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Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection

Javad Parvizi MD, FRCS
Thorsten Gehrke MD


Title:
Prevention of Late PJI

Liaisons:
Antonia Chen MD, MBA

Leaders:
Fares Haddad Mb, ChB, FRCS (International) and Paul Lachiewicz MD (US)

Delegates:
Michael Bolognesi MD, Luis E Cortes MD, Massimo Franceschini MD, Jiri Gallo MD, Aaron Glynn MD, Alejandro Gonzalez Della Valle MD, Aydin Gahramanov MD, Monti Khatod MD, Stergios Lazarinis MD, PhD, Guenther Lob MD, Arvind Nana MD, Peter Ochsner MD, Ibrahim Tuncay MD, Tobias Winkler MD, YiRong Zeng MD

Vol 1, Num S1, September 2014

 

   

Question 1: What is the definition of a late periprosthetic joint infection (PJI)?

Consensus: Late PJI can be defined as a PJI that develops at a variable length of time after an index arthroplasty procedure. Late PJI occurs after an initially successful index procedure with no clinical or radiographic signs of PJI. Risk factors for late PJI are similar to those described for PJI.

Delegate Vote: Agree 56%, Disagree 39%, Abstain 5% (Weak Consensus)


Question 2: Which diagnostic procedures have to be done to verify late PJI?

Consensus: The workup of patients with painful joint and suspected (late) PJI should follow the algorithm provided in Workgroup 7.

Delegate Vote: Agree 89%, Disagree 9%, Abstain 2% (Strong Consensus)


Question 3: Does the type, dose, and length of anticoagulation for prophylaxis influence the incidence of surgical site infection (SSI) following total joint arthroplasty (TJA)?

Consensus: Yes. The type, dose, and length of administration of anticoagulation drugs for prophylaxis against venous thromboembolism influence the incidence of SSI following TJA.

Delegate Vote: Agree 76%, Disagree 9%, Abstain 15% (Strong Consensus)


Question 4: Should a patient with TJA be given routine dental antibiotic prophylaxis?

Consensus: The use of dental antibiotic prophylaxis in patients with TJA should be individualized based on patient risk factors and the complexity of the dental procedure to be performed.

Delegate Vote: Agree 81%, Disagree 16%, Abstain 3% (Strong Consensus)

Justification: Based on the available literature, within which there is no consensus, there is increased bacteremia after dental procedures, and providing antibiotic prophylaxis before dental work can reduce the burden of the bacteria load. Additionally, most PJIs occur within the first 2 years after surgery. One study found that the use of antibiotic prophylaxis did not reduce the risk of infection, independent of the dental procedure performed in a 2-year period. Dental procedures may not be associated with the development of PJIs. However, many studies demonstrate that there is increased bacteremia after dental procedures, as the incidence of bacteremia from oral procedures ranged from 5% to 65%. Thus, we conclude that using antibiotic prophylaxis for dental procedures after TJA to decrease the risk of bacteremia following dental procedures is justifiable to decrease the risk of sustaining a PJI within the first 2 years after surgery.


Consensus: We recommend that high-risk patients receive lifetime dental antibiotic prophylaxis after TJA.

Justification: The risk factors for PJI after dental procedures are patient-dependent and the risk for infection is higher in patients who receive dental work.

The orthopaedic and dental literature both detail groups of patients that are at higher risk for developing a PJI after dental procedures and who could benefit from the use of antibiotic prophylaxis. The patients that could receive the greatest benefits include those with:
1- Inflammatory arthropathies (eg rheumatoid arthritis).
2- Immunosuppression (drug- or radiation-induced immunosuppression–including oncology or transplant patients and human immunodeficiency virus (HIV) patients).
3- Insulin-dependent diabetes.
4- A major systemic infection.
5- Hemophilia.

The following factors are to be determined by a dental care provider:
1- High gingival score and gingival index.
2- High plaque score and plaque index.
3- Gum probing depth.
4- Periodonitis.


Consensus: We recommend that an oral antibiotic be given at the following dosages for only one dose prior to dental procedures.

Justification: Using oral antibiotics can reduce the burden of bacteria that is released during dental procedures. The following oral antibiotics are recommended as prophylaxis prior to dental procedures:
1- Amoxicillin 2 gm, 1 hour prior to procedure.
2- Azithromycin 500mg, 30 minutes to 1 hour prior to procedure.
3- Cefaclor 1 gm 1 hour prior to procedure.
4- Cefalexin 2 gm, 30 minutes to 1 hour prior to procedure.
5- Clindamycin 600 mg, 1-1.5 hours prior to procedure.
6- Erythromycin 1.5 gm, 1-1.5 hours prior to procedure.
7- Moxifloxicin 400 mg 1-2 hours prior to procedure.
8- Penicillin 2 gm, 1 hour prior to procedure.


Consensus: We recommend that one of the following intravenous (IV) or intramuscular antibiotics be given at the following dosages for only one dose prior to dental procedures.

Justification: Using IV antibiotics can reduce the burden of bacteria that is released during dental procedures. The following IV antibiotics are recommended as prophylaxis prior to dental procedures:
1- IV Ampicillin 2 gm, 30 minutes to 1 hour prior to procedure.
2- IV Cefazolin 1 gm, 30 minutes to 1 hour prior to procedure.
3- IV Cefuroxime 1.5 gm, 10 minutes before procedure.
4- IV Ceftriaxone 1 gm, 30 minutes to 1 hour prior to procedure.
5- IV Teicoplanin 400 mg, immediately before procedure.


Question 5: Should patients at high risk of late PJI be given prophylactic antibiotics during viral illnesses?

Consensus: There is no role for the administration of oral antibiotics to patients with TJA who develop viral illnesses.

Delegate Vote: Agree 98%, Disagree 2%, Abstain 0% (Strong Consensus)


Question 6: Can transient bactermia be minimized during endoscopic procedures such as colonoscopy to prevent late PJI?

Consensus: The influence of transient bacteremia can be minimized during minor surgical procedures by administering prophylactic antibiotics to individualized patients and especially to high-risk patients.

Delegate Vote: Agree 85%, Disagree 13%, Abstain 2% (Strong Consensus)


Question 7: What is the role of herbal supplements, probiotics, and alternative medicine in decreasing translocation of bacteria across the intestinal wall?

Consensus: There is insufficient evidence that supports the use of herbal supplements, probiotics, and alternative medicine to decrease translocation of bacteria across the intestinal wall to prevent late PJIs.

Delegate Vote: Agree 95%, Disagree 3%, Abstain 2% (Strong Consensus)


Question 8: Is there a role for post-surgical monitoring of methicillin-resistant Staphylococcus aureus (MRSA) colonization in the asymptomatic patient?

Consensus: We recommend against post-surgical monitoring of MRSA colonization in the asymptomatic patient.

Delegate Vote: Agree 98%, Disagree 2%, Abstain 0% (Strong Consensus)


Consensus: We recommend that patients undergo repeat screening for Staphylococcus aureus and decolonization prior to additional arthroplasty.


Question 9: What are the methods to identify extra-articular sources of late PJI?

Consensus: Extra-articular sources that contribute to late PJI should be identified by obtaining history and performing a thorough physical exam, laboratory testing, and imaging of suspected areas of infection.

Delegate Vote: Agree 92%, Disagree 3%, Abstain 5% (Strong Consensus)


Question 10: When should further workup for postoperative fevers be performed after TJA?

Consensus: We recommend against the routine workup of fevers greater than 38.5ÂșC in the immediate postoperative period. However, the workup of persistent fevers after postoperative day 3 may be warranted.

Delegate Vote: Agree 81%, Disagree 15%, Abstain 4% (Strong Consensus)