BESS PJI Guidelines - 9

Rangan et al.

fosfomycin, often in combination with b-lactams, are
being used increasingly but clear prospective evidence
of their advantage is awaited.
Staphylococci are the archetypal bioﬁlm associated
organisms, especially in the context of PJI and device
related infection. Where possible, the addition of
adjunctive rifampicin should be considered but
should not be used as monotherapy due to the high
risk of resistance emergence. Although the optimal
dose of rifampicin has not been determined, 300 mg
BD appears to be eﬀective. Rifampicin and a ﬂuoroquinolone such as ciproﬂoxacin appears to be the most
eﬀective oral combination therapy in staphylococcal
bone and joint infection. Where ciproﬂoxacin cannot
be used, alternative oral agents include clindamycin,
doxycycline, co-trimoxazole, linezolid, fusidic acid
and pristinamycin. However, side eﬀects, lack of pharmacokinetic data and the potential inﬂuence of enzyme
induction by rifampicin mean that further prospective
data are required before recommendation can be made
in favor of one agent over the others.
Streptococcal infection. Antimicrobial therapy for
Streptococcal PJI most commonly consists of a beta
lactam. However, these agents have poor activity
against bacteria in the stationary phase of growth so
are they are poorly eﬀective against bioﬁlm. Recent
studies demonstrate improved outcome with adjunctive
rifampicin but this has yet to be conﬁrmed.18
Infection caused by Enterococci. Outcome following
enterococcal infection is often disappointing.
Intravenous therapy is most commonly with a glycopeptide such as vancomycin or, in the case of E. faecalis, with amoxicillin. Alternatives include daptomycin,
linezolid and tigecycline; addition of adjunctive rifampicin to these three agents reveal the best in vitro results.
E. faecalis (but not E. faecium) is innately resistant to
pristinamycin.
Infections caused by Gram negative rods. Betalactam antibiotic therapy is generally eﬀective against
susceptible organisms in the initial phase of growth.
This may include a 3rd generation cephalosporin for
sensitive Enterobacteriaceae, a carbapenem for ESBL
and AMP-C beta-lactamase producing organisms, or
an anti-pseudomonal beta-lactam for P. aeruginosa.
For bioﬁlm associated infection, ciproﬂoxacin is usually the treatment of choice provided the organism is
susceptible and that there are no contraindications.
Where this isn't possible, co-trimoxazole can be
considered.19
Propionibacterium/Cutibacterium
acnes
infections.
P. acnes is commonly isolated following upper limb

S9
surgery. It is a ubiquitous skin commensal so distinguishing its presence as a contaminant versus pathogen
requires careful correlation with clinical and histological ﬁndings. Due to its low virulence, there is
often limited local inﬂammatory response and systemic
markers such as CRP are frequently normal. It is usually susceptible to a range of narrow spectrum agents,
including penicillin and doxycycline, so use of broad
spectrum agents is rarely indicated. Clindamycin is recommended in international guidelines1 but resistance
rates are rising and may preclude its use. As P.acnes
is associated with bioﬁlm formation, the addition of
adjunctive rifampicin is recommended particularly in
metalware associated infection although its role is less
clear than with other bioﬁlm producing organisms.20
3.1.9 Culture negative PJI. The incidence of culture negative infection is between 5 - 25%. Its diagnosis relies
on clinical, radiological and histological ﬁndings.
Antimicrobial management of culture negative PJI is
guided primarily by local epidemiology, clinical history
and prior antibiotic exposure. In the absence of any
previous isolates, empiric therapy most commonly
reﬂects treatment of staphylococcal infection. The combination of either ciproﬂoxacin or doxycycline with
rifampicin would be reasonable examples for most
European centres.
Where surgery is indicated for a failing arthroplasty
and PJI is thought to be unlikely based on radiological
appearance, normal blood parameters, and a negative
joint aspirate culture, it is appropriate to proceed to
either a one or two stage revision based on an informed
discussion with the patient and taking in to account
their wishes. In either circumstance biopsies should be
obtained for microbiology and histology at the time of
revision surgery.

3.2 Surgical decision making
3.2.1 Shoulder PJI. The evidence for the most suitable
treatment regime for PJI following shoulder arthroplasty is currently poorly reported in the medical literature due to a low numbers and absence of multi-centre
clinical trials where diﬀerent treatment modalities are
directly compared. However, there are essentially four
options available to the clinician once infection is suspected or diagnosed. These include Debridement,
Antibiotics and Implant Retention (DAIR), one stage
revision, two stage revision and excision arthroplasty.
The indications for each treatment option are diﬀerent
(Figure 1).
3.2.1a Debridement, Antibiotics and Implant Retention
(DAIR). There is little role for the sole use of long term
antibiotic suppressive therapy in the management

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