Azienda Ospedaliero-Universitaria Careggi
FIRENZE
Prosthetic replacement in septic failure
Pharmacological prevention and treatment
Dr. Francesco Leoncini
SOD Malattie Infettive
Reggello, May 15th-16th, 2009
Not only antibiotics
• Increase
infections
patient
resistance
to
– Good pre-operative measures, treat all
infective foci, good nutritional status,
short pre-operative hospitalization, …
• Good wound care
– Surgical technique, dressings
• Keep wound aseptic
Surgical site infection
Risk 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.
Antibiotic prophylaxis
Indications
ORTHOPEDIC SURGERY
• Antibiotic prophylaxis is strongly recommended in:
Hip and knee replacement
Antibiotic selection
• Surgical site
• Pharmacokinetics
• Allergies
• Drug toxicity and drug interactions
• Demonstrated efficacy in randomized studies
• Ecosystem
• Costs
• Possible etiologic agents
Antibiotic
How to choose
• Spectrum
– Proven efficacy on probable contaminant
bacteria
• Monitoring
– Epidemiology in any Orthopedic Unit
– Any surgical unit MUST perform cultures
with drug sensitivity.
Timing -1• Prophylaxis
– Usually
started
anesthesia
immediately
before
– Antibiotic administration more then 2
hours
before
surgery
has
lower
prophylactic power
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
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%)
“Classic” schedule
Antibiotic
Pre-operative
dose
Intra-operative
dose
Post-operative dose
Cefazolin
2g
1 g after 3 h
1 g x 4 x 24 h
600 mg
600 mg after 4 h
600 mg x 4 x 24 h
15 mg/kg
500 mg after 8 h
500 mg x 4 x 24 h
If allergy
Clindamycin
or
Vancomycin
MRSA incidence >30%
Antibiotic
Pre-operative
dose
Vancomycin
15 mg/kg
(max 1 g)
Intra-operative
dose
500 mg after 8 h
Post-operative dose
500 mg x 4 x 24 h
or
Teicoplanin
6-10 mg/kg
After 12 e 24 h
Prosthetic infections
• Treatment:
– Expensive
– Hard for the patient
– Hard for the surgeon
– Hard for the infectivologist
Microbiological diagnosis
MANDATORY!!!
• Synovial fluid culture
• Peri-prosthetic culture
• Wound-swab
or
fistula-swab:
colonization!
Only
Staphylococcus
aureus should be considered
• Blood cultures?
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
Prosthetic infections
Antibiotic treatment alone
Success rate ~ 5%!!!!
Prosthetic infections
Conservative surgery
+
Antibiotic therapy
Success rate ~ 20%!!!!
Multidisciplinary treatment
Orthopedic
Infectivologist
Microbiologist
Infezione di
protesi
Wash out antibiotico
Legenda
Ortopedico
Modalità di prelievo
Modalità e tempi di
trasporto
Prelievo microbiologico
Tempi e modalità di
incubazione
Terapia antibiotica mirata
Wash out antibiotico
Intervento rimozione/spaziatore
Indici di flogosi
Terapia antibiotica mirata
Diagnostica per
immagini
Intervento riposizionamento
protesi
Infettivologo
Ortopedico,
Infettivologo
Ortopedico,
Infettivologo,
Microbiologo
Profilassi ritardata
fino a prelievo
microbiologico
Targeted therapy
Agent
MSSA
MRSA
Streptococci
Enterobacteriaceae
Pseudomonas aeruginosa
Therapy
Oxacillin ± rifampin
Amoxicillin/clav. ± rifampin
Cipro, levo or moxifloxacin ± rifampin
Cotrimoxazole or minocyclin ± rifampin
Teicoplanin or vancomycin ± rifampin
Linezolid ± rifampin
Daptomycin
Amoxicillin ± rifampin
Levo or moxifloxacin ± rifampin
Ceftriaxone ± Rifampin
Cipro or levofloxacin ± rifampin
Ceftriaxone
Cefepime or ceftazidime
Cipro o levofloxacin
Piperacillin/tazobactam
Meropenem or imipenem
Empirical therapy
No risk* for MRSA
Risk factors for MRSA
Ceftriaxone ± rifampin
Amoxicillin/clav ± rifampin
Moxi or levofloxacin ± rifampin
Cotrimoxazole ± rifampin
Doxi or minocyclin ± rifampin
Vancomycin or teicoplanin ± rifampin
Linezolid ± rifampin
Daptomicyn
*
•
Previous antibiotic treatment
•
Recent hospitalization (last 12 months)
•
Parenteral nutrition
Conclusions
•
•
•
•
•
Achieve microbiological diagnosis
Be aware of local epidemiology
Multidisciplinary involvement
Patient tailored treatment
Patient collaboration