PIANO Study Gives Insight into Successful Joint Infection Control

September 23, 2022

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Joint replacement surgery changes millions of lives each year, but complications, including prosthetic joint infections, occur in 1% to 2% of patients after major joint replacement surgery.

Prosthetic joint infections (PJIs) lead to patient morbidity and pose a significant financial burden to the healthcare system, costing the US an annual cost of over $1.6 billion in 2020. Determining the best management for optimal results is critical.

Kelly Percival

There are few randomized controlled trials (RCTs) to prescribe the best surgical and antimicrobial management, leading to an inadequate evidence base for the 2012 American Society for Infectious Diseases PJI guidelines. Most data are from small retrospective studies from centers with dedicated PJI expertise, and registry data often underestimate the actual incidence of especially late-acute PJI. To address this knowledge gap, the Prosthetic Joint Infection Observational (PIANO) study in Australia and New Zealand was conducted.

The PIANO study was a prospective observational study of PJI characteristics, etiology, and initial management from July 2014 to December 2017 in 27 hospitals in Australia and New Zealand. The study included 783 patients with PJI, including 427 knee (54.5%), 323 hip (41.3%), 25 shoulder (3.2%), and 6 elbow injuries during the first 90 years. (0.8%) and two ankle (0.3%) joint infections were included. Results of the day classified according to PJI definition, microbiological classification (monobacterial, polybacterial, or culture-negative) and surgical control strategy.

Surgical strategies include:

  • debridement, antibiotics, irrigation, implant retention (DAIR);
  • two-stage replacement arthroplasty;
  • one-stage replacement arthroplasty;
  • only inhibitory antibiotics;
  • resection arthroplasty; and
  • No plans have been identified.

The definition of PJI is:

  • Early PJI: Within 30 days after initial arthroplasty surgery.
  • Late-onset acute PJI (LA-PJI): more than 30 days post-implantation with symptom duration ≤7 days and no evidence of sinus ducts;
  • Late indeterminate PJI: More than 30 days post-implantation, symptom duration 8-30 days, no evidence of sinus ducts.When
  • Late-onset chronic PJI: More than 30 days post-implantation with duration of symptoms greater than 30 days or presence of sinus tract.

LA-PJI was the most common type, accounting for 44.8% of infections, followed by early PJI (25%) and late chronic PJI (18.9%). LA-PJI was most likely due to an infected knee prosthesis (71%), hip infection was most likely early PJI (59%), and rates of chronic infection were similar for both. was. The most common comorbidities were diabetes (22.1%) and ischemic heart disease (16.8%), and no association was found between comorbidity and type of PJI.

Most infections were monobacterial, followed by polybacterial and culture-negative. LA-PJI was more likely to be monomicrobial (81.2%) compared to early PJI (49.5%) and was predominantly Staphylococcus aureus, Coagulase-negative staphylococci (CoNS), or beta-hemolytic streptococci. Early infections were polybacterial 41.3% of the time. Staphylococcus aureus CoNS is the most common, with Enterobacteriaceae and Enterococci present at 12.2% and 16.3%, respectively.In chronic infections, 70.3% are unibacterial and 19.6% are polybacterial, with CoNS accounting for one-third of organisms, followed by Staphylococcus aureus, Enterobacteriaceae and enterococci each account for about 5%.

The most common surgical strategy used in 66.4% of cases was DAIR, followed by two-stage revision (18.6%), one-stage revision (4.6%), antibiotic suppression (6.7%), and excisional arthroplasty (0.9%). %) was. DAIR is the primary management strategy planned for 70% of LA-PJI, 81.6% of initial PJI, and 44.6% of chronic PJI, most requiring only one debridement and often No liner changes, arthroscopic debridement, or removal of all infectious material is required.

Empirical antibiotics were initiated in 82% of cases, with vancomycin being the most commonly prescribed (45%), cefazolin (40%), flucloxacillin (32%), piperacillin-tazobactam (9.6%), and ceftriaxone. (6%). A small number of patients received adequate Gram-negative coverage with empirical antibiotic regimens, often due to AmpC organisms.

This 90-day outcomes study identified LA-PJI as the most common symptom and demonstrated heterogeneity in PJI symptoms and management. This was followed by his 24-month outcome analysis of the PIANO cohort, examining relationships between practice variations and providing a platform for building intervention studies.

We evaluated 653 patients who completed 24 months of follow-up as part of the PIANO cohort to determine whether treatment success was associated with modifiable variables in surgical and antibiotic management. The primary outcomes defined were clinical cure (survival, no evidence of clinical or microbiological infection, no need for continued antibiotics) and treatment success (clinical cure and index prosthesis still in place).

Clinical cure was achieved in 69% of patients and 54% had successful treatment. DAIR was the most common surgical strategy, most successful in early PJI (74%) and less successful in LA-PJI (49%) and chronic PJI (44%). Factors associated with treatment success in univariate analysis were young age, hip joint, early infection, high baseline serum albumin, and absence of chronic renal disease or malignancy. Infections caused by: had the lowest success rate. Staphylococcus aureus (46%), Propionibacterium (Cutibacterium) Other organisms had 56% to 58% success and culture-negative had 71% success against species (46%) or Gram-negative bacilli (46%). In the PIANO cohort, there were only 23 MRSA infections, but the success rate for these infections was low at 39%.

LA-PJI was less likely to be successful than early PJI, but those managed in two-step revisions were as successful as those of early PJI (72% vs. 79%). LA-PJI administered with DAIR was successful in only 48% of cases. Treatment success was not different between patients treated with rifampin and those treated without rifampin (OR 1.15; 95% CI, 0.82-1.61), maintaining this significance. Staphylococcus aureus infections only.

Rifampin was used in 255 episodes, with 26% of adverse events. Larger RCTs are needed to determine whether there are benefits to adding rifampins to PJI administration.

Treatment success was determined by non-modifiable variables, including index joint, early versus late PJI, causative organism, patient age, absence of specific comorbidities, but surgical and antibiotic (modifiable ) factor was not associated with success. The low success rate of DAIR suggests that revision arthroplasty (stage 1 or stage 2) may be the preferred management strategy for patients with LA-PJI, but for his early PJI, DAIR may be the preferred management strategy. suggesting.

Empirical antibiotic therapy in PJI should target the most probable organism while avoiding overly broad spectrum of activity. Unnecessarily extensive antibiotic therapy leads to the development of antibiotic resistance and increases the risk of adverse events.

The PIANO cohort showed that early PJI was more likely to be polybacterial compared with LA-PJI. We analyzed the proportion of patients based on PJI type to determine an empirical regimen that adequately covered the identified organisms in 80% of patients without sepsis and 90% of patients with sepsis. Based on these data, the authors proposed empirical treatment based on the type of PJI and sepsis manifestations (Table).

Suggested Empirical Treatment Table

A similar study conducted in New Zealand evaluating 15 years of microbiological data from PJI of the knee concluded similar empirical antibiotic treatment recommendations for PJI. Recommendations should increase empirically adequate Gram-negative coverage from the 26% noted in the PIANO cohort. Cefazolin alone is recommended for LA-PJI, which is often a monomicrobial Gram-positive infection, which is reasonable in Australia and New Zealand because of the low incidence of MRSA in these cohorts, but in regions with high incidence. may need to be changed to vancomycin monotherapy. MRSA.


Data from this large cohort showed that the success of PJI treatment was mostly influenced by non-modifiable risk factors compared with surgical and antibiotic strategies, but early arthroplasty The timing of PJI from pneumothorax should be factored into initial surgical management and choice of empirical antibiotic therapy.

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