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Recommendations for the clinical practice
Osteo-articular infections (OAI) on material
(prosthesis, implant, osteosynthesis)
Pr M Dupon CHU Bordeaux, France
Organized by the SPILF (Society of Infectious Pathology of French Language)
with the cooperation of the following learned societies :
•CMIT (College of the Academics of Infectious and tropical Diseases)
•GPIP (Group of Pediatric Infectious Pathology)
•SFAR (French Society of Anaesthetics and Intensive Care)
•SFHH (French Society of Hospital Hygiene)
•SFM (French Society of Microbiology)
•SFMN (French Society of Nuclear Medicine)
•SOFCOT (French Society of Orthopaedic Surgery)
•SOFMER (French Society of Physical Medicine and Rehabilitation)
•SFR (French Society of Radiology)
•SFR (French Society) of Rheumatology)
Oct 07
Déc 07
Avril 08
• Décision SPILF • Réunion
• Travail des
RPC
physique
experts
• Sollicitation des comité
• Réunion
organisation
sociétés
physique
savantes
• Choix
Audition
partenaires
questions,
experts
experts, groupe
• Désignation
de travail
comité
organisation
• Organisation,
méthodologie
Mai 08
• Rédaction V1
• Réunion
téléphoniques
(GT)
• Rédaction V2
Juillet - Août
08
• JNI Marseille
• Mise en ligne site
infectiologie.com
• Présentation
(hors chirurgie, • Recueil réponse
réparation
site web
médico-légale)
infectiologie.com
• Recueil
remarques
Septembre –
Octobre 08
Juin 08
RPC are medical and professional recommendations which can
be used to establish medical references, that is " standards of
practice " determining what it is suited and\or inappropriate to
make, during the implementation of preventive, diagnostic
and\or therapeutic strategies in given clinical situations ". These
standards can be used for:
• Improve the quality of the professional practices
• establish a reference table of a clinical audit
• be at the origin of tools of regulation in a conventional
frame(executive).
A rigorous and explicit approach must be applied to prepare "
medical and professional valid and credible recommendations.
• Rédaction V3
complète
• Réunions
téléphoniques
•Rédaction V 4
•Textes long et court
• Gradation
Nov Décembre
08
• Comité de lecture
Janvier
09
• Ecriture V5 finale
Février
09
• Réunion physique
et validation CO et
GT
• Modifications définitives ,
mise en forme , acceptation
par le groupe , mise en
ligne versions courte et
longue sur site
infectiologie.com
Mars 09
Mai 2009
Recommandation gradation
French High Authority of
Health (HAS) gradation
This gradation of the recommendations
based on the scientific level of proof of the
literature does not suppose obligatorily a
degree of force of these
recommendations. It can exist
recommendations of rank C or founded on
a professional agreement nevertheless
strong in spite of the absence of a
scientific support.
Scientific level of proof
provided by the literature
Rank of the
recommendations
Niveau 1
A
Evidence based
-Comparative randomized studies with high
power
- Meta-analyse of randomized comparative
studies
- Decision analysis based on well led studies
Niveau 2
- Randomized comparative studies with
low power
- Well undertaken non-randomized
comparative studies
- Cohort studies
Niveau 3
Case-witness studies
Niveau 4
B
Scientific presumption
C
Weak level of proof
- Comparative studies with important bias
- Retrospective studies
- Series of cases
OAI : Variable levels of proof, mostly weak
In the absence of precision, the suggested recommendations correspond with
a professional agreement
The expression of a professional agreement must translate a professional consensus
obtained by a formalized method (vote, Delphi method…)
PLAN
1. How to classify the various osteo-articular
infections on material?
2. How to assert the diagnosis of osteo-articular
infections on material?
3. What are the modalities of the therapeutic care?
4. What are prerequisites to minimize this type of
infections?
5. What medico-legal repair for the consequences
of the postoperative ostéo-articular infections on
material?
Question 1
How to classify the various osteoarticular infections on material?
Determining factors of a classification
Definition of the type of material
• Material of osteosynthesis
– Material (affixed to the bone: plate, intramedullary : nail;
rachis: inter-somatic stems, screws, grafts, cages, artificial ligaments)
– External fixing
• Prostheses
• Osseous substitutes and allografts
Length of infection evolution
• Ambiguity of acute or chronic infection terms
(clinician≠microbiologist≠surgeon)
• Time of diagnosis after the material implantation :
– early infection: <1 mois
– delayed infection: 2 to 6 months
– late infection: > 6 months
No universal classification
Determining factors of a classification
To take account of 7 fundamental points
• Mode of contamination (direct, hematogen, by contiguity)
• Chronology, allowing to make difference between post-operative
infection and hematogenous infection) (symptom-free period, time of
contamination,delay before management)
Prosthesis
implantation
Remote
infectious
site
Beginning
of medical
care
Infectious signs
at prosthesis
level
Free interval
Time of
contamination
Delay
before
management
temps
• Infectious state (knowledge of microorganisms, repercussion of the infection)
• Mechanical state of the infected site (loosened prosthesis or not,
consolidated fracture or not, material present or not, explantable or not)
• Localization of the infection (peripheral bone, joint, spinal column)
• State of skin and soft tissues
• State of the patient (functional and general, immune status, underlying ground)
Surgical Site Infection risk factors (1)
Opened fractures, significant risks
• tibial localization
• severity of the soft tissue lesions evaluated by classification of Gustilo (level 2)
Closed fractures of the long bones
• Diabetes = factor of difficulty of cicatrization after osteosynthesis of ankle or the foot
(level 2)
Orthopedic Surgery
• significant increase of the SSI risk
– age >65 years, existence of another infectious site, preoperative stay exceeding
4 days (level 2)
• weak increase of the SSI risk
– obesity, corticosteroid therapy, recent radiotherapy on operational site, healing
delay, hematoma occurence (level 2), rheumatoid polyarthritis (opinion of expert)
Spine
• diabetes
• perioperative plasma glucose level rise (level 3)
• Rheumatoid polyarthritis
no stop of the corticosteroid therapy (risk of acute suprarenal incapacity)
Methotrexate continuation does not increase the risk of SSI (level 1)
• Anti-TNF (HAS recommendations)
Stop of the anti-TNF 2 -5 half-lives before the intervention and until complete cutaneous healing.
Microbial epidemiology
Microorganisms
Coagulase <0 Staph.
Staphylococcus aureus
Streptococcus sp
Enterococcus sp
Gram négative bacilli
Anaerobic (P acnes)
Polymicrobial
No bacteria
Frequency (%)
Total
Osteosynthesis
prosthesis
matérial
30 à 43
12 à 23
9 à 10
3à7
3à6
2à4
10 à 12
10 à 11
Others: Candida, Corynebacteria, ..
22
30
1
3
10
5
27
2
Question 2
How to assert diagnosis of osteoarticular infections on material?
Clinical signs
Fistula = infection (level 3)
In the month following material implantation (level3)
• Pain of abnormal intensity
• Purulent discharge
• Scar disunity or necrosis
At a distance of the implementation (rank C)
• Pain
After a long free interval, in front of local signs,
look for a hematogenic infection (rank B)
Absence of inflammatory sign: do not eliminate an
infection (level 2)
Biological signs
No biological parameter is specific
Leucocytose: low VPP or VPN (level 2)
A normal value of VS and of CRP does not
eliminate an infection (expert opinion)
In the month after the implantation (rank C)
• Interest of CRP follow-up
• SR: no diagnostic value
After 3 months, suspicion of infection if: (rank B)
• SR > 22 - 30 mm, = 82-93 %, Sp = 84 %
• CRP > 10-13,5 mg / l, Se = 91-97 %, Sp = 86-92 %
• if no confusing factors
Radiological signs
Need for producing a standard plain radio even if
normal in 50% of the cases (rank B)
Signs to be sought (level 2):
• Sequestration
• Bone loosening (border width >2mm during 1 year)
• Blurred osteolytic lesions
• Periosteal reaction
• Presence of intra-articular gas
• Mobilisation or fracture of the
material
Se : 14%; Spe : 70%
Computed tomography and ultrasonography signs
Computed tomography (CT)
It is recommended to produce a
scanner with injection of contrast
product (rank B)
Ultrasonography
Signs : (level 2) :
• Intraarticular fluid accumulation or
around the implant
• Soft tissues thickening
Peripheral bone structure
osseous, soft tissues ++
Interferences in the vicinity
of metal implants
Signs to be sought (level 2):
• Periosteal reactions
• Blurred osteolytic lesions
• Soft tissue abnormalities
and collections
• Absence
of intra-articular effusion: strong NPV
MRI, arthrographic signs
Arthrography (iodine contrast)
Magnetic resonance imaging (MRI)
Sinus tract, paraartifacts making interpretation
articular collection,
difficult (material, immediate postcan be used to guide
operative period)joint aspiration and
Injection of Gadolinium ++
drainage procedures.
Signs: (level 2):
(level 2):
•Oedema of soft tissues (hypersignal T2)
•Intra-osseous or soft tissues collection
•Sinus tract (hypersignal T2)
•Articular effusion (hypersignal T2)
•Osseous sequestration (hyposignal)
Nuclear imaging
Bone scintigraphy with HDP-Tc99m: abnormal fixation in the 3 phases
(level 2): Se: 90-100%; Sp: 30-40%;VPN: 100%
Labelled leukocyte scan (or scan with anti-granulocyte antibodies) with
late images at 24h (level 2) improved Spe
Hybrid imaging single photon emission tomography/ computed
tomography (SPET/CT) increased spatial resolution
• Se: 81-97%; Sp: 89-100%
But persistence of increased uptake between 6-12 months after a
surgery (perform sulfo-colloids-Tc99m medullar scintigraphy to look for
absence of congruence)
For the spine, scintigraphy with
Gallium 67 (level 2)
Positron Emission
Tomography/CT imaging with
F-18 fluorodeoxyglucose is
under evaluation
(for chronic infection)
Imaging strategy
Early (<1 month) or hematogenous infection :
• restricted contribution
• puncture of a collection, with surgical asepsis, under control echo
or TDM if nonaccessible clinically (rank C)
Delayed or late Infection (>1 month)
1.Radio operator standard (simplicity, reproducibility, low cost)(rank B)
2.TDM with injection (rank B)
puncture of a collection, with surgical asepsis, under echo or TDM or arthroscanner if
clinically non-accessible (rank C)
3.Imaging with radioisotopes (bone scintigraphy associated to
scintigraphy with tagged PNM) (rank C)
Rachis
• MRI (early or late infection)
• Scintigraphy with Ga67 (delayed or late infection)(rank B)
• Absence of intra-articular effusion: strong NPV
Question 2
How to assert diagnosis of osteoarticular infections on material?
2.4 What is the contribution of the
microbiology and the anatomo-pathology?
How should diagnostic microbiological sampling be
performed? (1)
General principles
wait a minimum of 15 days after any antibiotherapy before any test,
to decrease the rate of false negative samples (except in case of sepsis
and after evaluating the risk for disseminated infection)(expert advice).
Pre-operative sampling
•It is strongly recommended
– not to sample with a swab on the scar, even if it is not healed.
– to perform pre-operative sampling with surgical asepsis if diagnosis doubt
• It is recommended
– to perform hemocultures and pre-operative sampling (puncture of a joint or of an abscess)
to rapidly initiate probabilistic antibiotherapy if general signs of sepsis
– not to perform sampling from the outlet of a fistula;
– to carry out hemocultures and a preoperative puncture in order to begin a probabilistic
antibiotherapy quickly if sepsis with general signs
– to carry out a puncture (vpp: 67-100%, vpn: 95%) in case of intra-articular effusion or
abscess; if not liquid, tissue biopsy with the true-cut (rank B)
– to collect part of the liquid in a hermetically closed sterile syringe and to inoculate
hémoculture vials for aerobes and anaerobes with the other part
How should diagnostic microbiological sampling be
performed? (2)
Per-operative sampling
• It is recommended
– to sample at the beginning of surgery, without any antibiotherapy,
and before any antibioprophylaxis.
– to perform 5 samplings at the level of macroscopically pathological
areas (grade B). These samplings may be liquid (pus, articular fluid)
or solid (granulomatous tissue, bone tissue, interposition tissue,
and any suspicious tissue).
– to change sampling tools between each sampled site.
Post-operative sampling
• In case of septic surgery, the positivity (with the same bacterium or
another) of cultured drain fluids seems to be linked with a higher risk of
infection relapse (level 2).
• In case of infection on external fixator pin, it is recommended to
perform sampling along the pin (level 2)
Microbiological techniques at the laboratory (1)
It is recommended to maintain incubation of culture media for
at least 14 days (expert advice).
Pre-operative samplings: articular fluid
• It is recommended to perform a cytological test (count and formula)
in the 2 h following sampling.
• >1,700 leucocytes/mm3 (Se 94%, Spe 88%) and >65% of PMN
neutrophils are strongly suggestive of infection on prosthesis in
articular fluid (level 2).
• It is recommended to seed the articular fluid on enriched agars to be
incubated in aerobic condition, under 5% of CO2 and in anaerobic
condition, and to inoculate hemoculture vials for aerobics and
anaerobes.
Microbiological techniques at the laboratory (2)
Per-operative sampling
•It is recommended
– to crush solid samples
– to seed on solid and liquid enriched media and eventually on a medium for
mycobacteria
– to perform direct examination to screen for PMN neutrophils and bacteria (Gram
staining)(Se : 6%, Spe ~ 100%).
– to freeze a part of samples (-80°C) for specific screening (fungus,
mycobacteria) and eventually for molecular biological techniques.
•It is recommended
– to identify all the different colonies, especially staphylococci slow culture(« small
colony variants »)
– to perform an antibiogram on the various types of colonies
isolated. It is necessary to asses glycopeptide MICs
on staphylococci and to check, if possible, the susceptibility
to oxacillin by screening for the mecA gene. It is necessary to
assess MICs of beta-lactams on the non-groupable streptococci.
New methods under evaluation : sonication, broad-range PCR (16S RNA)
Question 2
How to assert diagnosis of osteoarticular infections on material?
2.5 What are the arguments in favour of the
diagnosis? Definite infection and probably
excluded or not detectable infection
What data suggests the diagnosis (proved infection,
and non detectable or no infection)?
The working group, with an exploratory objective, has
judged useful to propose a binary classification
(proved infection /infection probably excluded or not
detectable) by considering that between the two, there
are several situations of possible infection for which
specific criteria cannot be defined
Consider that the initial clinical, biological, and/or
imaging approach, has allowed to suspect infection.
Consider that 5 samplings at least were performed
What data suggests the diagnosis (proved infection,
and non detectable or no infection)?
Fistula
ou
Infection
Pus in joint
or in
contact
with
prosthesis
or
definite
+
+
infection
probably
excluded or
not
detectable
-
-
ou
or
>0 per-op
samplings
Culture :
bacteria of
the skin
flora
>0 per-op
samplings
Culture :
bacteria not
3 per-op or
2 per-op
samplings
and 1 joint
punct.
1 per-op
sampling
or 1 joint
punct. or 1
hemoc
-
-
-
-
-
or
1 per op
Histology
>5PN / field
In 5 fields
x40
Joint fluid
>65% PN
belonging to
the skin flora
-
Question 3
What are the modalities of
therapeutic management?
What are the specificities of surgical treatment?
What is the rational for the therapeutic strategy? Biofilm
and biomaterials
The oxides contained in the material are responsible
for a secondary binding interaction surface for bacteria.
1. This process begins by a phenomenon of attraction-adhesion
during which bacteria are reversibly adsorbed on the material.
2. Then, the bacteria irreversibly colonize the material.
3. Bacteria develop a survival strategy within a dynamic entity defined as the biofilm,
made of a polysaccharidic substance secreted by bacteria called « slime » which
permits the definitive adherence of bacteria on the material.
The bacteria in the biofilm are organized in micro-colonies (« small
colony variant ») under the influence of inter-cellular communications
leading to a stationary growth phase due to the absence of ATP
production. This has for consequence:
• to limit the activity of some antibiotics which diffuse badly in the biofilm,
• the prolonged persistence of S. aureus in osteoblasts,
• escaping the immune defense mechanism.
This biofilm spreads to all the material surface in a few days explaining
• why a late surgical lavage is inefficient beyond 15 days
• the need to remove the prosthetic material, most of the time
Conservation of the prosthesis
It is recommended to use synovectomy and lavage
(«debridement») with implant retention in the case of very
recent infection (post-operative until D15, recent secondary
infection without loosening) (grade C).
It is not recommended to perform arthroscopic synovectomy
at the knee level but open arthrotomy (grade C) .
It is recommended to initiate antibiotherapy as soon as
bacteriological samplings have been made, first in a
probabilistic way, then adapted to documentation. The
recommended course length is 6 weeks. It is useless to
prolong beyond this.
Removal of implants
Hip:
• Use the previous surgical approach provided it can be extended
• Femoral implants can be extracted by endo-femoral route or by
femorotomy. It is recommended to perform femorotomy with large
vascularized bone fragment to improve the removal of cement, to
carefully close the femorotomy, and to osteosynthesize it with strong
cerclage.
• In case of intra-pelvic implant dislocation, of protrusion without bone
barrier, or intra-pelvic foreign bodies, it is strongly recommended to
asses cases with vascular risk (expert advice)
Knee and other joints:
• Same principle Removal of infected implants does not present any
specific problem.
One or two stage surgical revision ?
The majority of the authors recommends revision with 2
separate procedures even if the analysis of the litterature
does not objectively define indications for 1 or 2 stages.
What can be the choice criteria?
a.The certitude to have identified the bacterium : choose a single procedure
b.The bacterial profile
Bacteria for which antibiotherapy is limited (multi-resistant bacterium,
Pseudomonas aeruginosa), a mycobacterium, a fungus are indications for surgery
with two procedures.
c.Knowledge of the terrain
it seems that a patient with a long history of prosthesis infection is not a good
candidate for surgery in one procedure.
d.Problems with anesthesia
If the patient cannot undergo 2 procedures, a single surgery should be chosen after
discussion with the anesthesiologist, the surgeon, and the patient (or his family).
antibiotherapy [6/8 w-6 m[
One -stage
explantation+
réimplantation
Follow-up
t
Modalities surgery in the two procedures
What is the ideal delay for replacement?
There is no answer in the literature.
• In case of 2 short steps, the recommended delay is between 4 and 6 weeks during
which antibiotherapy is given without interruption. If bacteriological samplings are
negative after 15 d of culture, treatment may be interrupted.
antibiotherapy  6/8 w
explantation
reimplantation
suivi
t
Modalities surgery in the two procedures
What is the ideal delay for replacement?
• In case of 2 long steps, the delay range from 3 to 6 months knowing that after 3
months the functionnal result will be less good. The antibiotherapy must be
interrupted for 15 days before replacement. The usefulness of performing a
puncture before reimplantation is not confirmed. The antibiotherapy will be resumed
post-operatively and stopped if the culture is negative (after 15 days). (expert advice)
reimplantation
antibiotherapy
explantation
Antibiotic window culture
puncture
Follow-up
t
Additionnal histological and
microbiological samplings
Using a spacer : recommended with an essentially mechanical aim so as to facilitate
replacement of the prosthesis
Question 3
What are the modalities of
therapeutic management?
What are the specificities of anti-infectious
treatment?
What is the contribution of local antibiotherapy?
Strong doses of antibiotics may need to be used for therapy.
These types of cement is prepared by the surgeon extemporaneously in
the operating room (high-loaded) and are only recommended temporarily
in 2 presentations:
•cement beads used to fill a cavity.
•spacer with cement impregnated with antibiotics,
with the objective on one hand to maintain the space after removing
the implant and, on the other hand, to obtain local antibiotherapy
The kinetics of antibiotic release includes two phases: an immediate
phase during 7 days, with a high concentration and a secondary phase,
for the years with much weaker doses (sub-inhibiting doses).
The antibiotics used in cement are currently aminosides, vancomycin,
and clindamycin.and need to be active against identified bacterium
These cements must in no case dispense from a prescription of general
antibiotherapy and differ from the licensed antibiotic cement used for
prosthesis (re)implantation prophylaxis.
General principles for sytemic antibiotherapy (1)
Rules for optimal antibiotherapy (grade C) :
• based on culture results (in case of sepsis, probabilistic
antibiotherapy must be initiated after microbiological sampling),
• antibiotherapy initiated as a combination;
• achieving adequate plasmatic concentrations;
• using molecules with a good bone distribution in order to
achieve high concentration in the tissue;
• in case of infection due to staphylococci, never use
monotherapy with rifampicin, fusidic acid, fluoroquinolones,
and fosfomycin:
• linezolid, daptomycin, tigecyclin do not have marketing
authorisation for medicinal products in 2009, for the
treatment of bone and joint infections
General principles for sytemic antibiotherapy (2)
Mode of administration :
• It is recommended to administer the treatment initially intravenously.
No study has validated the duration of parenteral antibiotherapy. It is
usually 10 to 15 days long (expert advice).
• After this, it is recommended to switch to per os administration if
antibiotics :
–
–
–
–
have a good bioavailability and a good bone distribution,
have a good digestive tolerance
have no negative interaction
and if observance is good .
• If switching to oral treatment is impossible, it is mandatory to maintain
parenteral antibiotherapy as long as necessary, either in hospital or in
ambulatory treatment (grade C).
• In this case, it is recommended to insert a central catheter which may
be changed if the planned duration of antibiotherapy <6 weeks, or a
totally implanted central venous access device (TICVAD) if the
planned duration of antibiotherapy >6 weeks
General principles for sytemic antibiotherapy (4)
Duration of antibiotic treatment: (expert advice)
• minimum of 6 weeks.
• usual length reported in litterature : 6 to 12 weeks.
• maintaining antibiotherapy >12 weeks should be discussed
• variation according to surgical management
Surveillance of antibiotherapy :
• effectiveness assessed first on clinical data then on biological
parameters (CRP). It is recommended to dose antibiotics with high
inter-individual variations of blood concentrations. It is recommended
to dose aminosides (peak) and glycopeptides. If rifampicin used,
check that the antibiotic to which it is combined is not under dosed.
• tolerance assessed on clinical and on biological parameters
(CBC/platelets, hepatic parameters, renal function). It is also
necessary to measure blood concentrations of some antibiotics such
as aminosides (trough level).
3.3.2.2. Choosing antibiotic: meticillin resistant staphylococci
Initial IV antibiotherapy
(2 weeks)
(vancomyci or teicoplanin) + rifampicin
or
(vancomycin or teicoplanin) + fusidic acid.
or
(vancomycin or teicoplanin) + fosfomycin
or
(vancomycin or teicoplanin) + doxycyclin
or
(vancomycin or teicoplanin) + linezolid
or
clindamycin (if the strain is susceptible to erythromycin)
+ gentamicin
then
clindamycin + rifampicin
Switching to oral route if the
bacterium susceptibility allows it
rifampicin + fusidic acid
or
rifampicin + clindamycin6 (if the strain is susceptible to
erythromycin)
or
rifampicin + cotrimoxazole
or
rifampicin + (minocyclin8 or doxycyclin)
or
rifampicin + linezolid
doses and ways of administration of antibiotics
(for a normal renal and hepatic function)
Antibiotics (DCI)
Dose/24h
Regimen
amoxicillin
100-200 mg/kg
4-6 injections IVL
3-4 oral intakes
cloxacillin
oxacillin
100-200 mg/kg (doses superior to
approval – expert advice)
4-6 injections IVL
amoxicillin- clavulanic
acid
100 mg/kg
4-6 injections IVL
3-4 oral intakes
cefazolin
60-80 mg/kg
4-6 injections IVL or
Infusion pump1
cefotaxime
100-150 mg/kg
3 injections IVL
ceftriaxone
30-35 mg/kg
1-2 injection(s) IVL
ceftazidime
100 mg/kg
Infusion pump1 or
3-4 injections IVL
imipenem
2à3g
3 to 4 administrations IV or IM
meropenem
3à6g
3 administrations IV
vancomycin2
40-60 mg/kg
Infusion pump1
teicoplanin2
12 mg/kg/12h for 3-5 days
then 12 mg/kg
IVL, IM or s/c
gentamicin3
3-4 mg/kg
1 administration IV 30 minutes
amikacin3
15 mg/kg
1 administration IV 30 minutes
Empirical antibiotherapy
Antibiotic scheme before obtaining per operative
bacteriological results when there is no reliable documentation
in the patient’s history, when there are general signs
indicating the emergency of treatment (sepsis), or for culture
negative infection.
suggested associations by order of preference, must be
adapted according to the microbial ecology of each institution
(expert advice):
•
•
•
•
ureidopenicillin/ beta-lactamase inhibitor + vancomycin
3rd generation cephalosporin + vancomycin
carbapenem (except ertapenem) + vancomycin
3rd generation cephalosporin + fosfomycin.
Suppressive antibiotherapy
(grade C)
indefinite long term oral antibiotics (≥1 year),
palliative but not curing the infection,
only with well-tolerated molecules and easy
administration (per os)
in the minority of patients in whom surgery is
precluded or declined,
available bacterial target
Follow-up of patients: organization and structures
optimal management requires :
• an accurate clinical evaluation
• a microbiological diagnosis requiring validated techniques both for
sampling and for identification of micro-organisms
• a therapeutic strategy defined during multidisciplinary staff
meetings
• implementing specific treatments especially for surgical and antiinfectious goals in the short term
• a global continuous and clear management until coming back home,
with a healthcare file including all the detail care
• continuous information of the patient
• interregional reference centers for the management of complex bone
and joint infections
Is cure possible?
• the infectious and functional criteria should be taken into account.
• there is no criterion defining infection cure. It is recommended to
follow-up patient between 1-2 years after the end of antibiotherapy
• the functional result is obtained by assessing mobility, pain, strength,
balance, and walking (specific score for joints).
Question 4
What are the pre-requisites to pour
minimize these types of infection?
What are the standards in terms of healthcare environment
control? Hygiene procedures? Environmental surveillance?
No formal proof of so-called “septic” units effectiveness on
the prevention of SSI
The procedures to be applied are the same that those
described during the non-septic surgery
They concern:
• Management of potential portals of entry during care giving
• Air treatment efficiency, (expert recommendations by the French Society for Hospital
Hygiène Société Française d’Hygiène Hospitalière –SFHH- 2004,
• Healthcare personnel discipline,
• Effectiveness of professional wear and operative sheets,
• Managing surgical instruments,
• Cleaning surfaces,
• Surgical block architecture,
• Environmental surveillance.
.What measures should be undertaken for the preparation
of the patient before surgery ? (1)
These measures concern preparation for an orthopedic
intervention as in a non-infected patient. (grade C)
Specific risk factors a priori accessible to corrective
treatment :
•
•
•
•
Length of pre-operative hospitalization >4 days
Tobacoo, diabetes, obesity, denutrition
Rheumatoid polyarthritis treatments
No systematical screen for nasal carriage of S. aureus
• When Staphylococcus aureus SSI rates remain unusually high (>2%), it
is recommended to perform nasal swabs of caregivers and patients.
• Nasal screening for methicillin resistant S aureus is recommended in patients who
must undergo planned cardiac or orthopedic surgery, transferred from ICU, long
and median stay structure, or in case of chronic cutaneous lesions.
• It is not recommended to use mupirocin systematically pour to prevent the onset of
SSI in MRSA carriers.
What measures should be undertaken for the preparation of
the patient before surgery ?(2)
Global prevention measures against infection in orthopedic
and trauma surgery:
• 1. Recommendations for skin care and preparation were specified in
the french consensus conference «pre-operative management of
infectious risk» (SFHH).
• 2. Systemic route antibioprophylaxis was codified by the 1992 french
consensus conference «antibioprophylaxis in surgical settings in the
adult», and updated in 1999 (SFAR).
• 3. Per-operative normothermia is applicable to orthopedic and
traumatological surgery.
• 4. Peri-operative hyperoxygenation could be used for orthopedic and
traumatological surgery.
• 5. It is recommended to use local antibiotherapy for prophylaxis
such as antibiotic impregnated cements for 1st intention arthroplasty
• 6. it is not necessary to carry out antibioprophylaxis in a septic
patient in order to avoid false negativity of the microbiology sample
What measures are undertaken to fight the risk of cross
transmission when managing a patient infected in an
orthopedic surgical block? ?
Should there be a chronological order for surgery?
• There is no need to impose a specific order of passage if hygiene
precautions are observed (grade C).
What precautions should be taken in the surgical block after
operating a septic patient?
• It is recommended to perform the usual cleaning program and to
respect the time needed for particle decontamination of the operating
room between two interventions
• In case of Multi Resistant Bacteria, there are no supplementary
precautions to take for the cleaning of the rooms but complementary
precautions of the «contact» type must be respected (grade C).
• No «septic» operating room is necessary if cleaning procedures
between two interventions with various contamination are observed
and if rooms are equipped with efficient ventilation systems (grade C)
• There is no need to have separate post surgery surveillance rooms for
patients having undergone different surgeries,
Thanks
RPC are available at www. infectiologie.com and will be published in Médecine et
Maladies Infectieuses (Elsevier)
RPC are available at www. infectiologie.com and will be published in Médecine et
Maladies Infectieuses (Elsevier)