Guidelines outlined for PJI prevention

Issue: May 2015

KOLOA, Hawaii — There is a lack of level 1 studies to support some of the common practices and protocols to avoid periprosthetic joint infection. At Orthopedics Today Hawaii 2015, Javad Parvizi, MD,FRCS, outlined effective strategies from The International Consensus Group on Periprosthetic Joint Infection, which he helped draft, and from the CDC guidelines for the prevention of surgical site infections.

“The good news is the CDC just published their results on joint infection. [There] has been a 12% drop in the incidence of periprosthetic joint infection, so it looks like we are making headway with moving forward,” Parvizi said.

Although antibacterial prophylaxis has not been studied in a level 1 fashion, Parvizi noted that it has been accepted as necessary and should be administered in a timely manner.

“A timely manner means within 1 hour,” Parvizi, who is an Orthopedics Today Editorial Board member, said. “It is fine to stop the antibiotics after one dose, but 24 hours at the most.”

Parvizi added that vancomycin combined with cephalosporin should be given to patients who are methicillin-resistant Staphylococcusaureus (MRSA) carriers, those who have a recent history of MRSA, are institutionalized, in nursing homes or on dialysis.

Reducing bioburden is incredibly important for preventing infection, according to Parvizi, who noted that the CDC has endorsed the use of alcohol as part of the skin preparation.

“Right now, as we stand, there is no difference between the various agents with regard to the efficacy of reducing bioburden. [The] consensus talks about no clear difference between [agents], but alcohol must be part of your skin antisepsis,” he said. “There is plenty of evidence to show that use of chlorhexidine wipes or soap does reduce the number of resident bacteria on the skin and [this] is a great thing to do to your patients prior to surgery.”

Parvizi noted reducing blood loss can help minimize complications, and the use of tranexamic acid has been shown to reduce blood loss. He added that surgeons need to be active with wound drainage and should not procrastinate.

“You have to be active with draining wounds and deal with them early and properly,” Parvizi said. “Wound drainage had been shown in numerous studies to be one of the most important risk factors leading to a [surgical site infection] SSI and periprosthetic joint infection.”

According to Parvizi, when it comes to glycemic control, the CDC recommends a threshold of 200 mg/dL, while the International Consensus held that a hemoglobin A1C of 7% should also be included. The CDC also tabled immunosuppression due to lack of evidence.

“Patients who are on disease-modifying agents developing infection are incredibly difficult to treat and because of that the International Consensus does recommend to stop the disease modifying agents after consulting the rheumatologist,” Parvizi said.

The CDC tabled Staphylococcus aureus colonization and screening, Parvizi noted, due to controversial issues. However, Parvizi stated the International Consensus holds that this could lead to a reduction in SSIs and the logistic issues of screening and effective decolonization strategies should be addressed.

“Moving forward, I think MRSA screening and decolonization will become part of our strategy, but right now the processes are in optimization,” he said. – by Casey Tingle

Reference:

Parvizi J. Prevention of infection: Strategies that work. Presented at: Orthopedics Today Hawaii; Jan. 18-22, 2015; Koloa, Hawaii.

For more information:

Javad Parvizi, MD, FRCS, can be reached at the Rothman Institute at Thomas Jefferson University, 925 Chestnut St., Philadelphia, PA 19107; email: parvj@aol.com.

Disclosure: Parvizi is a consultant to Zimmer, Smith & Nephew, 3M and Convatec.