This article is more than 5 years old. Information may no longer be current.
Aggressive anticoagulation associated with failed surgical treatment of infection
Patients with higher-dose anticoagulation have a a 1.8 times higher risk for failure, study finds.
Click Here to Manage Email Alerts
 Javad Parvizi |
They issued the latest study to evaluate whether such excessive INR also adversely affects the outcome of TJA patients being treated for periprosthetic infection.
ACCP guidelines questioned
Currently, the American College of Chest Physicians (ACCP) guidelines recommend administering warfarin (Coumadin, Bristol-Myers Squibb) to achieve an INR l of 2 to 2.5, according to Parvizi.
“We’ve heard a lot about pay-for-performance and administering appropriate anticoagulation is one of those issues right now,” Parvizi told colleagues at the 17th Annual Open Scientific Meeting of the Musculoskeletal Infection Society. “There are major concerns with the ACCP guidelines. The recommended INR by these guidelines is believed to be too aggressive which may lead to bleeding and other problems.”
INR of 1.5 to 1.7
Parvizi and his colleagues enrolled 353 infected TJA patients who were treated at the Rothman Institute between 2000 and 2005 into the study. These included 185 total knee arthroplasty (TKA) patients and 168 total hip arthroplasty (THA) patients.
“Our anticoagulation protocol was the same for everybody,” Parvizi said. “They had Coumadin on the night of surgery and the intended INR was 1.5 to 1.7 … [We administered] heparin bridge therapy for those patients who were at high risk.” Patients received 6 weeks of anticoagulation.
Ninety-two percent of the infections were gram positive, and, of concern, 31% were methicillin-resistant Staphylococcus aureus, Parvizi said.
The majority of patients underwent two-stage resection arthroplasty: 140 TKA and 102 THA. Four TKA patients and 10 THA patients underwent one-stage resection arthroplasty, and 42 TKA and 55 THA patients underwent irrigation and debridement (I & D), Parvizi said.
High failure rates
In the group of patients who underwent irrigation and debridement, investigators found a 34% success rate (eradication of infection) for TKA patients and a 39% success rate for THA patients.
“These are worrying numbers,” Parvizi said.
For those patients who underwent two-stage resection arthroplasty, investigators found a 62% success rate for TKA patients and a 75% success rate for THA patients, Parvizi said.
“[Five] patients required amputation and there were three people who died of periprosthetic infection,” he said.
The investigators found that high-dose anticoagulation was associated with 1.8 times higher risk of failure, classified by a complicated course of infection, repeated revisions, prolonged suppressive therapy and resection arthroplasty, according to the study abstract.
At discharge, 5% of the patients whose infections were successfully eradicated had a higher-than-intended INR, compared to 14% of the failed patients. Looking at data over all times, 8% of the successful patients and 21% of the failed patients had an INR that was higher than the intended 1.5 to 1.7. This finding was statistically significant, Parvizi said.
Editor’s note:
Read the earlier report of Parvizi’s investigation, Excessive anticoagulation shows link to infection after total joint arthroplasty, in the May issue of Orthopedics Today on page 14 of the print issue.
For more information:
- Javad Parvizi, MD, FRCS, can be reached at the Rothman Institute, 925 Chestnut St., Philadelphia, PA 19107; 267-339-3617; e-mail: parvj@aol.com. He has no direct financial interest in the products discussed in this article. He is a paid consultant for Stryker.
Reference:
- Parvizi J, Jaberi FM, Barr S, et al. Does anticoagulation affect the outcome of treatment for periprosthetic infection? Presented at the 17th Annual Open Scientific Meeting of the Musculoskeletal Infection Society. August 10-11, 2007. San Diego.