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    What Does the Future Hold for Prevention of PJIs?

    Advances in technology and new thinking on prevention strategies will be the keys to reducing the risk of periprosthetic joint infections (PJIs) in total joint arthroplasty (TJA) patients.

    That’s the takeaway message from a presentation by Kevin I. Perry, MD, on PJI prevention and diagnosis in the future at ICJR’s inaugural Emerging Technologies in Joint Replacement course.

    Prevention begins in the preoperative period, and Dr. Perry said the biggest push will be in efforts to modify host risk factors.

    For example, obesity is associated with increased risk of nearly every complication of TJA, and it is known to be 1 of the single greatest contributors to PJI in patients with obesity. [1] What’s needed, Dr. Perry said, are strategies to manage these patients before and after surgery to reduce their risks. Bariatric surgery and long-term antibiotic use have been suggested, but Dr. Perry said a culture change may be more valuable.

    Smoking also puts patients at increased risk for wound complications, including superficial and deep infections. At Dr. Perry’s institution – Mayo Clinic in Rochester, Minnesota – patients who smoke are referred to a smoking cessation program. He and his colleagues also test cotinine levels before surgery and will cancel elective procedures if the test is positive. [2]

    Another important aspect of PJI prevention is mitigating MSSA and MRSA colonization in TJA patients. Combined, MSSA and MRSA colonization account for nearly 50% of surgical site infections. [3] But guidance in this area is unclear: Dr. Perry said research can be found to support and refute the use of intranasal mupirocin and chlorhexidine body wash in colonized patients.

    He said that in the future, surgeons may see adoption of universal decolonization with a 5% solution of povidone-iodine administered intranasally while patients are in the preoperative holding area. [4] In Europe, a promising option is photodisinfection. [5] A photosensitizer dye is applied to the anterior nares for 30 seconds. Illumination with non-thermal red light is applied for 2 minutes and then repeated.

    A technologic advance being explored for the intraoperative period is surgeon decontamination with surgical gloves coated with antibiotics or povidone-iodine. This advance may help to minimize bacterial contamination from surgeon to patient. It may also allow for local delivery of an antibiotic during surgery.

    Novel coatings for the implants used in TJA are also being developed. The aim is to prevent bacterial adhesion and provide bactericidal activity. An example is nanoparticle bactericidal coatings, such as include silver, copper, and bismuth. Cost is an issue, though: A silver-coated prosthesis being used in Europe is at present still too expensive for the US market, Dr. Perry said.

    The operating room can be decontaminated with ultraviolet (UV) light, which is more effective than laminar flow. The UV light may also decontaminate the wound, although the role in reducing PJIs is unknown. Dr. Perry said more research is needed to determine if this technology can be harnessed to treat PJIs intraoperatively, just as intraoperative x-ray technology is used to treat tumors.

    Dr. Perry expects occlusive antimicrobial dressings to continue to be developed to reduce PJI risk postoperatively. Various antibiotic protocols are being explored – including an extended postoperative antibiotic prophylaxis – as is the use of wound oxygenation.

    Click the image above to hear more about the future of PJI prevention from Dr. Perry, as well as a summary of research from Mayo Clinic on advances in PJI diagnosis.

    Disclosures: Dr. Perry has no disclosures relevant to this presentation.

    References

    1. Wagner ER, Kamath AF, Fruth K, Harmsen WS, Berry DJ. Effect of body mass index on reoperation and complications after total knee arthroplasty. J Bone Joint Surg Am. 2016 Dec 21;98(24):2052-2060. doi: 10.2106/JBJS.16.00093.
    2. Hart A, Rainer WG, Taunton MJ, Mabry TM, Berry DJ, Abdel MP. Smoking cessation before and after total joint arthroplasty-an uphill battle. J Arthroplasty. 2019 Jul;34(7S):S140-S143. doi: 10.1016/j.arth.2019.01.073. Epub 2019 Feb 5.
    3. Weiser MC, Moucha CS. The current state of screening and decolonization for the prevention of staphylococcus aureus surgical site infection after total hip and knee arthroplasty. J Bone Joint Surg Am. 2015 Sep 2;97(17):1449-58. doi: 10.2106/JBJS.N.01114.
    4. Caffrey AR, Woodmansee SB, Crandall N, et al. Low adherence to outpatient preoperative methicillin-resistant Staphylococcus aureus decolonization therapy. Infect Control Hosp Epidemiol. 2011 Sep;32(9):930-2. doi: 10.1086/661787.
    5. Bryce E, Wong T, Forrester L, et al. Nasal photodisinfection and chlorhexidine wipes decrease surgical site infections: a historical control study and propensity analysis. J Hosp Infect. 2014 Oct;88(2):89-95. doi: 10.1016/j.jhin.2014.06.017. Epub 2014 Aug 1. Erratum in: J Hosp Infect. 2015 Sep;91(1):93.