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A Novel Method to Determine the Longitudinal Antibacterial Activity of Drug-Eluting Materials
Published on: March 3, 2023
Infection in orthopaedic implants
1Department of Microbiology, Edgware General Hospital, Middlesex.
Abstract:
The infection rate in hip prostheses should be less than 1.0% but in other joints is higher probably because of proximity to the skin surface and less experience in joint design. The organisms causing hip implant infection are Staphylococcus aureus 35%, S. epidermidis 15%, coliforms 25%, and anaerobes and others 25%; in other joints there may be a higher incidence of staphylococci. Clinical diagnosis is difficult since symptoms, X-rays and scans do not distinguish infection from loosening, but the erythrocyte sedimentation rate (ESR) moderately rises in infection. Treatment of deep infection by antibiotics alone is unlikely to succeed, but suppression of infection in patients unsuited to operation is possible. Surgeons should be encouraged to aspirate from the affected joint to obtain a bacteriological diagnosis; in the absence of this procedure broad spectrum antibiotics with good activity against S. aureus and S. epidermidis are required. Antibiotics must penetrate the membrane which forms in many patients at the implant or cement/bone interface but there is no evidence as to which antibiotics do so best. For prophylaxis there are three areas of uncertainty: (1) does antibiotic-impregnated cement provide additional effect to systemic antibiotics, since antibiotics can be found in the wound fluid after operation and gentamicin remains at the interface for many months?; (2) what proportion of late infections are haematogenous and do they demand prophylaxis for dental and surgical procedures?; (3) should greater protection from spread of staphylococci for the patient's skin and carrier sites be considered?
Insights
Preventing joint implant infections requires understanding common pathogens like Staphylococcus aureus and implementing effective antibiotic strategies. Diagnosis and prophylaxis remain challenging, necessitating further research into optimal treatments and preventative measures.
Area of Science:
- Orthopedic Surgery
- Infectious Diseases
- Biomaterials Science
Background:
- Joint implant infection rates exceed 1.0% in some procedures, potentially due to anatomical factors and design experience.
- Common causative organisms include Staphylococcus aureus, S. epidermidis, coliforms, and anaerobes, with variations between hip and other joint implants.
- Distinguishing infection from loosening is clinically challenging, though erythrocyte sedimentation rate (ESR) can indicate infection.
Purpose of the Study:
- To review the challenges in diagnosing and treating joint implant infections.
- To discuss the role of antibiotics in managing deep joint infections and prophylaxis.
- To identify areas of uncertainty in current prophylactic strategies for implant infections.
Main Methods:
- Literature review and synthesis of current knowledge on joint implant infections.
- Analysis of etiological agents and diagnostic challenges.
- Discussion of antibiotic treatment efficacy, penetration, and prophylactic measures.
Main Results:
- Antibiotic therapy alone is unlikely to cure deep infections, but can suppress them in non-operative candidates.
- Bacteriological diagnosis via aspiration is crucial; broad-spectrum antibiotics targeting S. aureus and S. epidermidis are recommended when diagnosis is absent.
- Antibiotic penetration through the implant/cement interface membrane is critical but not well-understood.
Conclusions:
- Effective management of joint implant infections requires accurate diagnosis and appropriate antibiotic selection, considering penetration capabilities.
- Significant uncertainties exist regarding antibiotic-impregnated cement efficacy, the need for prophylaxis against hematogenous infections, and skin staphylococcal carrier site management.
- Further research is needed to optimize antibiotic strategies for both treatment and prophylaxis to reduce joint implant infection rates.
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