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Enterococcal periprosthetic joint infection: clinical and microbiological findings from an 8-year retrospective
Nora Renz1, Rihard Trebse2, Doruk Akgün1
1Center for Musculoskeletal Surgery (CMSC), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
Background:
Treatment of enterococcal periprosthetic joint infections (PJI) is challenging due to non-standardized management strategies and lack of biofilm-active antibiotics. The optimal surgical and antimicrobial therapy are unknown. Therefore, we evaluated characteristics and outcome of enterococcal PJI.
Methods:
Consecutive patients with enterococcal PJI from two specialized orthopedic institutions were retrospectively analyzed. Both institutions are following the same diagnostic and treatment concepts. The probability of relapse-free survival was estimated using Kaplan-Meier survival curves and compared by log-rank test. Treatment success was defined by absence of relapse or persistence of PJI due to enterococci or death related to enterococcal PJI. Clinical success was defined by the infection-free status, no subsequent surgical intervention for persistent or perioperative infection after re-implantation and no PJI-related death within 3 months.
Results:
Included were 75 enterococcal PJI episodes, involving 41 hip, 30 knee, 2 elbow and 2 shoulder prostheses. PJI occurred postoperatively in 61 episodes (81%), hematogenously in 13 (17%) and by contiguous spread in one. E. faecalis grew in 64 episodes, E. faecium in 10 and E. casseliflavus in one episode(s). Additional microorganism(s) were isolated in 38 patients (51%). Enterococci were susceptible to vancomycin in 73 of 75 isolates (97%), to daptomycin in all 75 isolates, and to fosfomycin in 21 of 22 isolates (96%). The outcome data was available for 66 patients (88%). The treatment success after 3 years was 83.7% (95% confidence interval [CI]; 76.1-96.7%) and the clinical success was 67.5% (95% CI; 57.3-80.8%). In 11 patients (17%), a new PJI episode caused by a different pathogen occurred. All failures occurred within 3 years after surgery.
Conclusion:
About half of enterococcal PJI were polymicrobial infections. The treatment success was high (84%). All treatment failures occurred within the first 3 years after revision surgery. Interestingly, 17% of patients experienced a new PJI caused by another pathogen at a later stage.
Trial Registration:
The study was retrospectively registered with the public clinical trial identification NCT0253022 at https://www.clinicaltrials.gov on 15 July 2015.
Insights
Treatment for enterococcal periprosthetic joint infections (PJI) shows high success rates, with most failures occurring within three years. Some patients develop new infections from different pathogens later on.
Area of Science:
- Orthopedic Surgery
- Infectious Diseases
- Microbiology
Background:
- Enterococcal periprosthetic joint infections (PJI) present treatment challenges due to non-standardized strategies and a lack of biofilm-active antibiotics.
- Optimal surgical and antimicrobial therapies for enterococcal PJI remain undefined.
- This study evaluated the characteristics and outcomes of enterococcal PJI to inform treatment approaches.
Purpose of the Study:
- To characterize enterococcal periprosthetic joint infections (PJI).
- To evaluate treatment strategies and outcomes for enterococcal PJI.
- To identify factors influencing treatment success and failure in enterococcal PJI.
Main Methods:
- Retrospective analysis of consecutive patients with enterococcal PJI from two specialized orthopedic institutions.
- Kaplan-Meier survival analysis to estimate relapse-free survival, compared using log-rank test.
- Defined treatment success by absence of relapse, persistence of infection, or death related to enterococcal PJI; clinical success included infection-free status and absence of PJI-related death within 3 months.
Main Results:
- 75 enterococcal PJI episodes were analyzed, predominantly affecting hip and knee prostheses.
- Enterococcus faecalis was the most common species; 51% of cases involved additional microorganisms.
- High susceptibility to daptomycin (100%) and vancomycin (97%) was observed. Treatment success after 3 years was 83.7%, with clinical success at 67.5%.
- All treatment failures occurred within 3 years; 17% of patients experienced a new PJI caused by a different pathogen later.
Conclusions:
- Enterococcal PJI are often polymicrobial, necessitating comprehensive treatment strategies.
- High treatment success rates (84%) were achieved, indicating effective management protocols.
- Treatment failures predominantly occurred within the initial 3 years post-surgery, with a notable incidence of subsequent infections by different pathogens.
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