A protocol for periprosthetic joint infections from the Northern Infection Network for Joint Arthroplasty (NINJA) in the Netherlands

Abstract

Periprosthetic joint infection (PJI) is a devastating complication of joint arthroplasty surgery. Treatment success depends on accurate diagnostics, adequate surgical experience and interdisciplinary consultation between orthopedic surgeons, plastic surgeons, infectious disease specialists and medical microbiologists. For this purpose, we initiated the Northern Infection Network for Joint Arthroplasty (NINJA) in the Netherlands in 2014. The establishment of a mutual diagnostic and treatment protocol for PJI in our region has enabled mutual understanding, has supported agreement on how to treat specific patients, and has led to clarity for smaller hospitals in our region for when to refer patients without jeopardizing important initial treatment locally. Furthermore, a mutual PJI patient database has enabled the improvement of our protocol, based on medicine-based evidence from our scientific data. In this paper we describe our NINJA protocol.Level of evidence: III.

Keywords: Arthroplasty Surgery; Debridement Antibiotics and Implant Retention (DAIR); Periprosthetic joint infection (PJI); Protocol; Treatment.

Fig. 1

Flowchart of suspected early (postoperative) or late acute (hematogenous) PJI. *KLIC: Kidney, Liver cirrhosis, Index surgery, C-reactive protein and Cemented prosthesis (see Table 1) [7, 8]. ^#CRIME80: Chronic obstructive pulmonary disease, Rheumatoid arthritis, Index surgery, Male gender, Exchange of mobile components and age > 80 years (see Table 1) [9]

Fig. 2

Flowchart of suspected late chronic PJI. ¹Difficult to treat: chinolon resistant Gram-negative rods, rifampin-resistent Staphylocci, Enterococci, fungi and yeasts. ²In order to avoid secondary spacer infections with coagulase-negative Staphylococci [10]. ³For example in case of positive histology. ⁴Consider a nuclear bone or white blood cell scintigraphy if available. A bone scintigraphy is advised as a first step if the patient is > 5 years after the index surgery for knees and > 2 years for hips; when the affected prosthesis is younger, a white blood cell scintigraphy can be considered. If the bone scintigraphy is negative, infection is practically ruled out and no additional scans are needed. If the bone scan is positive, a white blood cell scintigraphy should be considered as it is more specific in diagnosing infection. If the white blood cell scintigraphy is negative, an infection is highly unlikely; if it is positive, cultures and histology should be performed as indicated above

Fig. 3

Surgical strategy in relation to antibiotic treatment duration. ¹A 2-stage exchange without antibiotic holiday is preferred. ²Targeted antibiotics in spacer (incl. vancomycin regardless of causative agent). If the causative agent is unknown, the most commonly used regimen is: gentamicin and vancomycin. Prefabricated spacers often contain gentamicin and clindamycin in the cement, but previous studies have shown that adding vancomycin (2 g per 40 g of cement) reduces secondary spacer infections with coagulase-negative Staphylococci [10], and is therefore recommended to be added. In general, it should be taken into account that the stability of the cement is adversely affected if more than 10% antibiotics are added to the cement (= 4 g of antibiotics per 40 g of cement). This is especially important with cement fixation (and less so when using temporary cement spacers). ³Provided that reimplantation cultures are negative