However, because of insufficient data this variable could not be included in the multivariate analysis, even although it is possible that BMI will one day be shown to be an important, independent predictor of SSI. It would therefore seem to be likely that our analysis has included the main patient-related risk factors for SSI. Even if the key factors were missing, the proportion of patients with these characteristics would need to vary significantly between different facilities if they were to explain the variation in incidence of SSI between hospitals.
Mangram et al 5 also cited evidence for the effect of a range of factors related to surgery, and how it is performed, on the risk of SSI. These included the operating theatre environment e. Since trauma is a significant risk factor, it may be that hospitals with separate facilities for trauma and elective patients may one day be shown to be a significant factor in the analysis of risk. The extent to which some of these practices are adopted in different hospitals may explain some of the variation in rates of infection.
This variation can therefore provide a useful opportunity for evaluating local clinical practice in relation to current recommendations to ensure that the risk of SSI is minimised. Our study also highlights the impact of SSI on morbidity and the subsequent use of resources. The length of hospital stay for patients with SSI was more than twice that of those without SSI for all types of hip arthroplasty.
However, it was not possible to establish the exact relationship between the length of stay in hospital, the severity of underlying illness and the development of SSI. The data for time to diagnosis and mean length of hospital stay show that there is often a small interval between the detection of a SSI and the discharge of the patient from hospital, particularly with deep and joint infections. Patients who stay in hospital longer are more likely to have their SSI detected.
In the simplistic adjustment for length of post-operative stay using a Poisson regression, age group was no longer a significant predictor of SSI. This suggests that part of the increased risk of SSI in older patients was related to their increased length of post-operative stay and the resulting, increased opportunity for SSI to be detected.
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Our study has also demonstrated the extent to which the emerging problem of infection due to methicillin-resistant strains of Staph. Nearly two-thirds of isolates of Staph. The characteristics of these patients probably increases the likelihood that they will be colonised with MRSA before surgery. There may, for example, be a history of exposure from an earlier hospitalisation, chronic wounds and other underlying illness. With continuing emphasis on clinical governance and quality control, there is increasing demand from both patients and government for methods of assessing surgical results.
Rates of morbidity and mortality may play important roles in these assessments. However, our study has indicated that, when crude comparisons between hospitals in the incidence of SSI are made, these should at least be stratified by the type of procedure. A better comparison can be made by combining data for all types of hip arthroplasty, and standardising the rates of SSI, in order to allow for the significant factors i.
These factors can be taken into account when making comparisons and should perhaps be considered when allocating special care to high-risk patients. There are some limitations to our study. Currently, there is no satisfactory and cost-effective system for the routine surveillance of post-operative patients who have been discharged from hospital. For this reason post-discharge SSIs were not included in our study. While the rates of post-discharge SSI do not represent all SSIs which develop after hip arthroplasty, it is likely that a considerable proportion will have become apparent before the patient is discharged from hospital.
However, it is also possible that the risk factors for SSI which we identified in this analysis may not apply to SSIs detected after discharge. Risk factors included in our analysis were only those for which data were available, although most major factors appear to have been incorporated. Hospitals contributing data were a self-selected group, which may introduce a small element of bias e. However, a large proportion of the NHS Trusts in England have contributed data and, for many, the reason for participation was an interest in auditing rates of SSI rather than particular concerns about its magnitude.
Table I. At least two of the following symptoms and signs: Pain or tenderness, localised swelling, redness or heat, and. An abscess or other evidence of deep infection found during re-operation, or by histopathological or radiological examination. Purulent drainage from a drain which is placed through a stab incision into the joint. The patient has at least two of the following signs or symptoms with no other recognised cause: joint pain, swelling, tenderness, heat, evidence of effusion or limitation of movement and at least one of the following: Organisms and white blood cells seen on Gram stain of the joint.
Cellular profile and chemistry of joint fluid compatible with infection and not explained by an underlying rheumatological disorder. Radiological evidence of infection, e. Table II. Table III. Table IV. Table V. Table VI.
British volume Vol. Abstract We wished to estimate the incidence of surgical-site infection SSI after total hip replacement THR and hemiarthroplasty and its strength of association with major risk factors. Antimicrobial prophylaxis in total hip replacement: a systemic review. Health Technol Assess ;— Trends in hospital admissions for fractures of the hip and femur in England: to J Public Health Med ;— The socio-economic burden of hospital-acquired infection.
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London: Public Health Laboratory Service. Google Scholar 4 Department of Health. The Path of Least Resistance. Standing Medical Advisory Committee. Sub-Group on Antimicrobial Resistance. Guideline for the prevention of surgical site infection.
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Surgical approach does not affect deep infection rate after primary total hip arthroplasty.
Age alone is not a risk factor for periprosthetic joint infection. Negative pressure wound therapy in total hip and knee arthroplasty: a meta-analysis. Wound closure and follow-up after total knee arthroplasty — Do they affect the rate of antibiotic prescription? An integrative care bundle to prevent surgical site infections among surgical hip patients: A retrospective cohort study.
Iodine-supported titanium implants have good antimicrobial attachment effects. The effectiveness of preoperative colon cleansing on post-operative surgical site infection after hip hemiarthroplasty. Surface degradation—enabled osseointegrative, angiogenic and antiinfective properties of magnesium-modified acrylic bone cement.
Risk factors for early infection following hemiarthroplasty in elderly patients with a femoral neck fracture. Implementation of a multidisciplinary infections conference affects the treatment plan in prosthetic joint infections of the hip: a retrospective study. Incidence and risk of surgical site infection after adult femoral neck fractures treated by surgery.
Femoral neck fractures in old age treated with hemiarthroplasty. Preoperative hematocrit on early prosthetic joint infection and deep venous thrombosis rates in primary total hip arthroplasty: A database study. Central sensitization is a risk factor for wound complications after primary total knee arthroplasty.
An observational study of door motion in operating rooms. Female radical cystectomy patients have a higher risk of surgical site infections. Postoperative wound management with negative pressure wound therapy in knee and hip surgery: a randomised control trial. Surgical site infection in overweight and obese Total Knee Arthroplasty patients. Impact of operative time on early joint infection and deep vein thrombosis in primary total hip arthroplasty. Multifaceted aseptic protocol decreases surgical site infections following hip arthroplasty. Two-stage treatment in patients with patients with high-energy femoral fractures does not lead to an increase in deep infectious complications: a propensity score analysis.
Epidemiology of Prosthetic Joint Infection. Risk factors of orthopedic surgical site infection in Jordan: A prospective cohort study. Novel approaches to surgical site infections: what recommendations can be made? Open subpectoral biceps tenodesis in patients over 65 does not result in an increased rate of complications. Patient and surgical factors affecting procedure duration and revision risk due to deep infection in primary total knee arthroplasty.
The frail fail: Increased mortality and post-operative complications in orthopaedic trauma patients. Intracavity lavage and wound irrigation for prevention of surgical site infection. Factors affecting the rate of surgical site infection in patients after hemiarthroplasty of the hip following a fracture of the neck of the femur. Klem , T. Kuijper , G. Aortic stenosis and non-cardiac surgery: A systematic review and meta-analysis.
Mechanical properties and antibiotic release characteristics of poly methyl methacrylate -based bone cement formulated with mesoporous silica nanoparticles. Of 20, Lumbar Discectomies, 2. Prosthetic joint infection—a devastating complication of hemiarthroplasty for hip fracture. Primary hip and knee arthroplasty in a temporary operating theatre is associated with a significant increase in deep periprosthetic infection. Bloch , A. Shah , S. Snape , T. Boswell , P. Inhibition of biofilm formation on iodine-supported titanium implants. One-year incidence of prosthetic joint infection in total hip arthroplasty: a cohort study with linkage of the Danish Hip Arthroplasty Register and Danish Microbiology Databases.
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What is the impact of age on reoperation rates for femoral neck fractures treated with internal fixation and hemiarthroplasty? A comparison of hip fracture outcomes in the very elderly population. Intraosseous concentration and inhibitory effect of different intravenous cefazolin doses used in preoperative prophylaxis of total knee arthroplasty. Factors that influence the non-technical skills performance of scrub nurses: a prospective study.
Prosthetic joint infection following hip fracture and degenerative hip disorder: a cohort study of three thousand, eight hundred and seven consecutive hip arthroplasties with a minimum follow-up of five years. Association between dementia and postoperative complications after hip fracture surgery in the elderly: analysis of 87, patients using a national administrative database.
Surgical site infection in elderly patients with hip fractures, silver-coated versus regular dressings: a randomised prospective trial. Potent antimicrobial activity of bone cement encapsulating silver nanoparticles capped with oleic acid. Periprosthetic Joint Infection after Ankle Arthroplasty. Cytotoxic Effects and Biocompatibility of Antimicrobial Materials. The hip fracture best practice tariff: early surgery and the implications for MRSA screening and antibiotic prophylaxis. There was no tenderness or swelling around the joint, and the infection was regarded as resolved.
A sinus tract communicating with knee joint was seen, around which was the yellowish fluid with tofu-like tissue Figure 1C. It did not appear to be synovial in nature so it was collected for pathogen and drug sensitivity test, which was subsequently identified as Candida albicans. The result was initially regarded as a contamination but repeated punctures confirmed the infection of C. The MIC of fluconazole for C. At that point, the WBC count was 2. The MIC of voriconazole for C. On October 20, , arthrocentesis was performed to examine the effect of the treatment method so far. The results of fungal stains, gram stains and bacterial cultures were all negative.
The patient had no systematic discomfort and no local erythema, no local heat, no resting pain, no discharge sinus in the infected joint. After 5 months of follow-up, the film of the left knee revealed the prosthesis was well-fixed Figure 2D — F and laboratory findings were normal. Currently, the patient is on a continued 6-month oral antifungal treatment. A secondary search of references cited in the articles related to our topics was performed. The patients had an average age of A sinus tract was present in 2 patients patients 1 and 4.
Three patients had one or more underlying systemic diseases, including COPD in 2 patients, chronic renal insufficiency in 1 patient, diabetes mellitus in 2 patients and renal cell carcinoma in 1 patient. The case in our hospital did not have systemic illness, but had a complicated history of multiple electric injury wounds to the extremity with the infected joint. Two patients with a previous history of bacterial infection prior to C. The delay between index surgery and diagnosis varied from 8 days to 4 months and 26 months; it was unavailable in 1 patient.
Four patients developed the infection after an average of 2. Patient 1 received intravenous injection with antibiotics including flucytosine combined with amphotericin B, but without oral antibiotics.
Patients 2 and 3 underwent fluconazole combined with vancomycin hydrochloride intravenously each and oral fluconazole. Our patient received vancomycin hydrochloride intravenously 19 days for MRSA and fluconazole intravenously 18 days combined with oral fluconazole and switched to voriconazole later for C.
Intra-articular injection was used in our patient only. PJI is a serious complication of arthroplasty associated with significant mortality. The present case had several risk factors including high frequency of door openings in the operating theater, 20 fluid resuscitation over 2, mL, 21 3 units of allogeneic red blood cells and mL fresh frozen plasma transfusion during the operation. The Pulido et al study showed patients receiving allogenic transfusions were regarded as an independent risk factor for PJI which was 2.
In addition, the complexity of arthroplasty, such as the use of hinged implants in our case, may also contribute to high complication rate. Also in our review, these four patients had several identifiable risk factors for PJI, either systemic diseases or local comorbidities, such as poorly controlled diabetes mellitus, male gender, chronic renal disease, diagnosis of post-traumatic arthritis, prior surgical procedure in the affected joint, which was consistent with potential risk factors for development of PJI described in The International Consensus on Periprosthetic Joint Infection.
Although reimplantation protocol resulted in a viable option for patients with infections by common organisms, it might be accompanied by a high recurrence rate, especially in patients with antibiotic resistant organisms. Our case is unique since the patient had successful eradication of infection by using open debridement, continuous lavage for MRSA infection and intra-articular washout for C.
In vitro, PVP-I has been proved to be effective against a wide range of pathogens, including Gram-positive and Gram-negative bacteria, bacillus, protozoa and viruses. In addition, continuous lavage was used after complete debridement in our patient. Mont et al study shows that in patients with acute PJI, multiple debridement and retention of the components can result in low morbidity with high success rates. It also remains uncertain about when to remove the drainage tube, how to confirm the absence of organism and how to prevent superinfection.
More importantly, intra-articular washout combined with oral antifungal agents was performed in our patient to control C. Salvati et al also reported that the proper antibiotic concentration in joint fluid could not be maintained by antibiotic-impregnated cement. Similar methods of intra-articular antibiotic delivery have been reported effectively in previous literature to treat acute and chronic-infected TKA.
The agents must be adjusted according to the results of susceptibility testing because fungal biofilms are more complex than other pathogens. The reason may be that voriconazole is a more active regimen to suppress the recovery of viable colony-forming units CFUs from the model at 24 h. In addition, voriconazole-exposed catheters exhibited a significantly lower burden of organisms, revealed by sonicated catheter cultures at 48 h, versus the fluconazole for isolated C. Lastly, the authors consider whether a prolonged time of local susceptible antibiotics delivery in acute PJI might be the major issue in treatment and induce a better outcome than radical revision surgery, which has also been shown effective in some of the earlier in vitro and clinical reports, but it needs further study to prove the hypothesis.
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Multiple irrigation, debridement, and retention of components in infected total knee arthroplasty.