Implications of the Changing Pattern of Bacterial Infections following Total Joint Replacements

Purpose. To retrospectively review the causative organisms isolated from infected hip and knee replacements requiring revision. Methods. We reviewed a consecutive series of 36 patients who underwent revision hip or knee arthroplasties due to bacterial infection at Pamela Youde Nethersole Eastern Hospital in Hong Kong between 1995 and 2003. The male to female ratio was 1:2, and the mean age of patients was 70 years (range, 54–82 years). The mean duration of follow-up was 3.8 years (range, 1.1–8.3 years). No patient was lost to follow-up. All 14 revision knee patients had previously undergone cemented and patella-resurfacing total knee arthroplasties. Of the 22 revision hip patients, 9 had cementless, 6 had cemented, and 7 had hybrid total hip arthroplasties previously. Results. None of the bacteria isolated from 1995 to 1996 were multiple-drug resistant. Subsequently, however, most of the isolates were multiple-drug resistant, with methicillin-resistant Staphylococcus aureus (MRSA) being the most common. Half of the isolates of Staphylococcus epidermidis and Escherichia coli demonstrated multiple-drug resistance. The incidence of positive culture in revision hip patients was 59%, 46% of which were MRSA. All 13 revision hips with positive cultures showed chronic sepsis: 4 occurred within one year and 10 occurred 2 or more years after the index arthroplasty. The incidence of positive culture in revision knee patients was 57%, 46% of which were MRSA. All 8 revision knees with positive cultures showed chronic sepsis: 3 occurred within one year, 5 occurred 2 or more years after the index arthroplasty. Only one patient, who was infected with gram-negative bacilli, required a second revision for residual sepsis. Harris hip scores for the revision hip patients improved from a mean of 65 (range, 55–75) to 85 (range, 75–90). Knee Society knee scores of the revision knee patients improved from a mean of 68 (range, 55–75) to 80 (range, 70–85). There were no radiological signs suggestive of loosening in the 2 groups at the latest follow-up. Conclusion. This study found a definite increase in multiple-drug–resistant bacteria isolated from periprosthetic infections around total hip and knee prostheses.

[1]  D. Robinson,et al.  Multilocus sequence typing and the evolution of methicillin-resistant Staphylococcus aureus. , 2004, Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases.

[2]  D. Crook,et al.  Diagnosis of infection by frozen section during revision arthroplasty. , 1995, The Journal of bone and joint surgery. British volume.

[3]  R. Lally,et al.  Rapid control of an outbreak of Staphylococcus aureus on a neonatal intensive care department using standard infection control practices and nasal mupirocin. , 2004, American journal of infection control.

[4]  W. Harris,et al.  Failed total hip replacement: assessment by plain radiographs, arthrograms, and aspiration of the hip joint. , 1984, The Journal of bone and joint surgery. American volume.

[5]  J. Lonner,et al.  Limited success with open debridement and retention of components in the treatment of acute Staphylococcus aureus infections after total knee arthroplasty. , 2003, The Journal of arthroplasty.

[6]  R. Skurray,et al.  Staphylococcus aureus multiresistance plasmid pSK41: analysis of the replication region, initiator protein binding and antisense RNA regulation , 2004, Molecular microbiology.

[7]  F. C. Ewald.  The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. , 1989, Clinical orthopaedics and related research.

[8]  J. Costerton,et al.  Pseudomonas aeruginosa biofilm as a diffusion barrier to piperacillin , 1992, Antimicrobial Agents and Chemotherapy.

[9]  D. Ip.  Orthopedic Principles - A Resident's Guide , 2005 .

[10]  S. Atukorala,et al.  Staphylococcus aureus with reduced susceptibility to vancomycin. , 2011, The Ceylon medical journal.

[11]  R F Kyle,et al.  Infection after total knee arthroplasty. A retrospective study of the treatment of eighty-one infections. , 1999, The Journal of bone and joint surgery. American volume.

[12]  S. Stefani,et al.  Epidemiology of methicillin-resistant staphylococci in Europe. , 2003, Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases.

[13]  A. Gristina,et al.  Biomaterial-centered infection: microbial adhesion versus tissue integration. , 1987, Science.

[14]  L. Borden,et al.  Infected total knee arthroplasty , 1987 .

[15]  B. Farber,et al.  Staphylococcus epidermidis extracted slime inhibits the antimicrobial action of glycopeptide antibiotics. , 1990, The Journal of infectious diseases.

[16]  J. Costerton,et al.  Microbial Biofilms , 2011 .

[17]  J. Kur,et al.  New effective sources of the Staphylococcus simulans lysostaphin. , 2005, Journal of biotechnology.

[18]  N. Woodford,et al.  Detection of the mec-A gene and phenotypic detection of resistance in Staphylococcus aureus isolates with borderline or low-level methicillinresistance. , 1996, The Journal of antimicrobial chemotherapy.

[19]  J. Insall,et al.  Two-stage reimplantation for the salvage of total knee arthroplasty complicated by infection. Further follow-up and refinement of indications. , 1990, The Journal of bone and joint surgery. American volume.