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Azienda Ospedaliero-Universitaria Careggi FIRENZE

Prosthetic replacement in septic failure Pharmacological prevention and treatment Dr. Francesco Leoncini SOD Malattie Infettive. Azienda Ospedaliero-Universitaria Careggi FIRENZE. Reggello, May 15th-16th, 2009. Not only antibiotics. Increase patient resistance to infections

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Azienda Ospedaliero-Universitaria Careggi FIRENZE

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  1. Prosthetic replacement in septic failurePharmacological prevention and treatment Dr. Francesco LeonciniSOD Malattie Infettive Azienda Ospedaliero-Universitaria Careggi FIRENZE Reggello, May 15th-16th, 2009

  2. Not only antibiotics • Increase patient resistance to infections • Good pre-operative measures, treat all infective foci, good nutritional status, short pre-operative hospitalization, … • Good wound care • Surgical technique, dressings • Keep wound aseptic

  3. Surgical site infectionRisk factors • Long pre-operative hospitalization • Long operative procedures • Co-morbidities • Prosthetic device • Any prosthetic device increase wound and surgical site infections rate; low bacterial load can be cause of infection.

  4. Antibiotic prophylaxisIndications ORTHOPEDIC SURGERY • Antibiotic prophylaxis is strongly recommended in: Hip and knee replacement

  5. Antibiotic selection • Surgical site • Pharmacokinetics • Allergies • Drug toxicity and drug interactions • Demonstrated efficacy in randomized studies • Ecosystem • Costs • Possible etiologic agents

  6. AntibioticHow to choose • Spectrum • Proven efficacy on probable contaminant bacteria • Monitoring • Epidemiology in any Orthopedic Unit • Any surgical unit MUST perform cultures with drug sensitivity.

  7. Timing -1- • Prophylaxis • Usually started immediately before anesthesia • Antibiotic administration more then 2 hours before surgery has lower prophylactic power

  8. Timing -2- • Additional dose during surgery Most antibiotics used in prophylaxis have short half-life (1-2 hours). Additional dose of antibiotics if surgery > 2-4 hours • Prophylaxis limited to surgical time Extended prophylaxis (24 hours) may be justified in clinical settings with high risk of infection

  9. Prosthetic infections Prophylaxis • Coagulase-negative Staphylococci (30-43%) • Staphylococcus aureus (12-23%) • Mixed flora (10-11%) • Streptococci (9-10%) • Enterococci (3-7%) • Gram negative Bacilli (3-6%) • Anaerobes (2-4%)

  10. “Classic” schedule

  11. MRSA incidence >30%

  12. Prosthetic infections • Treatment: • Expensive • Hard for the patient • Hard for the surgeon • Hard for the infectivologist

  13. Microbiological diagnosis MANDATORY!!! • Synovial fluid culture • Peri-prosthetic culture • Wound-swab or fistula-swab: colonization! Only Staphylococcus aureus should be considered • Blood cultures?

  14. Prosthetic infections Involved Bacteria • Coagulase-negative Staphylococci (30-43%) • Staphylococcus aureus (12-23%) • Mixed flora (10-11%) • Streptococci (9-10%) • Enterococci (3-7%) • Gram negative bacilli (3-6%) • Anaerobes (2-4%) • Negative cultures (11%) • Polimicrobic (12-19%) • Rare: Brucella, Candida, mycobacteria

  15. Prosthetic infections Antibiotic treatment alone Success rate ~ 5%!!!!

  16. Prosthetic infections Conservative surgery + Antibiotic therapy Success rate ~ 20%!!!!

  17. Multidisciplinary treatment

  18. Infezione di protesi Legenda Ortopedico Wash out antibiotico Modalità di prelievo Modalità e tempi di trasporto Tempi e modalità di incubazione Infettivologo Prelievo microbiologico Ortopedico, Infettivologo Terapia antibiotica mirata Ortopedico, Infettivologo, Microbiologo Wash out antibiotico Profilassi ritardata fino a prelievo microbiologico Intervento rimozione/spaziatore Indici di flogosi Terapia antibiotica mirata Diagnostica per immagini Intervento riposizionamento protesi

  19. Targeted therapy

  20. Empirical therapy * • Previous antibiotic treatment • Recent hospitalization (last 12 months) • Parenteral nutrition

  21. Conclusions • Achieve microbiological diagnosis • Be aware of local epidemiology • Multidisciplinary involvement • Patient tailored treatment • Patient collaboration

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