First Guidelines for Managing Prosthetic Joint Infections
The Infectious Diseases Society of America has published a set of clinical practice guidelines for the evaluation and management of prosthetic joint infections (PJIs).
The guidelines, the first on the subject issued by the society, call for close collaboration among all clinicians involved in a patient's care.
"It is anticipated that consideration of these guidelines may help reduce morbidity, mortality, and the costs associated with PJI," lead author Douglas R. Osmon, MD, and colleagues write in the guidelines, published online December 6 in Clinical Infectious Diseases. Dr. Osmon is an infectious diseases expert at the Mayo Clinic Medical School in Rochester, Minnesota.
Although total hip arthroplasty (THA) and total knee arthroplasty (TKA) can significantly improve quality of life, PJI is "one of the most serious complications of prosthetic joint implantation," the authors explain. Patients may require repeat surgery, prolonged courses of antibiotics, and in the most serious cases, amputation.
The cumulative incidence of PJIs is 1% to 2% during the life of the joint. In other words, of the 1 million THAs and TKAs performed each year, about 20,000 patients will develop PJIs. By 2030, it is projected that 4 million THAs and TKAs will be performed annually in the United States, with the incidence of PJIs rising accordingly.
Despite the growing popularity of these procedures, many unanswered questions persist regarding the diagnosis and optimal management of PJIs, the authors state.
Where enough evidence was available, the new guidelines are offered in the form of consensus statements. Where the evidence was thinner, the panel provides expert opinions, "realizing that the amount of data to support a specific recommendation is limited, and that there are diverse practice patterns which seem to be equally effective for a given clinical problem."
The panel emphasizes that effective intervention requires a strong collaborative approach among the various clinicians involved in a patient's care, including plastic and orthopaedic surgeons, infectious disease specialists, and internists.
The panel developed the guidelines by conducting an extensive review and analysis of literature in the field published between 1966 and 2011. The strength of the recommendations and the quality of the evidence were assigned letter and numeric grades, respectively, according to the volume and quality of the studies and reviews available. The major issues the panel considered were preoperative evaluation and diagnosis; surgical strategies; medical treatment after debridement, resection arthroplasty, and reimplantation; and medical treatment after amputation.
For each question, the panel provides its recommendations followed by a summary of the evidence used to develop those recommendations.
These guidelines are a good complement to the ones released by the American Academy of Orthopaedic Surgeons in 2010-2011, according to Andrew Urquhart, MD, associate professor of orthopaedic surgery at the University of Michigan Medical School in Ann Arbor. "They are designed for a wider audience that includes primary care and infectious disease physicians and address the issue of when the clinician should consider the possibility of a prosthetic joint infection in a patient."
PJIs are "a huge problem and a huge cost to society," Dr. Urquhart told Medscape Medical News. "As we are seeing more and more hip and knee replacements performed, and the association of prosthetic joint infections with obesity and tobacco use, I think everybody, whether they are a primary care physician or an infectious disease specialist or a community or academic orthopaedic physician, should have a high index of suspicion for these infections, and as long as everyone is on the same page, patients will get the highest level of care."
Guidelines are important because they "minimize the variability in practice that in the past confounded accurate comparison and interpretation of clinical research outcomes on the subject. They basically allow all interested parties to speak the same language," Erik N. Hansen, MD, assistant professor of orthopaedic surgery in the Division of Adult Reconstructive Surgery, University of California, San Francisco, School of Medicine, told Medscape Medical News via email. "Standardizing management practices provides clinicians with an accurate baseline by which we can judge and measure our treatment effects and make informed decisions when and how to alter our practices. Without standardization, it is very difficult to determine what factors contributed to the success or failure of a given patient's course, and therefore it is hard to move the field forward."
Unanswered questions include risk factors for developing PJIs, epidemiologic information best suited for improving the diagnosis and management of PJIs even further, the best laboratory tests and biomarkers for diagnosing the infections, medical and surgical algorithms for optimal management, and preventive methods such as the use of prophylactic antibiotics in dental procedures and higher oxygen therapy administered during surgery, the authors write. The authors plan to review the guidelines annually, with revisions recommended when deemed appropriate.
Dr. Osmon has received research grants from Cubist Pharmaceuticals and Ortho-McNeil. Other authors of the guidelines also report receiving funding from Cubist Pharmaceuticals and Ortho-McNeil, as well as Orthopedic Research. One author receives royalties from the Stryker Corporation and has been a board member of Pfizer as well as served on the speakers' bureaus of Pfizer and Synthes. One author is a member of the board of Basilea. One author was awarded a Pfizer Visiting Professorship to the Division of Allergy and Infectious Diseases at the University of Washington, Seattle. Dr. Urquhart and Dr. Hansen have disclosed no relevant financial relationships.
Clin Infect Dis. Published online December 6, 2012. Full text
Medscape Medical News © 2012 WebMD, LLC
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