What is the recommended treatment for a ruptured and infected gluteal implant?

Treatment of Ruptured and Infected Gluteal Implant

The recommended treatment for a ruptured and infected gluteal implant is immediate surgical removal of the implant with thorough debridement of all infected and necrotic tissue, followed by appropriate antibiotic therapy. 1

Surgical Management

Primary Intervention

• Complete implant removal is essential as the implant serves as a foreign body that harbors biofilm-forming bacteria
• Thorough surgical debridement of:
  • All infected tissue
  • Necrotic tissue
  • The implant capsule
  • Any silicone material that may have leaked into surrounding tissues

Debridement Technique

• Judicious and well-planned debridement with removal of all dead tissues 1
• Acquisition of deep tissue biopsies for microbiology and histopathology to guide targeted antibiotic therapy
• Ensure adequate drainage of any collections

Soft Tissue Management

• Optimal definitive soft tissue coverage should be achieved as soon as possible 1
• Options include:
  • Primary closure if tissue quality permits
  • Delayed closure with negative pressure wound therapy in cases of significant infection
  • Soft tissue reconstruction may be necessary in cases with substantial tissue loss

Antibiotic Therapy

Empiric Therapy

• After surgical debridement and sampling, empirical antibiotic therapy should be started immediately 1
• Initial empiric regimen should include:
  • A lipo/glycopeptide (vancomycin/teicoplanin) to cover gram-positive organisms including MRSA
  • An agent against gram-negative bacteria (e.g., piperacillin-tazobactam, cefepime, or a carbapenem) 1

Targeted Therapy

• Adjust antibiotics based on culture results and susceptibility testing
• Duration of therapy:
  • 6 weeks of antimicrobial therapy after implant removal 1
  • IV therapy should be limited to 1-2 weeks until the patient is stable and culture results are known 1
  • Followed by appropriate oral antibiotics to complete the course

Special Considerations for Biofilm

• Biofilm-active antibiotics should be considered if cultures show:
  • Staphylococci: rifampicin plus a companion antibiotic (fluoroquinolone preferred) 1
  • Gram-negative bacteria: fluoroquinolones have excellent activity on gram-negative biofilms 1
  • Streptococci: IV benzyl penicillin followed by oral amoxicillin 1
  • Enterococci: ampicillin or vancomycin/daptomycin for resistant strains 1

Follow-up Care

• Regular wound assessment and dressing changes
• Monitor for signs of persistent infection
• Follow-up for a minimum of 12 months after cessation of therapy 1
• Consider reimplantation only after complete resolution of infection (typically not before 6-12 months)

Pitfalls and Caveats

• Do not attempt implant retention in this scenario as the combination of rupture and infection makes successful treatment with implant preservation virtually impossible
• Avoid inadequate debridement which can lead to persistent infection
• Be aware that gluteal implant infections can spread to adjacent structures including the hip joint or sacroiliac joint
• Cultures may be falsely negative if antibiotics were administered prior to sampling
• Reimplantation carries a high risk of recurrent infection and should be approached with caution

By following this approach, the focus remains on addressing the infection to minimize morbidity and mortality risks while optimizing the patient's quality of life through effective elimination of the infection source.