Thursday, October 22, 2015

Propionibacterium periprosthetic infections of hip, knee and shoulder

Treatment of prosthetic joint infections due to Propionibacterium

These authors conducted a retrospective cohort study to evaluate treatment success at 1- and 2-year follow-up after treatment of 60 Propionibacterium-associated prosthetic joint infections (PJI) of the shoulder, hip, and knee at a median duration of 21 (0.1-49) months  39 patients received rifampicin combination therapy, with a success rate of 93% (95% CI: 83-97) after 1 year and 86% (CI: 71-93) after 2 years. The success rate was similar in patients who were treated with rifampicin and those who were not.

Most of the blood tests for inflammation were unremarkable. On average 6 specimens were sent for culture and on average 3 of these were positive for Propi. The specifics of the culturing protocol for Propi is not explained.

An open debridement and prosthesis retention was performed if an early postoperative or acute hematogenous PJI was diagnosed. Those patients with a late chronic infection were managed with a 2-stage exchange arthroplasty. Patients who, preoperatively, were not suspected of having an infection, e.g. with aseptic loosening, polyethylene wear, instability, or prosthesis dysfunction, were treated with a 1-stage exchange arthroplasty. In these patients, a PJI was therefore diagnosed from positive intraoperative cultures.

The combination of surgery and long-term antibiotic treatment postoperatively resulted in an overall success rate of 93% at 1-year follow-up and 86% at 2-year followup. At two year followup 7 of 36 patients had failed - four with evidence of ongoing infection with Propionibacterium and 3 with an infection by a different organism.

Comment: One of the first things to catch our eye was the number of Propionibacterium periprosthetic infections identified for the hip and knee. Up until recently, Propi infections were thought to be primarily in the shoulder. Most of the patients presented with the 'stealth' mode typical of Propi:  49 of the 60 patients with pain and 25 with stiffness.

The results of this series combining three different joints are quite similar to those we have previously note for the shoulder. Perhaps our hip and knee colleagues should consider the possibility of Propionibacterium periprosthetic infections in those patients with apparently 'aseptic' joint pain and stiffness.

In that this was not a prospective study, it is difficult make robust conclusions about the role of Rifampin in the management of these infections. There is no question that Rifampin can complicate the postoperative course by interfering with the action other medications the patient may need.


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