Treatment of infections associated with surgical implants.
01 Apr 2004-The New England Journal of Medicine (Massachusetts Medical Society)-Vol. 350, Iss: 14, pp 1422-1429
TL;DR: This review summarizes the diagnostic challenges and explains the approaches to managing infections that are associated with various devices, including prosthetic heart valves, vascular grafts, pacemakers and defibrillators, and joint prostheses.
Abstract: About half of all nosocomial infections are associated with indwelling devices. Infections associated with implanted surgical devices are particularly difficult to deal with because they can require prolonged antibiotic treatment and repeated surgical procedures. This review summarizes the diagnostic challenges and explains the approaches to managing infections that are associated with various devices, including prosthetic heart valves, vascular grafts, pacemakers and defibrillators, and joint prostheses.
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TL;DR: This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of S. aureus as a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections.
Abstract: Staphylococcus aureus is a major human pathogen that causes a wide range of clinical infections. It is a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections. This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of each of these clinical entities. The past 2 decades have witnessed two clear shifts in the epidemiology of S. aureus infections: first, a growing number of health care-associated infections, particularly seen in infective endocarditis and prosthetic device infections, and second, an epidemic of community-associated skin and soft tissue infections driven by strains with certain virulence factors and resistance to β-lactam antibiotics. In reviewing the literature to support management strategies for these clinical manifestations, we also highlight the paucity of high-quality evidence for many key clinical questions.
3,054 citations
TL;DR: This review offers guidance in establishing the diagnosis correctly and an algorithm summarizing the appropriate medical and surgical options for prosthetic joints infections.
Abstract: Modern techniques have reduced the frequency of infections that are associated with prosthetic joints, but such infections continue to pose difficult problems in clinical management. Advances in understanding biofilms and the pathogenesis of microbial interactions with the implant have led to more rational approaches to therapy. This review offers guidance in establishing the diagnosis correctly and an algorithm summarizing the appropriate medical and surgical options.
2,617 citations
TL;DR: These guidelines include evidence-based and opinion-based recommendations for the diagnosis and management of patients with PJI treated with debridement and retention of the prosthesis, resection arthroplasty with or without subsequent staged reimplantation.
Abstract: These guidelines are intended for use by infectious disease specialists, orthopedists, and other healthcare professionals who care for patients with prosthetic joint infection (PJI). They include evidence-based and opinion-based recommendations for the diagnosis and management of patients with PJI treated with debridement and retention of the prosthesis, resection arthroplasty with or without subsequent staged reimplantation, 1-stage reimplantation, and amputation.
1,716 citations
Additional excerpts
...nous or oral antimicrobial therapy [1–4]....
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TL;DR: The recently proposed consensus definitions of PJI and approaches to accurate diagnosis are reviewed in detail and an overview of the treatment and prevention of this challenging condition is provided.
Abstract: Prosthetic joint infection (PJI) is a tremendous burden for individual patients as well as the global health care industry. While a small minority of joint arthroplasties will become infected, appropriate recognition and management are critical to preserve or restore adequate function and prevent excess morbidity. In this review, we describe the reported risk factors for and clinical manifestations of PJI. We discuss the pathogenesis of PJI and the numerous microorganisms that can cause this devastating infection. The recently proposed consensus definitions of PJI and approaches to accurate diagnosis are reviewed in detail. An overview of the treatment and prevention of this challenging condition is provided.
1,164 citations
Duke University1, University of Barcelona2, Drexel University3, Tel Aviv University4, Alfred Hospital5, University of Michigan6, University of Zagreb7, Medical University of South Carolina8, Federal University of Rio de Janeiro9, Autonomous University of Barcelona10, Geelong Hospital11, University of Amsterdam12, Wayne State University13, University of California, Los Angeles14
TL;DR: Characteristics of patients with S aureus IE vary significantly by region, and further studies are required to determine the causes of regional variation.
Abstract: ContextThe global significance of infective endocarditis (IE) caused by Staphylococcus aureus is unknown.ObjectivesTo document the international emergence of health care–associated S aureus IE and methicillin-resistant S aureus (MRSA) IE and to evaluate regional variation in patients with S aureus IE.Design, Setting, and ParticipantsProspective observational cohort study set in 39 medical centers in
16 countries. Participants were a population of 1779 patients with definite
IE as defined by Duke criteria who were enrolled in the International Collaboration
on Endocarditis-Prospective Cohort Study from June 2000 to December 2003.Main Outcome MeasureIn-hospital mortality.ResultsS aureus was the most common pathogen among
the 1779 cases of definite IE in the International Collaboration on Endocarditis
Prospective-Cohort Study (558 patients, 31.4%). Health care−associated
infection was the most common form of S aureus IE
(218 patients, 39.1%), accounting for 25.9% (Australia/New Zealand) to 54.2%
(Brazil) of cases. Most patients with health care−associated S aureus IE (131 patients, 60.1%) acquired the infection outside of
the hospital. MRSA IE was more common in the United States (37.2%) and Brazil
(37.5%) than in Europe/Middle East (23.7%) and Australia/New Zealand (15.5%, P<.001). Persistent bacteremia was independently associated
with MRSA IE (odds ratio, 6.2; 95% confidence interval, 2.9-13.2). Patients
in the United States were most likely to be hemodialysis dependent, to have
diabetes, to have a presumed intravascular device source, to receive vancomycin,
to be infected with MRSA, and to have persistent bacteremia (P<.001 for all comparisons).ConclusionsS aureus is the leading cause of IE in many
regions of the world. Characteristics of patients with S aureus IE vary significantly by region. Further studies are required
to determine the causes of regional variation.
1,101 citations
References
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TL;DR: Improvements in understanding of the genetic and molecular basis of bacterial community behavior point to therapeutic targets that may provide a means for the control of biofilm infections.
Abstract: Bacteria that attach to surfaces aggregate in a hydrated polymeric matrix of their own synthesis to form biofilms. Formation of these sessile communities and their inherent resistance to antimicrobial agents are at the root of many persistent and chronic bacterial infections. Studies of biofilms have revealed differentiated, structured groups of cells with community properties. Recent advances in our understanding of the genetic and molecular basis of bacterial community behavior point to therapeutic targets that may provide a means for the control of biofilm infections.
11,162 citations
TL;DR: It is understood that biofilms are universal, occurring in aquatic and industrial water systems as well as a large number of environments and medical devices relevant for public health, and that treatments may be based on inhibition of genes involved in cell attachment and biofilm formation.
Abstract: Though biofilms were first described by Antonie van Leeuwenhoek, the theory describing the biofilm process was not developed until 1978. We now understand that biofilms are universal, occurring in aquatic and industrial water systems as well as a large number of environments and medical devices relevant for public health. Using tools such as the scanning electron microscope and, more recently, the confocal laser scanning microscope, biofilm researchers now understand that biofilms are not unstructured, homogeneous deposits of cells and accumulated slime, but complex communities of surface-associated cells enclosed in a polymer matrix containing open water channels. Further studies have shown that the biofilm phenotype can be described in terms of the genes expressed by biofilm-associated cells. Microorganisms growing in a biofilm are highly resistant to antimicrobial agents by one or more mechanisms. Biofilm-associated microorganisms have been shown to be associated with several human diseases, such as native valve endocarditis and cystic fibrosis, and to colonize a wide variety of medical devices. Though epidemiologic evidence points to biofilms as a source of several infectious diseases, the exact mechanisms by which biofilm-associated microorganisms elicit disease are poorly understood. Detachment of cells or cell aggregates, production of endotoxin, increased resistance to the host immune system, and provision of a niche for the generation of resistant organisms are all biofilm processes which could initiate the disease process. Effective strategies to prevent or control biofilms on medical devices must take into consideration the unique and tenacious nature of biofilms. Current intervention strategies are designed to prevent initial device colonization, minimize microbial cell attachment to the device, penetrate the biofilm matrix and kill the associated cells, or remove the device from the patient. In the future, treatments may be based on inhibition of genes involved in cell attachment and biofilm formation.
5,748 citations
TL;DR: The use of a left ventricular assist device in patients with advanced heart failure resulted in a clinically meaningful survival benefit and an improved quality of life.
Abstract: Background Implantable left ventricular assist devices have benefited patients with end-stage heart failure as a bridge to cardiac transplantation, but their long-term use for the purpose of enhancing survival and the quality of life has not been evaluated. Methods We randomly assigned 129 patients with end-stage heart failure who were ineligible for cardiac transplantation to receive a left ventricular assist device (68 patients) or optimal medical management (61). All patients had symptoms of New York Heart Association class IV heart failure. Results Kaplan–Meier survival analysis showed a reduction of 48 percent in the risk of death from any cause in the group that received left ventricular assist devices as compared with the medical-therapy group (relative risk, 0.52; 95 percent confidence interval, 0.34 to 0.78; P=0.001). The rates of survival at one year were 52 percent in the device group and 25 percent in the medical-therapy group (P=0.002), and the rates at two years were 23 percent and 8 percent...
3,540 citations
TL;DR: Among patients with stable implants, short duration of infection, and initial debridement, patients able to tolerate long-term therapy with rifampin-ciprofloxacin experienced cure of the infection without removal of the implant.
Abstract: Context.—
Rifampin-containing regimens are able to cure staphylococcal implant-related
infections based on in vitro and in vivo observations. However, this evidence
has not been proven by a controlled clinical trial.
Objective.—
To evaluate the clinical efficacy of a rifampin combination in staphylococcal
infections associated with stable orthopedic devices.
Design.—
A randomized, placebo-controlled, double-blind trial conducted from
1992 through 1997.
Setting.—
Two infectious disease services in tertiary care centers in collaboration
with 5 orthopedic surgeons in Switzerland.
Patients.—
A total of 33 patients with culture-proven staphylococcal infection
associated with stable orthopedic implants and with a short duration of symptoms
of infection (exclusion limit <1 year; actual experience 0-21 days).
Intervention.—
Initial debridement and 2-week intravenous course of flucloxacillin
or vancomycin with rifampin or placebo, followed by either ciprofloxacin-rifampin
or ciprofloxacin-placebo long-term therapy.
Main Outcome Measures.—
Cure was defined as (1) lack of clinical signs and symptoms of infection,
(2) C-reactive protein level less than 5 mg/L, and (3) absence of radiological
signs of loosening or infection at the final follow-up visit at 24 months.
Failure was defined as (1) persisting clinical and/or laboratory signs of
infection or (2) persisting or new isolation of the initial microorganism.
Results.—
A total of 18 patients were allocated to ciprofloxacin-rifampin and
15 patients to the ciprofloxacin-placebo combination. Twenty-four patients
fully completed the trial with a follow-up of 35 and 33 months. The cure rate
was 12 (100%) of 12 in the ciprofloxacin-rifampin group compared with 7 (58%)
of 12 in the ciprofloxacin-placebo group (P=.02).
Nine of 33 patients dropped out due to adverse events (n=6), noncompliance
(n=1), or protocol violation (n=2). Seven of the 9 patients who dropped out
were subsequently treated with rifampin combinations, and 5 of them were cured
without removal of the device.
Conclusion.—
Among patients with stable implants, short duration of infection, and
initial debridement, patients able to tolerate long-term (3-6 months) therapy
with rifampin-ciprofloxacin experienced cure of the infection without removal
of the implant.
987 citations
TL;DR: Orthopedic SSIs prolong total hospital stays by a median of 2 weeks per patient, approximately double rehospitalization rates, and increase healthcare costs by more than 300%.
Abstract: OBJECTIVE: To measure the impact of orthopedic surgical-site infections (SSIs) on quality of life, length of hospitalization, and cost. DESIGN: A pairwise-matched (1:1) case–control study within a cohort. SETTING: A tertiary-care university medical center and a community hospital. PATIENTS: Cases of orthopedic SSIs were prospectively identified by infection control professionals. Matched controls were selected from the entire cohort of patients undergoing orthopedic surgery who did not have an SSI. Matching variables included type of surgical procedure, National Nosocomial Infections Surveillance risk index, age, date of surgery, and surgeon. MAIN OUTCOME MEASURES: Quality of life, duration of postoperative hospital stay, frequency of hospital readmission, overall direct medical costs, and mortality rate. RESULTS: Fifty-nine SSIs were identified. Each orthopedic SSI accounted for a median of 1 extra day of stay during the initial hospitalization (P = .001) and a median of 14 extra days of hospitalization during the follow-up period (P = .0001). Patients with SSI required more rehospitalizations (median, 2 vs 1; P = .0001) and more total surgical procedures (median, 2 vs 1; P = .0001). The median total direct cost of hospitalizations per infected patient was $24,344, compared with $6,636 per uninfected patient (P = .0001). Mortality rates were similar for cases and controls. Quality of life was adversely affected for patients with SSI. The largest decrements in scores on the Medical Outcome Study Short Form 36 questionnaire were seen in the physical functioning and role-physical domains. CONCLUSIONS: Orthopedic SSIs prolong total hospital stays by a median of 2 weeks per patient, approximately double rehospitalization rates, and increase healthcare costs by more than 300%. Moreover, patients with orthopedic SSIs have substantially greater physical limitations and significant reductions in their health-related quality of life (Infect Control Hosp Epidemiol 2002;23:183-189).
819 citations