Eleven of the 20 patients were contacted by telephone for additional clinical followup and asked the following questions. (1) Have you required additional surgery for right/left hip/knee? What was the reason for the surgery (if applicable)? (2) Are you taking antibiotics for your hip/knee? Which antibiotic(s) are you taking (if applicable)? (3) When did you stop taking antibiotics for your hip/knee (if applicable)?
We defined treatment success as infection control. Infections were considered controlled if serum inflammatory makers (ESR and CRP) had normalized and there were no clinical signs or symptoms of infection. Controlled infections included both patients in whom all antibiotics were ultimately discontinued and those kept on long-term prophylactic antibiotic therapy. Treatment failure was defined as recurrence of infection requiring additional surgery or clinically apparent infection diagnosed with a positive aspiration or persistently elevated inflammatory markers and treated with long-term antibiotic suppression.
Of the 18 patients without evidence of persistent infection, 10 patients were no longer on antibiotics. These patients were on intravenous and oral antibiotics for an average total of 9.0 months (range, 1.2-21.6 months). Average followup for these patients since all antibiotics had been discontinued was 45.7 months (range, 16.2-75.3 months). Inflammatory markers returned to normal for all patients. Postoperative inflammatory markers were not available for one patient; however, she has been off all antibiotics for six years and has not required additional surgery for her knee. Eight patients were considered to be compromised hosts (Table 4) and were kept on prophylactic long-term antibiotic therapy. The average followup from the time of débridement for these patients was 28.7 months (range, 13.8-53.5 months). There have been no local or systemic complications secondary to long-term antibiotic use.
The two treatment failures in the study group had a symptom onset to débridement duration of 12 and 16 days (Table 3).
Due to the unsatisfactory infection control rates of débridement with component retention of acute periprosthetic joint infections reported in the literature (Table 1), a new treatment protocol was implemented at our institution involving a two-stage débridement with the implantation of antibiotic cement beads at Stage I. The purpose of this review was to determine our infection control rate with this procedure, the number of patients who received long-term antibiotic therapy, and the effect of infection duration on infection control rate.
This retrospective study has several important limitations, including a limited followup period, use of a historical control group, lack of inflammatory marker levels at the last followup for all patients, and potential bias in patient selection. However, all patients who presented with an acute infection were treated with this protocol, thereby reducing selection bias. The study sample size was also small (n = 20), however acute periprosthetic infections are a rare complication and the present study compares favorably to most published reports of acute periprosthetic joint infections (Table 1) in terms of sample size. Finally, numerous factors influence the chance of treatment controlling periprosthetic joint infections. These include: (1) host status; (2) symptom onset to débridement interval; (3) pathogen; (4) débridement technique; (5) antibiotic regimen; and (6) whether or not long-term antibiotic therapy was used. However, owing to the small number of treatment failures (two treatment failures occurred in patients staged as II-B-2 and II-C-2 hosts), we are unable to draw conclusions regarding the effect of host status, as classified by the system of McPherson et al. [15, 16], on treatment outcomes. Nevertheless, when reporting treatment outcomes of periprosthetic joint infections, we believe it essential to include these data for all patients to provide the most accurate description of the treatment technique and host characteristics. Inclusion of these data allows for better comparison of data with other studies and also allows for better comparison of subgroups of patients (eg, ‘B-hosts’).
Historically, the average success rate of retention débridement for the treatment of acute periprosthetic infections has ranged from 24-100% [3, 4, 8, 9, 11, 12, 14, 17, 19, 21-23, 27-29] (Table 1). The data presented here compare favorably, with successful infection control in 18 out of 20 patients. This protocol adds to the length of hospital stay and cost compared to a single débridement and there may be extra morbidity associated with a second surgical procedure. However, we believe that the improved success rate of this technique more than offsets the hospital stay, cost and morbidity associated with managing a failed débridement. Further research is required to analyze the individual contribution of host status, débridement technique, local depot antibiotics, and combination antibiotic therapy on treatment outcomes.
Of the 18 successfully treated infections, 10 are no longer on antibiotics. Eight patients were treated with prophylactic long-term antibiotics. These patients were kept on long-term antibiotics due to compromised host status (Table 4) or the impact a recurrent infection would have on the patient's health. In these instances, we believed the risks of long-term antibiotic treatment were acceptable when weighed against the consequences of a recurrent infection. We believe it would be inappropriate to consider these patients as “treatment failures,” since they never displayed evidence of persistent infection.
Prolonged infection duration is associated with increased biofilm formation and potential for deep osteomyelitis. It is unknown how quickly a clinically meaningful biofilm formation can form; however, retention débridement is not typically recommended if the interval between infection onset and débridement is greater than 28 days [11, 22]. Furthermore, various studies have provided evidence of improved outcomes if the débridement is performed within 3 weeks , 2 weeks [3, 26, 28], or 1 week  from infection onset. Of the 20 patients in our series, 16 underwent débridement within 1 week of infection onset. Two patients were treated at an interval of 10 days, one patient at 12 days, and the final patient at 16 days. The two treatment failures in the study group had a symptom onset to débridement duration of 12 and 16 days (Table 3). However, because there were only three patients treated with an infection duration between 11 and 28 days, we cannot comment on treatment efficacy for this subset of patients who have symptoms for greater than 10 days.
Successful infection control in 18/20 patients treated with this technique compares favorably with historical infection control rates. With proper patient selection, this technique is effective for the treatment of acute periprosthetic total joint infections.
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