Treating periprosthetic joint infection: adopting an individualized approach

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How should a clinician tackle the management and treatment of a periprosthetic joint infection (PJI)? An individualized approach must be developed for each patient, one that integrates appropriate surgical intervention and antimicrobial strategies. The complexities of treating a biofilm infection calls for careful consideration of each case, addressing the acute or chronic nature of infection.

Compared to primary arthroplasty and revision for aseptic loosening, surgical revision for PJI has significantly higher associated costs and higher demands on physician resources [1]. A study of 465,209 hip revisions in the US between 2003 and 2013 found the PJI prevalence to be 15% with hospitalization costs of USD 31,529 [2]. When indirect treatment costs, such as lost wages, were taken into account, another estimate determined the base cost of treating an infected total hip arthroplasty (THA) to be between USD 389,307 and USD 474, 004, depending on the age of the patient at the time of infection [3].

See Part 1 of this article series for further elaboration of PJI risk factors and pre-, intra-, and postoperative infection prevention strategies. Part 2 looks at different components of diagnosing PJI, culminating in a recommended diagnostic algorithm.

Did you miss AO Recon’s webinar on periprosthetic joint infection (PJI)?

In June 2019, AO Recon gathered an online community of close to 200 surgeons for an interactive information session and Q&A led by Olivier Borens, Head of Septic Surgery and Head of Traumatology at the Centre Hospitalier Universitaire Vaudois (Lausanne, Switzerland) and chat moderator Andrej Trampuz, Infectious Diseases Consultant in Septic Surgery at Charité–Universitätsmedizin (Berlin, Germany) on the topic of infection after joint arthroplasty.

Access a recording of the webinar here

Treatment goals

The goal in treating a PJI is to deliver a pain-free and functional joint, which can be achieved by eliminating the infection [4]. Treatment plans should be customized to each individual patient and contingent on the microorganism(s) responsible for the infection [5]. These are simple statements to make yet the pernicious nature of device biofilm, coupled with antibiotic resistance, can make a conclusive diagnosis and successful treatment a challenge.

 
Treatment success rates

Compared to hospital admissions for aseptic loosening, PJI patients have a 2-times higher chance of in-hospital mortality. Treatment of PJI cases often requires multiple surgical admissions and the risk of mortality accumulates with each surgery [6]. Infection of implanted prosthetic joints is more often associated with revisions than with primary arthroplasty [7].

The rate of PJI eradication varies. Sidhu et al reported an overall rate of 50% after two years and 38.9% after five, pointing out that if there is a polymicrobial infection that includes a fungal component, patients are less likely to have their infection cured [8]. A fungal PJI has lower treatment success rates [9]. Akgun et al were able to obtain a 3 year infection-free survival rate of 89.3% in 84 hip PJI patients who underwent two-stage prosthesis exchange [10]. Similarly, Aboltins et al reported a 2 year infection-free survival of 87% in 41 hip and knee PJI patients [11].

Both abovementioned studies conducted patient follow up for 3 and 2 years, respectively. It has been suggested that follow up of any less than 10 years will not capture late PJI, leading to underreporting of its occurrence [7].

Treatment options: two elements—surgery and antibiotics

Depending on how much time has passed from implantation, or the length of symptoms, PJI is classified as either acute or chronic. This designation also indicates the maturity stage of the pathogenic biofilm, the virulence of the microorganism(s), and is associated with different clinical features [12]. See Table 1. This classification also provides direction on how to begin a treatment plan, which has two interrelated components—surgery and antibiotics. Let’s look at surgical options first.

 
Table 1. Classification of prosthetic joint infection (PJI) and associated surgical treatment option(s)

Used with permission. From: Pocket Guide to Diagnosis & Treatment of PJI; PRO-IMPLANT Foundation (October 2019).

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  • SURGICAL treatment strategies
  • Debridement, antibiotics, and implant retention (DAIR)
  • Surgical controversies: not everyone agrees
  • One-stage exchange
  • Two-stage exchange
  • Three-stage exchange
  • If it doesn’t work
  • ANTIMICROBIAL treatment recommendations
  • Suppressive antibiotic treatment
  • Antibiotic holidays: yes or no? No
  • PRO-IMPLANT Foundation recommended treatment algorithm
  • New innovations—the future looks bright
  • Conclusion
  • References

Part 1 | Preventing PJI: how to lower infection rates
 

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Part 2 | Diagnosing PJI: where to start, what to look for

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Contributing experts

This series of articles was created with the support of the following specialists (in alphabetical order):

Olivier Borens

University Hospital Lausanne
Lausanne, Switzerland

Nora Renz

Inselspital—University Hospital Bern
Bern, Switzerland

Andrej Trampuz

Charité—University Medicine Berlin
Berlin, Germany

This issue was created by Word+Vision Media Productions, Switzerland.

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