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Antibiotics in Orthopedic Infections

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A special issue of Antibiotics (ISSN 2079-6382). This special issue belongs to the section "Antibiotics Use and Antimicrobial Stewardship".

Deadline for manuscript submissions: closed (15 August 2021) | Viewed by 28879

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Prof. Dr. Konstantinos Anagnostakos

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Guest Editor

Zentrum für Orthopädie und Unfallchirurgie, Klinikum Saarbrücken, Saarbrücken, Germany
Interests: primary and revision joint arthroplasty of hip and knee; diagnostics and therapy of bone and joint infections; local antibiotic therapy; antibiotic-loaded bone cement
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Prof. Dr. Bernd Fink

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Guest Editor

Department for Joint Replacement, Rheumatoid and General Orthopaedics, Orthopaedic Clinic Markgröningen, Markgröningen, Germany
Interests: primary and revision joint arthroplasty of hip and knee; diagnostics and therapy of bone and joint infections
Special Issues, Collections and Topics in MDPI journals

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Dear Colleagues,

The management of orthopedic infections has been continuously gaining interest in the past few years. Various developments of new techniques have enhanced the pre- and intraoperative diagnostics, leading to an increased number of identified pathogen organisms in septic but also assumed aseptic revisions. In addition to surgical debridement, knowledge about the systemic and local antibiotic therapy of bone and joint infections is an indispensable premise for a successful outcome.

This Special Issue of Antibiotics deals with these topics. The issue welcomes original research papers, short communications, reviews, case reports, and perspectives.

Potential topics for this Special Issue include but are not limited to:

Local antibiotic therapy in orthopedic infections;
Antibiotic-loaded bone cement;
Systemic antibiotic therapy in bone and joint infections;
Antibiotic resistance of pathogen organisms of orthopedic infections;

Role of biofilm in orthopedic infections

Prof. Dr. Konstantinos Anagnostakos
Prof. Dr. Bernd Fink
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Antibiotics is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2900 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

antibiotic therapy
orthopedic infections
bone and joint infections
antibiotic resistance

Published Papers (11 papers)

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Editorial

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3 pages, 158 KiB

Open AccessEditorial

Antibiotics in Orthopedic Infections

by Konstantinos Anagnostakos and Bernd Fink

Antibiotics 2021, 10(11), 1297; https://doi.org/10.3390/antibiotics10111297 - 25 Oct 2021

Cited by 1 | Viewed by 1549

Abstract

The management of orthopedic infections has continuously been gaining increasing interest in the past few years [...] Full article

(This article belongs to the Special Issue Antibiotics in Orthopedic Infections)

Research

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14 pages, 541 KiB

Open AccessArticle

Detailed Revision Risk Analysis after Single- vs. Two-Stage Revision Total Knee Arthroplasty in Periprosthetic Joint Infection: A Retrospective Tertiary Center Analysis

by Lars-Rene Tuecking, Julia Silligmann, Peter Savov, Mohamed Omar, Henning Windhagen and Max Ettinger

Antibiotics 2021, 10(10), 1177; https://doi.org/10.3390/antibiotics10101177 - 27 Sep 2021

Cited by 10 | Viewed by 1967

Abstract

Periprosthetic joint infection (PJI) remains one of the most common causes of revision knee arthroplasty. Controversy continues to surround the proper operative technique of PJI in knee arthroplasty with single- or two-stage replacement. Significant variations are seen in the eradication rates of PJI and in implant survival rates. This detailed retrospective analysis of a single tertiary center is intended to provide further data and insight comparing single- and two-stage revision surgery. A retrospective analysis of all revision total knee arthroplasty (TKA) surgeries from 2013 to 2019 was performed and screened with respect to single- or two-stage TKA revisions. Single- and two-stage revisions were analyzed with regard to implant survival, revision rate, microbiological spectrum, and other typical demographic characteristics. A total of 63 patients were included, with 15 patients undergoing single-stage revision and 48 patients undergoing two-stage revision. The mean follow-up time was 40.7 to 43.7 months. Statistically, no difference was found between both groups in overall survival (54.4% vs. 70.1%, p = 0.68) and implant survival with respect to reinfection (71.4% vs. 82.4%, p = 0.48). Further, high reinfection rates were found for patients with difficult-to-treat organisms and low- to semi-constrained implant types, in comparison to constrained implant types. A statistically comparable revision rate for recurrence of infection could be shown for both groups, although a tendency to higher reinfection rate for single-stage change was evident. The revision rate in this single-center study was comparably high, which could be caused by the high comorbidity and high proportion of difficult-to-treat bacteria in patients at a tertiary center. In this patient population, the expectation of implant survival should be critically discussed with patients. Full article

(This article belongs to the Special Issue Antibiotics in Orthopedic Infections)

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13 pages, 294 KiB

Open AccessArticle

Superinfection with Difficult-to-Treat Pathogens Significantly Reduces the Outcome of Periprosthetic Joint Infections

by Ali Darwich, Franz-Joseph Dally, Khaled Abu Olba, Elisabeth Mohs, Sascha Gravius, Svetlana Hetjens, Elio Assaf and Mohamad Bdeir

Antibiotics 2021, 10(10), 1145; https://doi.org/10.3390/antibiotics10101145 - 23 Sep 2021

Cited by 4 | Viewed by 2007

Abstract

Periprosthetic joint infection (PJI) is a serious complication after total joint arthroplasty. In the course of a PJI, superinfections with pathogens that do not match the primary infecting micro-organism may occur. To our knowledge, there are no published data on the outcome of such infections in the literature. The aim of this study was to assess the outcome of PJI with superinfections with a difficult-to-treat (DTT) pathogen. Data of 169 consecutive patients with PJI were retrospectively analyzed in this single-center study. Cases were categorized into: Group 1 including non-DTT-PJI without superinfection, Group 2 DTT-PJI without superinfection, Group 3 non-DTT-PJI with DTT superinfection, and Group 4 non-DTT-PJI with non-DTT superinfection. Group 3 comprised 24 patients and showed, after a mean follow-up of 13.5 ± 10.8 months, the worst outcome with infection resolution in 17.4% of cases (p = 0.0001), PJI-related mortality of 8.7% (p = 0.0001), mean revision rate of 6 ± 3.6 (p < 0.0001), and duration of antibiotic treatment of 71.2 ± 45.2 days (p = 0.0023). PJI caused initially by a non-DTT pathogen with a superinfection with a DTT pathogen is significantly associated with the worst outcome in comparison to non-DTT-PJI, PJI caused initially by a DTT pathogen, and to non-DTT-PJI with a non-DTT superinfection. Full article

(This article belongs to the Special Issue Antibiotics in Orthopedic Infections)

12 pages, 260 KiB

Open AccessArticle

Delayed Rifampin Administration in the Antibiotic Treatment of Periprosthetic Joint Infections Significantly Reduces the Emergence of Rifampin Resistance

by Ali Darwich, Franz-Joseph Dally, Mohamad Bdeir, Katharina Kehr, Thomas Miethke, Svetlana Hetjens, Sascha Gravius, Elio Assaf and Elisabeth Mohs

Antibiotics 2021, 10(9), 1139; https://doi.org/10.3390/antibiotics10091139 - 21 Sep 2021

Cited by 2 | Viewed by 2254

Abstract

Rifampin is one of the most important biofilm-active antibiotics in the treatment of periprosthetic joint infection (PJI), and antibiotic regimens not involving rifampin were shown to have higher failure rates. Therefore, an emerging rifampin resistance can have a devastating effect on the outcome of PJI. The aim of this study was to compare the incidence of rifampin resistance between two groups of patients with a PJI treated with antibiotic regimens involving either immediate or delayed additional rifampin administration and to evaluate the effect of this resistance on the outcome. In this retrospective analysis of routinely collected data, all patients who presented with an acute/chronic PJI between 2018 and 2020 were recorded in the context of a single-center comparative cohort study. Two groups were formed: Group 1 included 25 patients with a PJI presenting in 2018–2019. These patients received additional rifampin only after pathogen detection in the intraoperative specimens. Group 2 included 37 patients presenting in 2019–2020. These patients were treated directly postoperatively with an empiric antibiotic therapy including rifampin. In all, 62 patients (32 females) with a mean age of 68 years and 322 operations were included. We found a rifampin-resistant organism in 16% of cases. Rifampin resistance increased significantly from 12% in Group 1 to 19% in Group 2 (p < 0.05). The treatment failure rate was 16% in Group 1 and 16.2% in Group 2 (p = 0.83). The most commonly isolated rifampin-resistant pathogen was Staphylococcus epidermidis (86%) (p < 0.05). The present study shows a significant association between the immediate start of rifampin after surgical revision in the treatment of PJI and the emergence of rifampin resistance, however with no significant effect on outcome. Full article

(This article belongs to the Special Issue Antibiotics in Orthopedic Infections)

11 pages, 267 KiB

Open AccessArticle

Periprosthetic Infections of the Shoulder Joint: Characteristics and 5-Year Outcome of a Single-Center Series of 19 Cases

by Mohamad Bdeir, Franz-Joseph Dally, Elio Assaf, Sascha Gravius, Elisabeth Mohs, Svetlana Hetjens and Ali Darwich

Antibiotics 2021, 10(9), 1125; https://doi.org/10.3390/antibiotics10091125 - 18 Sep 2021

Cited by 5 | Viewed by 2197

Abstract

Periprosthetic shoulder infection (PSI) remains a devastating complication after total shoulder arthroplasty (TSA). Furthermore, there is a paucity in the literature regarding its diagnostic and therapeutic management, especially the absence of therapy concepts devised exclusively for PSI. The aim of the presenting study is to examine the characteristics and outcome of patients with PSI who were treated according to well-established algorithms developed originally for periprosthetic joint infection (PJI) of the hip and knee and determine if these algorithms can be applied to PSI. This single-center case series included all patients with a PSI presenting between 2010 and 2020. Recorded parameters included age, sex, affected side, BMI, ASA score, Charlson comorbidity index, preoperative anticoagulation, indication for TSA (fracture, osteoarthritis or cuff-arthropathy), and type of infection (acute or chronic PSI). The outcome was divided into treatment failure or infect resolution. Staphylococcus epidermidis and aureus were the commonest infecting pathogens. Acute PSI was mainly treated with debridement, irrigation, and retention of the prosthesis (DAIR) and chronic cases with two/multiple-stage exchange. The treatment failure rate was 10.5%. C-reactive protein was preoperatively elevated in 68.4% of cases. The mean number of operative revisions was 3.6 ± 2.6, and the mean total duration of antibiotic treatment was 72.4 ± 41.4 days. The most administered antibiotic was a combination of clindamycin and fluoroquinolone. In summary, the data of the current study suggest that therapeutical algorithms and recommendations developed for the treatment of PJI of the hip and knee are also applicable to PSI. Full article

(This article belongs to the Special Issue Antibiotics in Orthopedic Infections)

10 pages, 1284 KiB

Open AccessArticle

Does Vancomycin Wrapping in Anterior Cruciate Ligament Reconstruction Affect Tenocyte Activity In Vitro?

by Rocco Papalia, Claudia Cicione, Fabrizio Russo, Luca Ambrosio, Giuseppina Di Giacomo, Gianluca Vadalà and Vincenzo Denaro

Antibiotics 2021, 10(9), 1087; https://doi.org/10.3390/antibiotics10091087 - 8 Sep 2021

Cited by 9 | Viewed by 1940

Abstract

Knee septic arthritis is a devastating complication following anterior cruciate ligament (ACL) reconstruction. To prevent this issue, intraoperative soaking of ACL grafts with vancomycin is often performed before implantation. Although vancomycin cytotoxicity has been reported several times, little is known about its biological effect on tenocytes. The aim of this study was to evaluate the in vitro effects of vancomycin on human primary tenocytes (hTCs). hTCs were isolated from hamstring grafts of four patients undergoing ACL reconstruction. After expansion, hTCs were treated with different concentrations of vancomycin (0, 2.5, 5, 10, 25, 50 and 100 mg/mL) for 10, 15, 30 and 60 min. In vitro cytotoxicity was evaluated measuring metabolic activity, cell toxicity, and apoptosis. hTC metabolic activity was affected starting from 10 mg/mL vancomycin and decreased markedly at 100 mg/mL. Cell viability remained unaffected only at a concentration of 2.5 mg/mL vancomycin. Vancomycin cytotoxicity was detected from 10 mg/mL after 15 min and at all higher concentrations. Cells died when treated with concentrations higher than 5 mg/mL. The use of this antibiotic on tendons to prevent infections could be useful and safe for resident cells if used at a concentration of 2.5 mg/mL for up to 1 h of treatment. Full article

(This article belongs to the Special Issue Antibiotics in Orthopedic Infections)

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12 pages, 2176 KiB

Open AccessArticle

New Technique for Custom-Made Spacers in Septic Two-Stage Revision of Total Hip Arthroplasties

by Moritz Mederake, Ulf Krister Hofmann and Bernd Fink

Antibiotics 2021, 10(9), 1073; https://doi.org/10.3390/antibiotics10091073 - 4 Sep 2021

Cited by 6 | Viewed by 2194

Abstract

The choice of spacer in the interim phase of two-stage revision hip arthroplasty is crucial. Conventional concepts like a Girdlestone situation, handformed or preformed bone cement spacers show complications like soft-tissue contractions, abrasion of bone cement particles, dislocation, breakage and a low level of mobility in the interim phase. To address these disadvantages, the senior author developed a new technique for custom-made spacers in septic two-stage revision of total hip arthroplasties using prosthetic implants with individualized antibiotic mixture in the cement applying a mechanical inferior cementation method. The aim of this study was to evaluate the results of these spacers with respect to their non-inferiority in terms of reinfection and survival-rate of the new implant and to describe the complications associated with this procedure. Our collective consisted of 130 patients with a median follow-up of nearly five years. With a reinfect-free rate of 92% and a spacer-related complication rate of 10% (8% articular dislocation, 1% periprosthetic joint fracture, 1% breakage), this procedure seems to be safe and superior regarding complications compared to conventional concepts. Further studies are necessary to show the clinical benefit of this procedure. Full article

(This article belongs to the Special Issue Antibiotics in Orthopedic Infections)

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17 pages, 831 KiB

Open AccessArticle

Occurrence of Rare Pathogens at the Site of Periprosthetic Hip and Knee Joint Infections: A Retrospective, Single-Center Study

by Konstantinos Anagnostakos, Christoph Grzega, Ismail Sahan, Udo Geipel and Sören L. Becker

Antibiotics 2021, 10(7), 882; https://doi.org/10.3390/antibiotics10070882 - 20 Jul 2021

Cited by 7 | Viewed by 4369

Abstract

The frequency and clinical relevance of rare pathogens at the site of periprosthetic infections of the hip and knee joint and their antibiotic resistance profiles have not yet been assessed in-depth. We retrospectively analyzed all periprosthetic hip and knee joint infections that occurred between 2016 and 2020 in a single center in southwest Germany. Among 165 infections, 9.7% were caused by rare microorganisms such as Veilonella sp., Pasteurella sp., Pantoea sp., Citrobacter koseri, Serratia marcescens, Parvimonas micra, Clostridium difficile, Finegoldia magna, Morganella morganii, and yeasts. No resistance to piperacillin/tazobactam, carbapenemes, fluoroquinolones, or gentamicin was observed. Some bacteria displayed resistance to ampicillin, ampicillin/sulbactam, and cefuroxime. We present follow-up data of patients with infections due to rare pathogens and discuss the importance of close, interdisciplinary collaboration between orthopedic surgeons and clinical microbiologists to carefully select the most appropriate anti-infective treatment regimens for the increasing number of patients with such infections. Full article

(This article belongs to the Special Issue Antibiotics in Orthopedic Infections)

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13 pages, 3655 KiB

Open AccessArticle

The Graphical Representation of Cell Count Representation: A New Procedure for the Diagnosis of Periprosthetic Joint Infections

by Bernd Fink, Marius Hoyka, Elke Weissbarth, Philipp Schuster and Irina Berger

Antibiotics 2021, 10(4), 346; https://doi.org/10.3390/antibiotics10040346 - 24 Mar 2021

Cited by 4 | Viewed by 3718

Abstract

Aim: This study was designed to answer the question whether a graphical representation increase the diagnostic value of automated leucocyte counting of the synovial fluid in the diagnosis of periprosthetic joint infections (PJI). Material and methods: Synovial aspirates from 322 patients (162 women, 160 men) with revisions of 192 total knee and 130 hip arthroplasties were analysed with microbiological cultivation, determination of cell counts and assay of the biomarker alpha-defensin (170 cases). In addition, microbiological and histological analysis of the periprosthetic tissue obtained during the revision surgery was carried out using the ICM classification and the histological classification of Morawietz and Krenn. The synovial aspirates were additionally analysed to produce dot plot representations (LMNE matrices) of the cells and particles in the aspirates using the hematology analyser ABX Pentra XL 80. Results: 112 patients (34.8%) had an infection according to the ICM criteria. When analysing the graphical LMNE matrices from synovia cell counting, four types could be differentiated: the type “wear particles” (I) in 28.3%, the type “infection” (II) in 24.8%, the “combined” type (III) in 15.5% and “indeterminate” type (IV) in 31.4%. There was a significant correlation between the graphical LMNE-types and the histological types of Morawietz and Krenn (p < 0.001 and Cramer test V value of 0.529). The addition of the LMNE-Matrix assessment increased the diagnostic value of the cell count and the cut-off value of the WBC count could be set lower by adding the LMNE-Matrix to the diagnostic procedure. Conclusion: The graphical representation of the cell count analysis of synovial aspirates is a new and helpful method for differentiating between real periprosthetic infections with an increased leukocyte count and false positive data resulting from wear particles. This new approach helps to increase the diagnostic value of cell count analysis in the diagnosis of PJI. Full article

(This article belongs to the Special Issue Antibiotics in Orthopedic Infections)

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13 pages, 5671 KiB

Open AccessArticle

Are Cement Spacers and Beads Loaded with the Correct Antibiotic(s) at the Site of Periprosthetic Hip and Knee Joint Infections?

by Konstantinos Anagnostakos and Ismail Sahan

Antibiotics 2021, 10(2), 143; https://doi.org/10.3390/antibiotics10020143 - 1 Feb 2021

Cited by 4 | Viewed by 2514

Abstract

The optimal impregnation of antibiotic-loaded bone cement in the treatment of periprosthetic hip and knee joint infection is unknown. It is also unclear, whether a suboptimal impregnation might be associated with a higher persistence of infection. A total of 93 patients (44 knee, 49 hip) were retrospectively evaluated, and the most common organism was a methicillin-resistant Staphylococcus epidermidis, followed by methicillin-susceptible Staphylococcus aureus. Of all the organisms, 37.1% were resistant against gentamicin and 54.2% against clindamycin. All organisms were susceptible against vancomycin. In 41 cases, gentamicin-loaded beads were inserted and in 52 cases, spacers: (2 loaded only with gentamicin, 18 with gentamicin + vancomycin, 19 with gentamicin + clindamycin, and 13 with gentamicin + vancomycin + clindamycin). The analysis of each antibiotic impregnation showed that complete susceptibility was present in 38.7% of the cases and partial susceptibility in 28%. In the remaining 33.3%, no precise statement can be made because either there was a culture-negative infection or the antibiotic(s) were not tested against the specific organism. At a mean follow-up of 27.9 months, treatment failure was observed in 6.7% of the cases. Independent of which antibiotic impregnation was used, when the organism was susceptible against the locally inserted antibiotics or not tested, reinfection or persistence of infection was observed in the great majority of cases. Future studies about the investigation of the optimal impregnation of antibiotic-loaded bone cement are welcome. Full article

(This article belongs to the Special Issue Antibiotics in Orthopedic Infections)

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Review

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12 pages, 297 KiB

Open AccessReview

Think Twice before Prescribing Antibiotics for That Swollen Knee: The Influence of Antibiotics on the Diagnosis of Periprosthetic Joint Infection

by Graham S. Goh and Javad Parvizi

Antibiotics 2021, 10(2), 114; https://doi.org/10.3390/antibiotics10020114 - 26 Jan 2021

Cited by 15 | Viewed by 2719

Abstract

Periprosthetic joint infection (PJI) is a rare but devastating complication after total joint arthroplasty. An estimated 7–12% of patients have negative cultures despite clear clinical evidence of infection. One oft-cited reason for this occurrence is the administration of antibiotics in the weeks prior to obtaining cultures. This article reviews the influence of antibiotics on the diagnosis of PJI. Specifically, we examine the effect of prophylactic and therapeutic antibiotic administration on the diagnostic accuracy of microbiological cultures as well as serum and synovial biomarkers. We also explore the potential of molecular techniques in overcoming these limitations in patients who have received antibiotics before specimen collection and propose areas for future research. Full article

(This article belongs to the Special Issue Antibiotics in Orthopedic Infections)

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