What is the treatment for postoperative orthopedic infection?

From the Guidelines

Treatment of postoperative orthopedic infection typically involves a combination of surgical and antimicrobial interventions, with a focus on debridement, implant retention, and long-term antimicrobial therapy, as suggested by the ESCMID guideline for the diagnosis and treatment of biofilm infections 2014 1.

Key Components of Treatment

• Surgical debridement: necessary to remove infected tissue and promote healing, with evidence suggesting that debridement, implant retention, and long-term antimicrobial therapy can achieve a success rate of at least 85% in patients with acute infections 1.
• Antimicrobial therapy: empiric treatment with broad-spectrum antibiotics, such as rifampicin against staphylococci and fluoroquinolones against Gram-negative bacilli, is recommended, pending culture and sensitivity results 1.
• Implant retention or replacement: in cases of chronic infections (>3-week duration or >4 weeks after surgery), prosthetic devices should be replaced after thorough debridement, with a two-stage exchange and local therapy with an antibiotic-containing cement spacer being a common approach 1.

Antimicrobial Therapy

• Duration of treatment: typically ranges from 6-12 weeks, with a treatment period of 6 weeks being sufficient if the implant is not replaced before 2 months 1.
• Antibiotic selection: should be based on the patient's risk factors for multidrug-resistant (MDR) pathogens, with empiric broad-spectrum, multidrug therapy recommended for patients at risk for MDR pathogens 1.
• Combination therapy: may be more effective, with the use of two antibiotics with different mechanisms of action, systemic + local treatment, or antibiotic + local disinfectant being suggested 1.

Monitoring and Adjustment

• Close monitoring: of the patient's response to treatment is essential, with adjustments to the antibiotic regimen made as needed 1.
• Consultation with an infectious disease specialist: may be necessary for complex cases, to ensure optimal management and treatment outcomes.

From the FDA Drug Label

The cure rates in microbiologically evaluable patients with MRSA skin and skin structure infection were 26/33 (79%) for linezolid-treated patients and 24/33 (73%) for vancomycin-treated patients The cure rates by pathogen for microbiologically evaluable patients are presented in Table 19. Table 19 Cure Rates at the Test-of-Cure Visit for Microbiologically Evaluable Adult Patients with Diabetic Foot Infections PathogenCured ZYVOXn/N (%)Comparatorn/N (%) Staphylococcus aureus49/63 (78)20/29 (69) Methicillin-resistant S aureus12/17 (71)2/3 (67) Streptococcus agalactiae25/29 (86)9/16 (56)

The treatment for postoperative orthopedic infection is not directly addressed in the provided drug label. However, based on the information provided for the treatment of complicated skin and skin structure infections, linezolid may be considered as a treatment option for certain types of infections, including those caused by Staphylococcus aureus and methicillin-resistant Staphylococcus aureus (MRSA).

• The cure rates for linezolid-treated patients with MRSA skin and skin structure infection were 79%.
• The cure rates for linezolid-treated patients with diabetic foot infections were 71%. However, it is essential to note that the provided drug label does not specifically address postoperative orthopedic infections, and the treatment should be determined based on the specific type of infection and the causative pathogen. 2

From the Research

Treatment Options for Postoperative Orthopedic Infection

• The treatment of postoperative orthopedic infections is typically multimodal and involves various combinations of drug delivery and surgical procedures 3.
• Surgical debridement and prolonged antibiotic therapy are common treatment approaches for postoperative orthopedic infections 4, 5.
• The use of antibiotic-releasing systems, such as bone cements and porous calcium sulfate, has been shown to prevent bacterial growth and may be effective in preventing postoperative orthopedic infections 3.
• The optimal duration of surgical antibiotic prophylaxis for preventing surgical site infection in orthopedic surgeries remains poorly supported by high-level evidence, and prolonging antibiotic prophylaxis duration may not demonstrate a statistically significant protective effect against surgical site infection 6.

Antimicrobial Strategies for Staphylococcal Prosthetic Joint Infection

• Treatment of staphylococcal prosthetic joint infection usually consists of surgical debridement and prolonged rifampicin combination therapy, but alternative antibiotic strategies may be effective and reduce side effects and drug-drug interactions 7.
• A short-term rifampicin strategy with either clindamycin or flucloxacillin and only 5 days of rifampicin was found to be as effective as traditional long-term rifampicin combination therapy for staphylococcal prosthetic joint infection 7.
• The effectiveness of different antimicrobial strategies for staphylococcal prosthetic joint infection may depend on various factors, including the type of infection, the presence of implants, and the patient's overall health status 7, 5.

Predictors of Treatment Success and Failure

• Late infection, long instrumented fusions, polymicrobial infections, and Propionibacterium acnes have been identified as risk factors associated with treatment failure of postoperative spine surgical site infections 5.
• Superficial infection and methicillin-sensitive Staphylococcus aureus have been identified as predictors of early resolution of postoperative spine surgical site infections 5.
• The removal of implants and direct or staged re-implantation may be a useful strategy in cases with high risk of treatment failure 5.