Diagnosis and Management of Prosthetic Joint Infection: Clinical ...

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Figure 3.Management of prosthetic joint infection—removal of prosthesis. Abbreviation: THA, total hip arthroplasty.PJI Due to Other Organisms26. Four to 6 weeks of pathogen-specific intravenous orhighly bioavailable oral antimicrobial therapy (Table 2; B-II).27. Monitoring of outpatient intravenous antimicrobialtherapy should follow published guidelines (A-II) [6].28. Indefinite chronic oral antimicrobial suppression mayfollow the above regimens (Table 3) based on in vitro sensitivities,allergies, and intolerances (B-III). Chronic suppressionafter fluoroquinolone treatment of PJI due to gram-negativebacilli was not unanimously recommended (W. Z., D. L.).Clinical and laboratory monitoring for efficacy and toxicity isadvisable. Similar considerations regarding hazards and effectivenessapply to those above.IV. What is the medical treatment for a patient with PJIfollowing resection arthroplasty with or without planned stagedreimplantation?Recommendations29. Four to 6 weeks of pathogen-specific intravenous orhighly bioavailable oral antimicrobial therapy is recommended(Table 2; A-II).30. Monitoring of outpatient intravenous antimicrobialtherapy should follow published guidelines (A-II) [6].V. What is the medical treatment for a patient with PJIfollowing 1-stage exchange?RecommendationsStaphylococcal PJI31. Two to 6 weeks of pathogen-specific intravenous antimicrobialtherapy in combination with rifampin 300–450 mgorally twice daily followed by rifampin plus a companion oraldrug for a total of 3 months is recommended (Table 2; C-III).Recommended oral companion drugs for rifampin includeciprofloxacin (A-I) or levofloxacin (A-II). Secondary companiondrugs to be used if in vitro susceptibility, allergies, intolerances,or potential intolerances support the use of an agentother than a quinolone include but are not limited to co-trimoxazole(A-II), minocycline or doxycycline (B-III), or oralfirst-generation cephalosporins (eg, cephalexin) or antistaphylococcalpenicillins (eg, dicloxacillin; C-III). If rifampincannot be used because of allergy, toxicity, or intolerance,than the panel recommends 4–6 weeks of pathogen-specificintravenous antimicrobial therapy.32. Monitoring of outpatient intravenous antimicrobialtherapy should follow published guidelines (A-II) [6].33. Indefinite chronic oral antimicrobial suppression mayfollow the above regimen with either cephalexin, dicloxacillin,co-trimoxazole, or minocycline or doxycycline based on invitro susceptibility, allergies, or intolerances (Table 3; B-III).Rifampin alone is not recommended for chronic suppression,and rifampin combination therapy is also not generally recommended.One member of the panel uses rifampin combinationtherapy for chronic suppression in selected situations(A. R. B.). The recommendation regarding using suppressivetherapy after rifampin treatment was not unanimous (D. L.,W. Z.). Clinical and laboratory monitoring for efficacy andtoxicity is advisable. The decision to offer chronic suppressivetherapy must take into account the individual circumstancesof the patient including the ability to use rifampin in theinitial phase of treatment, the potential for progressiveDownloaded from http://cid.oxfordjournals.org/ at IDSA member on January 9, 2013e6 • CID 2013:56 (1 January) • Osmon et al
Figure 4. Management of prosthetic joint infection when patients are not a candidate for new prosthesis. Abbreviations: TEA, total elbow arthroplasty;TKA, total knee arthroplasty.implant loosening and loss of bone stock, and the hazards ofprolonged antibiotic therapy; it is therefore generally reservedfor patients who are unsuitable for, or refuse, further exchangerevision, excision arthroplasty, or amputation.bacilli was not unanimously recommended (D. L., W. Z.).Clinical and laboratory monitoring for efficacy and toxicityis advisable. Similar considerations regarding hazards andeffectiveness apply to those above.Downloaded from http://cid.oxfordjournals.org/ at IDSA member on January 9, 2013PJI Due to Other Organisms34. Four to 6 weeks of pathogen-specific intravenous orhighly bioavailable oral antimicrobial therapy is recommended(Table 2; A-II).35. Monitoring of outpatient intravenous antimicrobialtherapy should follow published guidelines (A-II) [6].36. Indefinite chronic oral antimicrobial suppressionshould follow regimens in Table 3 and be based on in vitrosensitivities, allergies, and intolerances (B-III). Chronic suppressionafter fluoroquinolone treatment of gram-negativeVI. What is the medical treatment for a patient with PJIfollowing amputation?37. Pathogen-specific antimicrobial therapy should be givenuntil 24–48 hours after amputation assuming all infected boneand soft tissue has been surgically removed and there is noconcomitant sepsis syndrome or bacteremia. If sepsis syndromeor bacteremia are present, treatment duration is to beaccording to recommendations for these syndromes (C-III).Diagnosis and Management of Prosthetic Joint Infection • CID 2013:56 (1 January) • e7
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