Painful and stiff shoulder arthroplasties may come to surgical revision. Because Cutibacterium periprosthetic infection (Cuti PJI) is a common cause of a stiff, painful arthroplasty and because Cuti PJI cannot be reliably diagnosed before or at the time of revision arthroplasty, the surgeon needs to make a decision regarding postoperative antibiotic therapy without knowledge of the results of introperative cultures (which are only finalized weeks after the procedure).
These authors determined infection-free survival, revision-free survival, complications, and patient-reported outcomes for 92 patients selected to receive oral or intravenous (IV) antibiotics after single stage revision arthroplasty. IV antibiotics were administered if the surgeon had a high index of suspicion for infection, and oral antibiotics were given if there was a low suspicion. Factors contributing to a high index of suspicion included young age, male sex, prior infection, prior surgery on the shoulder, humeral loosening or osteolysis, synovitis, and high levels of Cutibacterium on cultures of the unprepared skin over the shoulder. Antibiotic therapy was modified as necessary when the results of intraoperative culture became available. Patient-reported outcomes and adverse events were documented at a mean of 4.1 years.
Patients opting out of the recommended antibiotic protocol and those with obvious infection (e.g., draining sinus, purulence, or multiple cultures positive for virulent bacteria) were excluded from this study given that IV antibiotic treatment was used in all of these patients. 27 patients who did not have 2-year followup were excluded.
In selecting antibiotic therapy, surgeons correctly predicted the presence or absence of multiple positive cultures of specimens from the revision surgery in 72% of the 92 cases. This means that in the great majority of cases, those with multiple positive cultures were assigned to receive intravenous antibiotics and those without multiple positive cultures were assigned to receive oral antibiotics.
Post-revision antibiotic therapy was associated with an infection-free survival rate of 91% at a mean of >4 years of follow-up.
Subsequent re-revision surgery was performed in 17 (18%) of the patients; 8 of these 17 patients had ≥2 positive cultures at re-revision, indicating that the revision and antibiotics failed to resolve the infection. Patients having ≥2 positive cultures at re-revision were more likely to be younger, to be male, and to have been deemed "high risk" for Cutibacterium PJI at the initial revision.
The IV and oral antibiotic groups had similar postoperative Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES), and satisfaction scores.
Patients receiving IV antibiotics had a higher rate of antibiotic-related adverse events.
10 out of 37 (27%) of patients started on IV antibiotics had complications: 4 had gastrointestinal complications, 3 had dermatologic complications and 3 had other complications.
12 out of 55 (22%) patients started on oral antibiotics had complications: 3 had gastrointestinal complications, 5 had dermatologic complications, and 4 had other complications.
While patients requiring a change from oral to IV antibiotics based on positive intraoperative cultures had similar survivorship compared with those initially treated with IV antibiotics, the highest rate of antibiotic related complications - 8 out of 15 (53%) - was seen in patients initially started on oral antibiotics and converted to IV antibiotics when intraoperative cultures turned positive.
Comment: These authors' approach to post-revision antibiotic therapy yielded an infection-free survivorship of 91% at an average of >4 years of follow-up. They were able to predict the presence or absence of ≥2 positive cultures of specimens taken at revision arthroplasty in 72% of the cases. The outcomes of treating patients deemed to be at high risk for Cuti PJI with IV antibiotics were similar to the outcomes of treating patients deemed to be at low risk for Cuti PJI with oral antibiotics. Overall, patients demonstrated a median decrease in the VAS pain score of 4 points and a median improvement in the SSTscore of 3 points, both of which surpass the minimum clinically important difference for these instrument
There are advantages to starting IV antibiotics prior to hospital discharge in patients with a high suspicion for PJI, including increased efficacy of the IV therapy (i.e. consistency of administration and achievement of the desired antibiotic serum levels) and establishment of a peripherally inserted peripheral central catheter (PICC line) before the patient leaves the medical center. Disadvantages of a PICC line include the cost and the risks of venous throboembolism and catheter migration.
While the initial use of oral antibiotics may seem more benign, the delayed implementation of IV antibiotics can be difficult to arrange (especially if the patient lives in a city remote from the surgeon's site of practice) and, for reasons that remain unclear, patients started on oral antibiotics and converted to IV antibiotics because of positive cultures have the highest rate of antibiotic related complications.
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