobial PJIs. Rheumatoid arthritis has also been described to be associated with polymicrobial PJI. [5] The infection rate in hip prostheses is less than that in other joints, probably because of proximity to the skin surface in other joints and less experience in joint design. [27] Meanwhile, Berbari et al. [28] described culture-negative PJI, where the prosthetic infection is diagnosed solely by the presence of characteristic signs such as sinus tract communicating with the joint, periprosthetic purulence, or acute inflammation of periprosthetic tissue.


  Gram-Positive Bacteria Top


Gram-positive organisms that cause PJI range from virulent organisms such as Staphylococcus aureus and Streptococcus spp. to less virulent ones such as coagulase-negative Staphylococcus spp. (CoNS), Enterococcus spp., and Propionibacterium spp. Staphylococcus aureus and CoNS are the most frequent causes of PJI. [29] Berbari et al. showed the isolation rate of Staphylococcus aureus to be 28% and that of CoNS to be 30%. [30] Salgado et al. [31] reported Staphylococcus aureus to be the causative organism in 33% of PJIs, out of which 24% were methicillin-sensitive Staphylococcus aureus (MSSA) and 9% were MRSA. This finding differs significantly from that in the review by Peel et al., [5] who reported 45% of PJIs to be caused by MRSA. Razonable et al. [32] described a 70-year-old man who developed late PJI caused by Staphylococcus simulans. Cases of total knee arthroplasty infection caused by S. lugdunensis have also been reported. [33] S. lugdunensis is more virulent than other CoNS and in many clinical situations behaves like S. aureus. Although Staphylococcus aureus and CoNS cause PJI with approximately equal frequency, [24],[30] S. aureus is the predominant cause of PJI that results from hematogenous spread. [34]

Streptococcus spp. is commonly isolated from PJI. Berbari et al. [30] showed the isolation rate of Streptococcus spp. to be 4%. Duggan et al. [35] reported six cases of group B streptococcal PJIs and a single case of group C streptococcal PJI has also been reported. [36] In a study conducted by Meehan et al., [37] six PJIs were due to group G streptococci, seven were due to group B streptococci, four were due to viridans streptococci, and two were due to group A streptococci. Gaunt et al. [38] also reported two cases of PJI caused by group G streptococci.

Enterococcus spp. accounts for only 3% of PJI. [29],[30] Raymond et al. showed 11 enterococcal PJIs reported in the period 1966-1993 in their review literature. [39] Berbari et al. [30] reported three cases of PJI caused by Streptococcus pneumoniae. Another case report also stated the same infection in an 86-year-old woman with a total knee arthroplasty. [40] There have been reports on prosthetic shoulder joint infection by Corynebacterium bovis[41] and Corynebacterium jeikeium. [42]

There have also been several reports on PJIs caused by Mycobacterium tuberculosis, [43] which usually involve the hips or knees and can result from either local reactivation or, less often, hematogenous spread. Berbari et al. [44] reported seven tuberculous PJI cases over a 22-year period. The diagnosis of tuberculous prosthetic joint disease is often delayed, because a history of prior Mycobacterium tuberculosis septic arthritis is not known. The predisposing conditions include rheumatoid arthritis, chronic steroid use, and pulmonary diseases. [43] Eid et al. [45] reported eight cases of PJI due to rapidly growing Mycobacterium spp. (RGM) over the span of almost four decades. The RGMs reported are M. smegmatis, M. fortuitum, M. chelonae, and M. abscessus.[46],[47] Neuberger et al. [48] reported prosthetic knee joint infection by M. kansasii in an 82-year-old man. There has also been a case report of isolated PJI with Mycobacterium avium complex (MAC) in an immunosuppressed, failed kidney transplant recipient. [49] Cases of PJIs caused by Listeria monocytogenes[50] usually occur in patients who are immunocompromised due to malignancy or other illnesses or in nonimmunocompromised elderly patients. Other uncommon organisms causing PJI include a Gram-positive Nocardia-like bacilli Oerskovia xanthineolytica; [51] Tropheryma whippeli causing a prosthetic knee joint infection in a 58-year-old woman 2 years after she had been considered cured of Whipple's disease; [52] Lactococcus garvieae (formerly known as the lactic group of streptococci) causing a prosthetic hip joint infection in a 71-year-old woman who was a fishmonger; [53] and a Gram-positive coccus Rothia mucilaginosa, which is a normal commensal of the oral cavity and commonly mistaken as CoNS. [54]


  Gram-Negative Bacteria Top


Gram-negative bacteria, which are less commonly associated with PJI, account for 6-23% of all episodes. [55] Although such infections constitute a relatively minor proportion of all PJIs, they are of significant clinical importance because treatment of such infections is considered more complicated as a result of the virulence of the organisms, their growing resistance to antimicrobial agents, and the comorbid conditions of patients. [56] Members of the family Enterobacteriaceae and Pseudomonas aeruginosa are the Gram-negative pathogens most commonly isolated from PJIs. [57],[58] There has been a report of PJIs caused by Haemophilus influenzae[57] and Haemophilus parainfluenzae, which were followed by dental extractions that had not been covered by antibiotic prophylaxis. [59],[60] Vikram et al. reported a case of primary meningococcal arthritis in a woman with a prosthetic knee joint. [61]

Pasteurella multocida, a Gram-negative bacillus that forms part of the normal nasopharyngeal and gastrointestinal flora of cats and many other animals, has been reported to cause cat scratch-related prosthetic hip joint infections [62] and a prosthetic knee joint infection. [63] Most patients with PJIs caused by P. multocida are immunocompromised and all but one [64] of the reported cases of P. multocida PJIs have been in women. [65] Brucellosis, another zoonotic disease of worldwide distribution, is a systemic infection caused by Brucella species, whose association with PJI has also been reported. The species that have been isolated are B. melitensis and B. abortus.[66],[67] In contrast to those caused by P. multocida, PJIs caused by Brucella species are mostly seen in men. [66] Salmonella spp. have also been occasionally reported to cause PJIs. The species reported so far are S. dublin, S. Typhimurium, S. Newport, S. Muenchen, S. enteritidis, S. enterica, and S. hirschfeldii.[57],[68],[69],[70],[71] Legionella micdadei, one of the most frequent non-L. pneumophila species, has also been reported to cause PJI in an 83-year-old woman who underwent total knee arthroplasty due to rheumatoid arthritis. [72] Campylobacter spp. are also reported to cause PJIs, which usually occurs in immune-compromised patients, and the species that has been isolated are: C. fetus, from patients who had total hip arthroplasty; [73],[74] C. coli from a 60-year-old man, which presumably resulted from the ingestion of contaminated raw oysters; [75] C. jejuni from a patient who had AIDS and a hip prosthesis; [76] and C. lari from an immune-competent patient. [77] There has also been a report of PJI caused by an unusual Gram-variable coccus that is genetically related to Helcococcus pyogenica.[78]


  Anaerobes Top


Anaerobic bacteria are probably underestimated as agents of orthopedic foreign-body infections when culture is used as the only bacterial detection method. The importance of molecular detection methods in identifying these microorganisms in these circumstances cannot be overemphasized. Finegoldia magna, previously called Peptostreptococcus magnus, is the most commonly reported anaerobic coccus that causes PJI. Physicians should suspect F. magna infection in cases of infection that occur <4 months after hip or knee prosthesis implantation, particularly if cultures appear to be sterile. [79] Micromonas (Peptostreptococcus) micros, an organism frequently associated with periodontal infection, has also been described as a causative pathogen of PJI in a woman who had total hip arthroplasty. [80] Peptococcus saccharolyticus and Peptostreptococcus anaerobius have also been reported. [81] PJI caused by Actinomyces viscosus, which is an unusual Gram-positive threadlike organism, has been reported. [82] Late infections with Actinomyces israelii have also been described for prosthetic hip joints. [83] Propionibacterium acnes, a Gram-positive anerobic bacillus that is generally considered to be a commensal organism found in skin sites with high numbers of sebum-excreting sebaceous follicles, is a common contaminant of cultures and interpretation is difficult when it is isolated from a single specimen. [84] Studies show that P. acnes has been implicated in arthroplastic infections, [84],[85] and shoulder infections due to P. acnes have become an emerging problem, as documented in recent reports of 52 cases of prosthetic infection due to P. acnes.[86] Males are more predisposed to infections by Propionibacterium spp., which is probably due to the tropism of the organism for sebaceous glands and hair bulbs. [85]

Clostridium difficile has been described to cause PJI in an 83-year-old woman who developed culture-positive C. difficile-associated diarrhea. [87] Another case of C. difficile PJI has also been reported in a 16-year-old boy who had had a total knee arthroplasty due to osteosarcoma. [88] Clostridium perfringens has also been stated to cause delayed postbacteremic PJI. [89] Other anaerobes that have been reported to cause PJI are Veillonella dispar, [90] Bacteroides spp., and Staphylococcus saccharolyticus. [30]


  Fungi Top


Fungal PJI is rare, with Candida species being the most frequently reported pathogen in the medical literature. MacGregor et al. reported the first case of candidal PJI in 1979. During the past 21 years, only 30 cases of PJI due to Candida species have been reported in the medical literature. Despite knowledge regarding the risk factors of invasive candidal infections, approximately half of the reported cases of candidal PJI have no identifiable risk factor, and most patients with candidal PJIs present with an indolent onset of symptoms. [91] Candida parapsilosis[92] and Candida albicans[93] are the species commonly isolated from PJI. Noncandidal fungal PJI is very rare.

A prosthetic hip joint infection due to C. neoformans has been reported in an 84-year-old man with chronic lymphocytic leukemia. [94] A case report of prosthetic knee infection with Aspergillus fumigatus has been described in a low-grade osteosarcoma patient who was treated with a segmental distal femoral allograft prosthetic composite knee arthroplasty. [95] Fowler et al. [96] described the first case of PJI due to Histoplasma capsulatum complicating total hip arthroplasty. Berbari et al. [30] reported PJI caused by fungal pathogens such as Sporothrix schenckii and Coccidioidomycosis immitis.


  Clinical Features Top


The clinical diagnosis of PJI is challenging. In an uncompromised host, invading bacteria are usually eliminated by the innate immune response. If this initial response fails to eradicate the offending bacteria, a mountable immune response may be provoked, producing the characteristic signs and symptoms of infection. These may vary clinically from almost asymptomatic to superacute sepsis with erythema, edema, pain, effusions, local warmth, fever, and sinus tract formation. [97],[98] These clinical signs of infection can give rise to a high degree of suspicion, but cannot be relied upon alone for diagnosis and need not necessarily be present. [55],[99] Pain is the most common symptom of PJI, present in 90-100% of patients. The presence of fever is variable, with 4-43% of patients in most case series having documented elevated temperatures. [56],[100] As mentioned above, acute infections often present with erythema and swelling of the joint, but are less common in chronic infections. A discharging sinus is associated with chronic, indolent presentations. [101] Arthroplasty infections have been characterized as: Early (developing in the first 3 months after surgery), delayed (occurring 3-24 months after surgery), and late (greater than 24 months). [3]


  Microbiological Analysis Top


The microbiological confirmation of prosthetic PJIs, following their diagnosis by radiological investigations, provides useful information related to the antimicrobial therapy of PJIs.

Specimen collection and transport

Microbiologic diagnosis is often based on cultures of periprosthetic tissue. At least three and optimally five or six periprosthetic intraoperative tissue samples or the explanted prosthesis itself should be submitted for aerobic and anaerobic culture at the time of surgical debridement or prosthesis removal to maximize the chance of obtaining a microbiologic diagnosis. [1] However, this method is insufficient because microorganisms are attached as a biofilm on the prosthesis. [102] In this condition, bacteria change their phenotype to a sessile form and adhere strongly to the device. They may remain surface-adherent even if the whole prosthesis is cultured in broth, leading to false-negative culture results. In contrast, sonication can dislodge pathogens from implants. [103] Recently, Trampuz et al. [104] showed that culture of samples obtained by sonication from removed hip and knee prostheses was more sensitive than conventional culture from periprosthetic tissue. However, as this method reveals isolates in sessile forms also, showing variations in both phenotypic appearance and biochemical reactions, [105] species identification of such bacteria may be false or misleading, which should be considered in routine laboratory testing.

Synovial joint fluid aspiration may be performed prior to surgical joint capsule incision in order to minimize the risk of false-positive results. A minimum of 1 mL should be collected, and transported in collection syringes. After opening the joint, sampling of granulation tissue from at least three different sites (i.e., one from the capsule and two from host bone beds) gives satisfactory results. Tissue samples must be deposited in sterile tubes, while swabs can be kept in transport medium (Amies medium/Stuart's medium/Cary-Blair medium). All materials are to be transported to the diagnostic laboratory immediately after sampling. Specimens should be processed by the laboratory within 2 h of collection. [81]

Intraoperative frozen sections of periprosthetic tissues are shown to perform well in predicting a diagnosis of culture-positive periprosthetic joint infection, but have moderate accuracy in ruling out this diagnosis. Frozen-section histopathology should, therefore, be considered a valuable part of the diagnostic work-up for patients undergoing revision arthroplasty, especially when the potential for infection remains after a thorough preoperative evaluation. [106]

Cultural and non-cultural techniques

One of the routinely used intraoperative tests for diagnosis of PJI is the Gram stain, which has little value in ruling out prosthetic infections. [107] The utility of joint fluid culture has also been repeatedly questioned based on high false-negative rates, [108] which may be due to bacteria-related factors, such as their paucity in the joint fluid, highly fastidious growth, the biofilm nature of PJI, or the impact of previous antibiotic therapy. Moreover, sampling factors such as the surgeon's experience, use of special transport medium, time delay, anaerobic environment, and improper laboratory practice may play some role as well. Therefore, there is a need for a method that will decrease the false-negative rate of culture assays or another method that could target the blind window of the culture technique. With regard to improving culture performance, new transport and diagnostic sets have been developed and are in use. [109] Alternatively, polymerase chain reaction (PCR)-based methods provide a theoretically more sensitive means of detecting and identifying infectious bacteria; a few copies of bacterial DNA may be enough to obtain a positive result. [110],[111] This method is dependent neither on the occurrence of viable bacteria in samples nor on antibiotic treatment history. The PCR technique, based on detection of highly-conserved 16S rDNA sequences common to all bacteria, was introduced into the diagnosis of PJI in the early 1990s, [112] and has met the demanding expectations of the orthopedic community. [81],[113] However, these techniques are cost-intensive and methodically cumbersome. Furthermore, the significance of genotypic characterization is severely restricted with regard to the evaluation of antibiotic susceptibility. Thus, at present, there is no reasonable alternative to classical microbiological culture. Periprosthetic tissue or synovial fluid culture with an incubation period of 2 weeks is a promising approach toward optimization of periprosthetic infection diagnostics. [114]


  Antimicrobial Treatment Top


The treatment of infections following total joint arthroplasty involves surgery and antimicrobial treatment. Complete removal of all foreign materials is essential, while simple surgical drainage coupled with a finite course of antibiotics is characterized by a high failure rate. A two-stage reimplantation is considered the standard surgical procedure in the treatment of septic prosthetic joints. However, when prosthetic removal is not possible or is contraindicated, suppressive antibiotic therapy with retention of the functioning joint arthroplasty may be considered. [115] The empirical antibiotic treatment depends on the most likely organism to be associated with the infection. Glycopeptides or linezolid cover all Gram-positive organisms, including MRSA, whereas infections due to Gram-negative organisms are treated with third-generation cephalosporins with antipseudomonal activity. [5]

Penicillins and cephalosporins

Local and international guidelines, at present, recommend a single dose of cefazolin or flucloxacillin at the time of induction based on data from randomized control trials performed in the 1970s and 1980s. [116],[117] However, the rate of polymicrobial infection and the isolation rate of MRSA affect the success rate of surgical antibiotic prophylaxis. In a study conducted by Peel et al., [7] the majority (88%) of patients received cefazolin as an antibiotic prophylaxis at the time of arthroplasty. In 63% of patients in this cohort, the microorganisms subsequently obtained were not susceptible to the antibiotic prophylaxis administered. The guidelines stipulate, therefore, that the antibiotics chosen as prophylaxis should be selected to cover the most frequently encountered pathogens. [117]

Fluoroquinolones

Recent data have demonstrated the efficacy of treating patients with early (symptoms for <21 days) staphylococcal orthopedic implant infections with retention and debridement of a stable prosthesis, combined with oral rifampicin and a fluoroquinolone. [118] Ciprofloxacin is a rational choice, given its good activity against Staphylococcus aureus, excellent oral absorption, and activity against adherent bacteria. [119] However, fluoroquinolone resistance is now at high levels in nosocomial strains of staphylococci, [120] thereby limiting the usefulness of rifampicin and fluoroquinolone combinations.

Aminoglycosides

Gentamicin and tobramycin are commonly impregnated into poly(methyl methacrylate) for the treatment and prevention of PJI. Anguita-Alonso et al. [121] did a study to determine the minimum inhibitory value of 93 staphylococci from patients with PJI and found that 41% and 66% of the isolates were resistant to gentamicin and tobramycin, respectively. MRSA are more likely to be resistant to these drugs than their MSSA counterparts.

Rifampicin and fusidic acid

Rifampicin and fusidic acid have good activity against most staphylococci, and have retained activity against the majority of methicillin-resistant and fluoroquinolone-resistant staphylococci isolated in most parts of the world. [122] These antimicrobial agents are well absorbed after oral administration, and demonstrate excellent penetration into tissues and the intracellular space. [123] Rifampicin has demonstrated excellent efficacy against slow-growing organisms and organisms associated with biofilms, both of which are important in the pathogenesis of infections involving prosthetic material. [124] Resistance develops quickly in staphylococcal infections when either of these antibiotics is used alone. However, the risk of emergence of resistance is considerably reduced when the agents are used in combination. [122],[123],[124] Recommendations published recently include rifampicin in combination with fusidic acid as an option after debridement and prosthesis retention for the management of early PJI. [3] This option is particularly useful in the case of MRSA infections, where fluoroquinolone resistance is common, or where the patient shows intolerance to fluoroquinolones.

Linezolid

Linezolid is a recently approved agent for the treatment of MRSA infections. An important advantage of linezolid over glycopeptides is the oral administration that reduces time of hospitalization and increases the compliance, especially when the duration of therapy is considerable, as in the treatment of PJIs. Bassetti et al. have successfully used linezolid in two patients with MRSA PJIs. [125] The efficacy of linezolid in the long-term treatment of a case of methicillin-resistant S. epidermidis prosthetic hip infection has also emerged from another report. [126]


  Conclusion Top


PJI places a substantial burden on individuals, communities, and the health-care system, and thus, early diagnosis and appropriate intervention are extremely important. Determining the various host and environmental factors that put an individual at risk for development of PJI may reduce the morbidity and cost of total joint arthroplasties. Increased reliance on novel molecular techniques has enriched our knowledge of the diverse polymicrobial collections that cause PJI. At present, there is no consensus on gold-standard treatment, as evidenced by the wide variety of surgical protocols and prescription of antibiotics. Data available at present suggest that empirical antibiotic therapy should be tailored to the local ecology. Antimicrobials should be reserved for patients for whom prosthesis removal is not possible or is contraindicated. Given the high rate of isolation of methicillin-resistant organisms and the large number of infections involving Gram-negative organisms, it is suggested that empirical antibiotic therapy for patients who present with PJI should include a glycopeptide and an antipseudomonal beta-lactam antibiotic. [5]

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.

 
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