Aims. Periprosthetic joint infections (PJIs) are rare, but represent a great burden for the patient. In addition, the incidence of methicillin-resistant Staphylococcus aureus (MRSA) is increasing. The aim of this rat experiment was therefore to compare the antibiotics commonly used in the treatment of PJIs caused by MRSA. Methods. For this purpose, sterilized steel implants were implanted into the femur of 77 rats. The metal devices were inoculated with suspensions of two different MRSA strains. The animals were divided into groups and treated with vancomycin, linezolid, cotrimoxazole, or rifampin as monotherapy, or with combination of antibiotics over a period of 14 days. After a two-day antibiotic-free interval, the implant was explanted, and bone, muscle, and periarticular tissue were microbiologically analyzed. Results. Vancomycin and linezolid were able to significantly (p < 0.05) reduce the MRSA bacterial count at implants. No significant effect was found at the bone. Rifampin was the only monotherapy that significantly reduced the bacterial count on implant and bone. The combination with vancomycin or linezolid showed significant efficacy. Treatment with cotrimoxazole alone did not achieve a significant bacterial count reduction. The combination of linezolid plus rifampin was significantly more effective on implant and bone than the control group in both trials. Conclusion. Although rifampicin is effective as a monotherapy, it should not be used because of the high rate of resistance development. Our animal experiments showed the great importance of combination antibiotic therapies. In the future, investigations with higher case numbers, varied bacterial concentrations, and changes in individual drug dosages will be necessary to be able to draw an exact comparison, possibly within a clinical trial. Cite this article: Bone Joint Res 2022;11(3):143–151

Aim. Successful management of native Joint septic arthritis (SA) hinges on the timely initiation of appropriate antibiotic therapy coupled with thorough joint debridement. Since 2018 we have implemented a protocol for empirical antibiotic in patients with suspected SA recommending amoxicillin/clavulanate (and cotrimoxazole in cases of beta-lactams allergy) based on local flora. Nevertheless we have recently found that institutional compliance to the protocol is only about 50% and many physicians are still choosing alternative wider spectrum regimens. The aim of this study is to assess whether current clinical and epidemiological characteristics of patients treated for this condition justify an update or whether previous recommendations are still valid. Method. All adult patients admitted to our institution with suspected SA between 2018-2022 were retrospectively reviewed. Data was collected from electronic medical records and then compared to similar data previously collected concerning the 2009-2017 period (that served as a basis for the aforementioned protocol). Results. A summary of available data from both time periods can be found in table 1. Overall, among the 35 patients with positive microbiology treated between 2018-2022, amoxicillin/clavulanate is appropriate for 30 (86%) of isolates (vs 88% in historic control). Analysing the whole cohort, we found that previous contact with healthcare services (hospital admission or prolonged ER stay) (p=0.0044) and antibiotic treatment for any infection (p= 0.0213) in the previous six months correlate with resistance to amoxicillin/clavulanate. In these patients, the proposed alternative cotrimoxazole is effective in 77% of cases. Conclusions. The institutional guideline for empirical antibiotic therapy in native joint SA remains adequate and there seems to be no justification to deviate from protocol except in cases of patients admitted to the hospital or antibiotic treatment in the previous six months. In these cases methicillin-resistance coverage is probably appropriate. Pseudomonal coverage is seldom required in SA. For any tables or figures, please contact the authors directly

Aim. The aim of the present work was (i) to survey the situation of healthcare regarding the use of antibiotics in orthopaedics and trauma surgery in Germany, (ii) to determine which empiric antibiotic regimens are preferred in the treatment of periprosthethic joint infections (PJI) and (iii) to evaluate the hypothetical antibiotic adequacy of the applied empirical antibiotic therapy regimens based on a patient collective of a German university hospital. Method. A survey on empirical and prophylactic antibiotic therapy was conducted at German university and occupational health clinics (BG clinics), each in the specialties of orthopedics and trauma surgery. A total of 71 clinics were contacted by email. The questionnaire sent included open-ended questions on systemic antibiotic prophylaxis in primary hip arthroplasty; a distinction was made between hip arthroplasty due to femoral fractures and elective hip arthroplasty. In addition, the empirical antibiotic therapy used in PJIs was surveyed. To determine the success rate of prophylaxis and therapy according to sensitivity to the antibiotics applied, the survey results were compared with previously published data on antimicrobial treatment in n=81 PJI patients treated in our department between 2017 and 2020. Results. In 93.2% (elective) and 88.6% (fracture care) of the hospitals, 1st- and 2nd-generation cephalosporins are administered perioperatively for infection prophylaxis in primary hip arthroplasty. In contrast, empiric antibiotic treatment for PJI showed a clearly inhomogeneous therapeutic picture. Monotherapy with an aminopenicillin/betalactamase inhibitor is most frequently used (38.7%); 1st- and 2nd-generation cephalosporins are second most frequently used as monotherapy (18.2%). In addition, dual combination therapies have become established, mostly aminopenicillin/betalactamase inhibitor or 1st- and 2nd-generation cephalosporins, whose administration is supplemented with another antibiotic. The most common combination in PJI is aminopenicillin/betalactamase inhibitor + vancomycin (11.4%). The most widely used therapy (monotherapy with aminopenicillin/betalactamase inhibitor) would have covered 69.0% of PJI patients. Monotherapy with 1st- and 2nd-generation cephalosporins would have been susceptible to 57.8% of PJI patients. In contrast, a combination of vancomycin + 1st- and 2nd-generation cephalosporins would have been most effective, with an efficacy of 91.5% according to the resistograms, but this was used by only two hospitals. Conclusions. Empirical antibiotic therapy for the treatment of PJI is applied in more than half of the clinics with a single broad-spectrum beta-lactamase inhibitor antibiotic. This discrepancy between the everyday care in the clinics and the administration of clearly more effective combination therapies underlines the need for recommendation guidelines

Prosthetic joint infection (PJI) is a severe complication of prosthetic joint implantation, with an estimated incidence of 2.18%. Most frequently used treatment strategy for PJI is a two-stage revision procedure. However there are specific patients with a new or persisting infection after primary or revision surgery where further surgical treatment is not attractive. This may be because of medical or local surgical conditions, or patient's refusal to undergo (further) surgical therapy. For these patients suppressive antibiotic therapy (SAT) may be an alternative treatment. The aim of this study is to describe the clinical and radiological outcome of patients with a PJI of a hip arthroplasty, treated with SAT. Twenty-four patients with a hip arthroplasty treated with suppressive antibiotic therapy for PJI between January 1, 2008 and December 31, 2013 were included. All patients had a proven prosthetic joint infection, either by ≥2 intraoperative cultures or joint aspiration. SAT was defined as treatment with antibiotic therapy for more than three months. Most used antibiotics were doxycycline in 15 patients and cotrimoxazole in six patients. Patients were supposed to have a successful outcome when their prosthesis remained in situ and they had no relapse or new infection. Suppressive antibiotic therapy was considered successful in 15 (62.5%) patients with a mean follow-up of 20.6 months. Two patients (8.3%) had to stop the antibiotic therapy due to adverse effects. The mean duration of the SAT was 20.4 months (range 0.92–92.65 months). Mean modified Oxford hip score of the successfully treated patients at the latest follow up was 35 (range 16–49) and mean Harris hip score 71 (range 40–93). The mean visual analogue scale (VAS) was 16 (range 0–70) in rest, 32 (range 0–85) during exercise and 65 (range 10–100) for satisfaction. Of the 9 patients with an unsuccessful outcome, there was a radiological loosening of the cup in 4 patients. In the group of 15 patients that were considered successful, 2 patients had a radiological loosening of the cup and one patient loosening of the stem. Suppressive antibiotic therapy can be an attractive alternative treatment in selected patients with a prosthetic joint infection of a hip arthroplasty who cannot or will not undergo (further) surgical therapy. Further research with a larger number of patients is required. Also the optimal dosage and duration of suppressive antibiotic therapy and possible resistance to the antibiotic therapy is unknown

Spondylodiscitis is a severe infectious disease of the vertebral column and the intervertebral disc space and may be complicated by an epidural abscess. A wide range of pathogens have been described as causative agents. Since several weeks of antibiotics are necessary for successful therapy detection of the causative pathogen is essential. Specific antibiotic therapy improves outcome and reduces antibiotic related complications. Antibiotic Stewardship (ABS) programs are bundled approaches aimed at improving antibiotic therapy. In 2012 an ABS program including weekly interdisciplinary clinical rounds and development of algorithms for diagnosis and therapy of patients with spondylodiscitis was established in the Department of Orthopedic Surgery in a University hospital. We evaluated the effects of ABS with regard to the appropriateness of specimen and pathogen detection and antibiotic therapy in patients with spondylodiscitis. We retrospectively analysed diagnostic procedures and pathogen detection of 100 patients that were hospitalized with spondylodiscitis and compared the data of patients that were treated before (2004–2011) and after introduction of ABS measures (2012–2014). After introduction the effect of ABS on antibiotic therapy was analysed. 100 patients with radiologically confirmed spondylodiscits were enrolled. The pre-ABS group (2004–2011) contained 58 patients. Of these no samples were taken for microbiological examination from 21 patients (36%) and from 8 patients (14%) only swabs were submitted for culture. Aspirates or tissue samples were taken from 22 patients (38%) and blood cultures from 18 patients (31%). Pathogen detection was successful in 18 patients (31%). After introduction of ABS in the beginning of 2012 aspirates or tissue samples were taken from 34 patients (81%) and blood cultures were taken from 34 patients (81%). Pathogen detection was successful in 26 patients (62%). The most commonly detected pathogens were Gram positive cocci (S.aureus, S. epidermidis, and streptococci) in 31 patients. Less common pathogens were found in 12 patients (Gram negative rods (8), fungi (3), Moraxella (1) and Propionibacterium (1). After introduction of ABS antibiotic therapy was changed in 18 of 20 patients (90%) after pathogen identification. In 50 % of cases the inappropriate empiric therapy was changed (MRSA, MRSE and Gram negative rods) and in 50 % broad-spectrum antibiotic therapy could be deescalated. ABS significantly improved the number and quality of samples, increased the number of blood cultures taken and doubled the pathogen detection rates in patients with spondylodiscitis leading to an improvement in antibiotic therapy in almost all patients with pathogen detection

The management of periprosthetic joint infection is challenging and the duration of systemic antibiotic therapy whether it be during the interval phase or after reimplantation of a new prosthesis is controversial. We report our experience of managing chronic periprosthetic infection of the hip by the two stage exchange procedure. Patients who were scheduled to undergo a two stage revision for chronic periprosthetic infection of the hip were identified from our prospective database. Of 425 patients with microbiologically proven periprosthetic infection, 369 (87%) underwent a two stage procedure, leaving 56 patients who did not proceed to reimplantation. 41 of these were clinically infection free but for personal or medical reasons did not proceed. The remaining 15 had persistent infection. The mean age at the time of the first stage was 68 years (26 – 92 yrs). 256 (61%) patients were alive for review. The mean time between stages was 6.3 months with a mean follow up after the second stage was 65 months (range 5 to 276 months). The success rate of a single 1. st. stage debridement, confirmed by negative cultures at the time of second stage reimplantation was 94%. 19 patients underwent a repeat 1. st. stage debridement and were classed as failures of the 1. st. stage. At the time of final review, 340 (92%) patients were deemed infection free out of those who had completed a 2 stage exchange. The duration of systemic antibiotic treatment after both the 1. st. and 2. nd. stages was divided into <48 hrs and >48 hours. There was no significant difference in the success of the 1. st. stage procedure in patients who received < 48 hours (48% of the patients) as opposed to > 48 hours (p = 0.98, Chi Squared Test, Relative Risk 1.009). Similarly there was no difference in the overall success of the two stage procedure irrespective of the duration of antibiotic therapy with 76% of patients receiving <48hrs of antibiotics after the second stage. Aggressive surgical debridement together with targeted local and short term systemic antibiotic therapy should be the mainstay of treatment in two stage revision surgery

Purpose. To analyse the effectiveness of using outpatient management of paediatric bone and joint infections with parenteral antibiotic therapy in terms of its efficacy, safety and cost-effectiveness compared to prolonged inpatient treatment. Method. Paediatric cases of septic arthritis or osteomyelitis were identified over a seven year (2004–2011) period in a regional teaching hospital. This included patients either treated as long-term inpatients or given outpatient parenteral antibiotic therapy. The outcome measures recorded included: whether treatment was successful, complications, and length of hospital stay. A cost analysis was also calculated. Results. A total of 41 paediatric patients diagnosed with osteomyelitis or septic arthritis were reviewed, of which 8 were treated as inpatients during the course of their IV antibiotic therapy, and 33 were treated with outpatient parenteral antibiotic therapy (requiring a PICC line to be in situ). The mean length of hospital stay for the inpatient group was 23 days, compared to 3.9 days for the outpatient group. The cost saving in terms of hospital stay is (19 × £464=) £8816. Treatment was effective in all groups. In terms of complications of therapy, there was 1 antibiotic-related case in the inpatient group, and 4 cases in the outpatient group of which 3 related to antibiotic side-effects and 1 related to the PICC line. Conclusion. Outpatient treatment of paediatric bone and joint infections is both clinically and cost effective when compared to long stay inpatient management. It is safe, well tolerated and we advocate its adoption, wherever resources allow

Introduction and Aims: The appropriate duration of antibiotic therapy in children suffering from acute haematogenous osteomyelitis (AHO) and acute septic arthritis (SA) has not been clearly established by clinical trials. In recent years there has been a tendency to shorter courses of both intravenous and oral therapy, but evidence is currently limited as to the efficacy of short duration antimicrobial therapy. . Method: This study was conducted in two phases. A retrospective study of 71 children in which we investigated the duration of both intravenous and oral antimicrobial therapy in relation to recurrent disease and side effects. A prospective study, now underway investigating the efficacy of a combined short IV (three days)/short oral (three weeks) combination of antibiotics in children with acute osteomyelitis and acute septic arthritis. Results: Duration of antibiotics in the retrospective study varied from two to 28 days with a median duration of 4.5 days. Duration of the oral phase of antibiotic therapy varied from two to 10 weeks with a median value of 4.7 weeks. The recurrence rate, requiring admission or an additional operative procedure was 1.4%. There were no long-term sequelae. In the prospective study the duration of intravenous and oral antibiotics has been successfully reduced in the majority of patients, without any increase in the need for surgical procedures, re-admission or evidence of chronic osteomyelitis. However, in 26% of patients, the duration of the IV phase of antibiotic therapy was electively increased, because of clinical signs, suggestive of inadequate response. To date recurrent/chronic disease has only been seen in patients judged clinically to have an inadequate response to short-term therapy and who received a longer course of IV antibiotics. Conclusion: Shorter courses of antimicrobial therapy in children with acute haematogenous osteomyelitis and acute septic arthritis, are safe and effective with a low incidence of recurrent disease. However clinical judgment is required to identify those children who require longer courses of both intravenous and oral therapy in order to eradicate the disease during the primary presentation. Further study is required to identify with greater certainty the profile of children who require longer courses of therapy than the emerging standard, three weeks IV/three weeks oral

There is currently no consensus on the use of suppressive antibiotic therapy (SAT) in prosthetic joint infections (PJI) (1). We describe herein the experience of a French Reference Centre for Complex Osteo-Articular Infections on use of oral cyclines (doxycline and minocycline) for SAT. A retrospective analysis was performed on consecutive patients with PJI who received oral cyclines (doxycycline or minocycline) for SAT between January 2006 and June 2014. All patients had surgical management, followed by systemic antibiotic treatment and SAT instauration thereafter. Remission was defined as an asymptomatic patient with a functioning prosthesis. Seventy-nine patients with a mean age of 63.8 ± 16.8 years were included. Sixteen patients (20%) had neoplasia, 9 (11%) diabetes mellitus, 10 (13%) rheumatoid arthritis, and 6 patients (8%) were receiving corticosteroids or chemotherapy. There were 37 knee (47%), 36 hip (46%), 4 elbow (5%), and 2 shoulder (3%) infections, with a mean delay from implantation of 7.37 ± 6.94 months (range 1–27). Surgical management consisted in debridement and implant retention for 60 patients (76%), or in implant exchange for 19 patients (24%). Main pathogens were coagulase-negative staphylococci (37%) and Staphylococcus aureus (41%); 23 patients had polymicrobial infection (29%). The most frequent initial antibiotic regimens debuted before SAT were rifampicin combinations (70%). Mean duration of curative antibiotic therapy was 103 ± 75 days. Indications of SAT were (i) patients unsuitable for or refusing further surgery (n=23), suboptimal (ii) surgery (n=26) or (iii) curative antibiotic therapy (n=11), (iv) complex orthopaedic surgery (n=11), and (v) immunosuppressive status (n=8). Seventy-three patients received doxycycline and 6 patients received minocycline as SAT (n=48). Mean SAT duration was 625± 536 days (range 30–2900), with a mean follow-up of 765 ± 572 days. Adverse events were reported in 13 patients (16%), leading to SAT discontinuation in 5 (6%). During follow-up, 59 patients were considered in remission (75%), and 20 failed including 13 relapses (16%) and 7 reinfections (9%). Among failure patients, 10 pathogens resistant to doxy/minocycline were identified, including 5 with acquisition of cycline resistance. In our study, SAT with cyclines is associated to a 75% remission rate, with an acceptable tolerability. Further studies are warranted to determine ideal regimens and optimal duration of SAT. We would like to thank Dron Hospital and Lille University Hospital medical teams. The authors declare that there are no conflicts of interest

There have been a worldwide change in the susceptibility patterns of antibiotics by many community-acquired microorganisms including those associated to wound infection after open fractures. However, the current antibiotic prophylaxis practice adopted by orthopedic surgeons to prevent infectious complications following open fractures has not changed, since Gustilo and Andersen classification was published several decades ago. Few studies have addressed the current pattern of infectious organisms identified in open fracture wounds and its susceptibility to antibiotics that have been empirically used. We aim to study the incidence of community-acquired resistant organisms isolated in lower extremities open fracture and analyze if antibiotic therapy based upon identified resistant pathogens, would decrease surgical site infection (SSI) rates. In a prospective, single center cohort study, from August 2013 to March 2015 at a tertiary public university institution, 136 subjects presenting Gustilo type II or III lower extremities open fractures were randomly assigned in two arms. Both arms were submitted to surgical debridement, fracture stabilization, and empirical antibiotic therapy, but subjects on Group II had at least three samples of tissue cultures collected during debridement. Patients previously treated at an emergency department other them ours were excluded. When resistant bacteria was identified, antibiotic therapy was modified according to antibiogram tests. The primary outcome was to compare the infection rates between these two groups, after early 60-days follow up. We included 136 patients with Gustilo-II (43.4%), –III, (34.5%) open fractures, of which 86% were male, with median age of 33.7 years, and 69.1% presented no comorbidities. Group II (collection of tissue cultures) accounted 36.7% of patients, and among them bacterial growth were detected in 36% (16/50). Microorganism resistant to empirical antibiotic therapy was identified in 18% (9/50), including Staphylococcus aureus, coagulase-negative Staphylococci, Enterococcus sp, Pseudomonas aeruginosa, Klebsiella sp, Serratia sp, Escherichia coli, and Enterobacter sp. Median duration of antibiotic treatment was eleven days. During 60-days of follow up, 71 patients (52.2%) were evaluated for signs of infection using the Centers for Disease Control and Prevention criteria, of which 63.4% (45/71) and 36.6% (26/71) were on Group I and II, respectively. No significant difference in the rates of SSI was observed between the study arms (19.2% vs 22.2%, respectively, P = 0.95). We detected higher rates of bacterial resistance on Gustilo type II and III open fracture wounds, but adjusting antibiotic therapy towards these contaminants did not affected the rates of infection afterwards

Purpose: Patients hospitalized for osteomyelitis due to multi-resistant strains are often given prolonged parenteral antibiotics. Ambulatory parenteral antibiotic therapy is an alternative allowing outpatient care. The purpose of this study is to assess tolerance, cost and efficacy of this type of treatment. Material and methods: Thirty-nine patients followed for osteomyelitis were included in this study. These patients were given antibiotics in a continuous infusion using a portable diffuser connected to an implanted chamber. Mean duration of treatment was four months, range 1.5–12 months. The follow-up team included the primary care physician, an infectious diseases specialist, and a nurse with special training in prolonged ambulatory antibiotic treatments. Results of weekly blood tests were transmitted to the referral hospital physician. Adverse effects and cost of prolonged ambulatory antibiotic therapy were recorded. Cost included costs for nurses, physical therapists, and physicians as well as drugs, supplies and laboratory tests. The cost of hospitalisation was determined on the basis of the standard cost for one day of hospitalisation in France. Results: There were three cases of thrombophlebitis and one case of allergic reaction, both required re-hospitalisation. Cure was achieved in 93% of the patients. Mean follow-up since cure with discontinuation of the antibiotics was 18 months (14–22). Home care was possible in 100% of the patients and 23% of the patients were able to resume their occupational activity; 25% resumed their schooling. Self-administered schemes were possible in 23% of the patients. Compared with conventional hospitalisation, ambulatory parenteral antibiotic therapy enabled a cost savings of 1352 euros per patient. Discussion: These results demonstrate that ambulatory antibiotic therapy is a very good alternative to classical hospitalisation enabling low morbidity, early resumption of social activities without loss of efficacy

The use of prolonged courses of parenteral or oral antibiotic therapy in the management of two stage revision of infected total knee arthroplasty is reported by all major series. We present a series of 59 consecutive patients, all with microbiologically proven deep infection managed at our unit where a prolonged course of antibiotic therapy has not been routinely used. The mean follow-up is 56.4 months (range 24–114 months). Of the 38 patients undergoing a staged exchange, infection was successfully eradicated in 34 patients (89%) with recurrent or persistent infection in 4 (11%). The infection cure rate in our series is similar that reported elsewhere. A prolonged course of antibiotic therapy does not seem to alter the incidence of recurrent or persistent infection. The costs of antibiotic administration are high, both to the patient and care facility. It may be unnecessary

Objectives. The risk of infection after type III° open fractures is high (10–50%). Preemptive antibiotic therapy may prevent posttraumatic infection and improve the outcome. Recommendations about the type and duration of antibiotic vary among the institutions and it remains unclear whether gram-negative bacilli or anaerobs need to be covered. In Europe, the most commonly recommended antibiotic is amoxicillin/clavulanic acid. We retrospectively analyzed microbiology, characteristics and outcome of patients with open type III° fractures treated at our institution. Methods. Between 01/2005 and 12/2009 we retrospectively included all type III grade open fractures of the leg at our institution classified after Gustilo (JBJS Am 1976) into type IIIA (adequate soft-tissue coverage of bone with extensive soft-tissue laceration or flaps), IIIB (extensive soft-tissue loss with periosteal stripping and bone exposure), and IIIC (requiring arterial injury repair). Demographic characteristics, clinical presentation, microbiology, surgical and antibiotic treatment and patient outcome were recorded using a standardized case-report form. Results. 30 cases of patients with type III° open fractures were included (25 males, mean age was 40.5 years, range 17–67 years). 27 fractures (90%) were located on the lower leg and 3 (10%) on the upper leg. 24 cases (80%) were high-energy and almost half of the patients (n=16, 53%) had a polytrauma. Microbiology at initial surgery was available for 19 cases (63%), of which 10 grew at least one organism (including 8 amoxicillin/clavulanic acid-resistant gram-negative bacilli [GNB], 7 amoxicillin/clavulanic acid-resistant Bacillus cereus), 11 were culture-negative. Preemptive antibiotics were given in all cases (100%) for an average duration of 8.5 days (range 1–53 days), the most common antibiotic was amoxicillin/clavulanic acid in 60 % (n=18). 11 cases just received preemptive antibiotic treatment, in 19 of 30 cases the antibiotic therapy was changed and prolonged. Microbiology at revision surgery was available for 25 cases and 22 grew at least one pathogen (including 32 amoxicillin/clavulanic acid-resistant gram-negative bacilli and 10 amoxicillin/clavulanic acid-resistant Bacillus cereus), 3 were culture-negative. Conclusions. At initial surgery, most common isolated organisms were coagulase-negative staphylococci (43%), Bacillus cereus (23%), and gram-negative bacilli (27%), and others (7%) of which 48% were resistant to amoxicillin/clavulanic acid. At revision surgery, isolated organisms were gram-negative bacilli (64%), Bacillus cereus (20%), and others (16%) of which 88% were resistant to amoxicillin/clavulanic acid. The spectrum of amoxicillin/clavulanic does not cover the most common isolated organisms

Introduction. Success rate after Debridement-Irrigation, Antibiotic Therapy and Implant Retention (DAIR) for treatment of Acute Haematogenous (AH) and Early Post-surgical (EP) periprosthetic joint infection (PJI) varies widely among published studies. Prosthesis exchange is recommended to treat PJI after a failed DAIR. However, no early postoperative prognostic factors permitting to identify future failures have been described. Aim. Identify early prognostic factor of failure after DAIR in order to propose efficient treatment before onset of chronic PJI. Hypothesis. Positive suction drainage fluid culture is a strong early predictive factor of failure. Methods. We conducted a retrospective study, with a minimum 2 years follow-up. Twenty-two consecutive patients (78 years-old +/-10) with EPPJI: i.e. infection within 1 month after joint replacement (n=12; 55%) or AHPJI: i.e. acute haematogenous infection with less than 2 weeks evolution (n=10; 45%) were included. The involved prostheses were: Total Knee Arthroplasty (n=12; 55%), Total Hip Arthroplasty (n=7; 32%) and Hip Hemi-Arthroplasty (n=3; 14%). DAIR was indicated for each patient. Suction drainage fluid was systematically analysed at day 1, 3 and 5 postoperative. Failure of the procedure was defined as: need for iterative surgery to control PJI or suppressive antibiotherapy to control PJI or death related to PJI. Results. At 2 years follow-up, failure rate after DAIR was 55%. Only positive suction drainage fluid culture was statistically associated with treatment failure (p=0,039). Neither type of prosthesis: knee prosthesis vs hip prosthesis (Odds Ratio (OR)=1; IC95%[0.14; 7.21]) nor type of fixation : cemented vs uncemented prothesis (OR=4,39; IC95%[0.29; 269]) were associated with treatment failure. In addition, type of bacteria causing PJI and especially S. aureus (OR=3,1; IC95%[0.42; 28.61]), type of infection (OR= 1,47; IC95%[0.21; 11.37]), delay between onset of symptoms and DAIR (OR= 1,63; IC95% [0.21; 14.85]) or retaining of modular component (OR= 1.32; IC95% [0.17; 10.59)) were not associated with a higher rate of failure. Conclusion. Positive suction drainage fluid culture could be an early postoperative predictive factor of failure after open Irrigation-Debridement, Antibiotic Therapy and Implant Retention for EPPJI and AHPJI

Aim: To review our practice of performing two-stage revision for infected total knee arthroplasty by using articulating interval prosthesis and short course parenteral antibiotic therapy. Patients and Methods: We included 70 patients treated by a single surgeon using a uniform protocol since 2001. All patients were planned to have two- stage revision for infected total knee arthroplasty with an articulating interval prosthesis made up of cruciate retaining femur and all poly tibia at stage one. All patients were given short course parenteral antibiotic therapy (5 days IV) followed by and 6 weeks dual oral therapy. Results: The average age was 68 yrs at the time of first stage. Five patients required repeat of 1st stage procedure because of persistent infection. Twenty six (40%) patients opted not to have a 2nd stage procedure because of eradication of infection after 1st stage and good functional result with interval prosthesis. We had recurrence of infection in 6 patients after two-stage procedure at a mean follow up of 42 months. Four patients out of these six had multiple surgeries for infection before our two-stage protocol. Conclusion: Articulating interval prosthesis gives excellent function and also makes subsequent revision easier with well preserved soft tissue balance. It also takes pressure off on the time constraint for the 2nd stage and good number of them may not require a 2nd stage at all. Our results of recurrence are comparable with published literature evidence and we don’t think that prolonged parenteral antibiotics therapy is required provided adequate surgical debridement has been performed

Aim. Antibiotic loaded spacers are often used during a two-stage exchange for periprosthetic joint infections (PJI) both for its mechanical properties and as a means for local antibiotic delivery. The main goal of this study is to compare the rate of positive cultures during reimplantation with the use of different antibiotic loaded spacers: aminoglycoside only vs. combined glycopeptide/aminoglycoside vs. combined glycopeptide/carbapenem/aminoglycoside. Method. We retrospectively evaluated every two-stage exchange procedures for infected hip/knee arthroplasty between 2012–2018. Microbiological findings in the first and second stage were registered as well as the type of spacer and antibiotic(s) used. Cases in whom no cultures were obtained during reimplantation and cases without sufficient data on antibiotic(s) used in cement spacers were excluded. Results. Fifty-four cases were included (20THA and 34TKA), with an overall rate of positive cultures during reimplantation of 18.5% (10/54). The rate of positive cultures was statistically significant higher among spacers with monotherapy with aminoglycoside compared to spacers with combined antibiotic therapy- 35.7% (5/14) vs. 12.5% (5/40) respectively(p<0.05). Comparing those with combined glycopeptide/aminoglycoside (2/19) with triple glycopeptide/carbapenem/aminoglycoside therapy (3/21) there was no significant difference. Microorganisms present during the second stage were mostly staphylococci (coagulase-negative in four cases, S.aureus in three), Corynebacterium striatum, Enterococcus faecalis, C.albicans in one case each. In most cases (8/10), the isolated microorganism was the same as the first stage and was resistant to the antibiotic(s) used in the spacer in seven cases. Failure rate with the need for subsequent surgery was significantly higher at 60% (6/10) in cases with positive cultures at reimplantation compared to 4.5% (2/44) for those with negative cultures during reimplantation(p=0.0005). Conclusions. It has recently been suggested that adding a glycopeptide to the spacer may be advantageous when compared to spacers with aminoglycoside monotherapy, as it will produce significantly lower rates of positive cultures during reimplantation which have been shown to increase the risk of subsequent failure as is the case in our study. Local unavailability of obtaining powder aminoglycosides has driven us to manually add high doses of vancomycin and meropenem to commercially available low-dose gentamicin cement in many of our spacers and they seem to to perform just as well as commercially available vancomycin/gentamicin combination. Although many other variables not considered in this study may influence the rate of positive cultures during the second stage (quality of initial debridement, systemic antibiotic therapy, etc.), we believe these results portrait a sufficiently accurate picture of clinical results with the use of different spacers

Aim

Local antibiotics, delivered to the site of infection, achieve high tissue concentrations and are used as an adjunct to systemic therapy. Local gentamicin provides levels well above the minimum inhibitory concentration and may be sufficient on its own, however, the efficacy of single or combination local antibiotics has not been studied. This retrospective study evaluated the effect of combination aminoglycoside and vancomycin local antibiotic treatment compared to aminoglycoside alone in the surgical management of bone infection.

For local antibiotic therapy gentamycin is in clinical use since many years, originally in the form of PMMA beads, later also in the form of resorbable collagen fleece. A prospective study comparing the efficacy of both application forms so far is missing. In a prospective study 108 patients with chronic sclerosing osteomyelitis were treated by a standardised operative debridement protocol. The debrided cavities were filled with 54 patients (group 1) were treated by local antibiotic beads (Septopal) and 54 patients (group 2) by local resorbable antibiotic fleece (Sulmycin). Both groups were comparable concerning age, location, duration of operation, type of osteomyelitis and predisposing factors. The mean follow-up was 6.1 years (range 3.8 – 9.3). Evaluation was done for the re-operation rate, CRP and ESR, white blood cells and local wound healing criteria. Twenty-six patients (44 per cent) underwent one or more revision operations because of persistent infection. In group I 67 per cent and in group II 20 per cent (p = 0.0001). No difference was noted for CRP (p = 0.46), ESR (p = 0.09), white blood cells (p = 0.24) and local wound healing criteria (p =0.34). After local gentamycin fleece application the early re-operation rate is significantly lower compared to gentamycin beads. After a treatment period of 3 month this difference disappears

Introduction: Purified plaster of Paris can be used as a resorbable carrier material for local antibiotic therapy. Clinical use already has been published with vancomycin and the aminoglycosides gentamycin and tobramycin. Calcium sulphate pellets with vancomycin can be manufactured during operation from Osteoset. ®. and vancomycin powder, whereas calcium sulphate with tobramycin is available as ready-to-use pellets under the brand name Osteoset T. ®. Results are promising. However, no data on systemic serum levels in humans have been published so far, despite well known toxicity issues of these antibiotics in systemic therapy. Methods: Following implantation of calcium sulphate with vancomycin or tobramycin, systemic serum levels of these antibiotics have been measured for up to 10 days, and prospectively gathered. Considering serum levels and renal function, pharmacokinetics have been estimated. Results: Between August 2006 and February 2008, calcium sulphate with vancomycin has been implanted in 15 patients, and with tobramycin in 12 patients. Whereas vancomycin levels remained very low, tobramycin levels close to the usually accepted trough levels could be observed at 24h post-operation. Conclusion: Vancomycin added to calcium sulphate has a safe systemic profile. On the contrary, significant serum levels of tobramycin can be measured more than 24h after implantation. Caution is mandatory when using this antibiotic, and explantation should be considered if levels too high are observed

Staphylococcus aureus osteo-articular infections (OAI) are frequently accompanied by blood stream infections (BSI) diagnosed by positive blood culture (BC). Microbiological protocols in adults advise prolonged intravenous antibiotics and repeat BC 48-hourly in the presence of a BSI, however evidence to support the systematic employment of these guidelines in paediatric patients is lacking. We aimed to determine whether there was an increased incidence of orthopaedic and systemic complications in patients with s aureus BSI, and whether a shorter duration of intravenous antibiotics was associated with the development of complications.

Following ethical approval, the departmental surgical database was searched for patients that underwent surgery for acute OAI over a 5-year period. Patients with no sample taken for BC were excluded, as were those with other or no organisms identified from any site. Demographic and clinical data were captured, including duration of IV antibiotics and development of complications. Statistical significance was set at p<0.05.

Following exclusions, 44 patients with a median age of 85 months remained to be analysed. Thirty patients (68%) had a positive BC. A positive BC was associated with a higher rate of systemic complications (p=0.026) but not orthopaedic complications (p=0.159). Patients who had developed any complication had a significantly longer duration of IV antibiotic treatment compared to those without complications (p<0.001). The presenting CRP levels were significantly higher in patients that developed complications (p=0.004).

Patients with staphylococcal BSI in association with an OAI are at increased risk of developing systemic complications. In our cohort, a shorter duration of antibiotic use was not associated with the development of complications, which does not support the systematic use of long courses of IV antibiotics in s aureus BSI. Further research will be required to determine the ideal protocol for these patients.