Implant materials and prosthetic joint infection: the battle with the biofilm

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Abstract

Prosthetic joint infection (PJI) is associated with poor clinical outcomes and is expensive to treat.
Although uncommon overall (affecting between 0.5% and 2.2% of cases), PJI is one of the most commonly encountered complications of joint replacement and its incidence is increasing, putting a significant burden on healthcare systems.
Once established, PJI is extremely difficult to eradicate as bacteria exist in biofilms which protect them from antibiotics and the host immune response.
Improved understanding of the microbial pathology in PJI has generated potential new treatment strategies for prevention and eradication of biofilm associated infection including modification of implant surfaces to prevent adhesion of bacteria.
Much research is currently ongoing looking at different implant surface coatings and modifications, and although most of this work has not translated into clinical medicine there has been some early clinical success.

Cite this article: EFORT Open Rev 2019;4:633-639. DOI: 10.1302/2058-5241.4.180095

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Biofilm bacteria: formation and comparative susceptibility to antibiotics.

Merle E Olson, Howard Ceri, Douglas Morck … (2002)

The Calgary Biofilm Device (CBD) was used to form bacterial biofilms of selected veterinary gram-negative and gram-positive pathogenic bacteria from cattle, sheep, pigs, chicken, and turkeys. The minimum inhibitory concentration (MIC) and minimum biofilm eradication concentration (MBEC) of ampicillin, ceftiofur, cloxacillin, oxytetracycline, penicillin G, streptomycin, tetracycline, enrofloxacin, erythromycin, gentamicin, tilmicosin, and trimethoprim-sulfadoxine for gram-positive and -negative bacteria were determined. Bacterial biofilms were readily formed on the CBD under selected conditions. The biofilms consisted of micro-colonies encased in extracellular polysaccharide material. Biofilms composed of Arcanobacterium (Actinomyces) pyogenes, Staphylococcus aureus, Staphylococcus hyicus, Streptococcus agalactiae, Corynebacterium renale, or Corynebacterium pseudotuberculosis were not killed by the antibiotics tested but as planktonic bacteria they were sensitive at low concentrations. Biofilm and planktonic Streptococcus dysgalactiae and Streptococcus suis were sensitive to penicillin, ceftiofur, cloxacillin, ampicillin, and oxytetracycline. Planktonic Escherichia coli were sensitive to enrofloxacin, gentamicin, oxytetracycline and trimethoprim/ sulfadoxine. Enrofloxacin and gentamicin were the most effective antibiotics against E. coli growing as a biofilm. Salmonella spp. and Pseudomonas aeruginosa isolates growing as planktonic populations were sensitive to enrofloxacin, gentamicin, ampicillin, oxytetracycline, and trimethoprim/sulfadoxine, but as a biofilm, these bacteria were only sensitive to enrofloxacin. Planktonic and biofilm Pasteurella multocida and Mannheimia haemolytica had similar antibiotic sensitivity profiles and were sensitive to most of the antibiotics tested. The CBD provides a valuable new technology that can be used to select antibiotics that are able to kill bacteria growing as biofilms.

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Patient-Related Risk Factors for Periprosthetic Joint Infection after Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

Setor Kunutsor, Michael Whitehouse, Ashley W. Blom … (2016)

Background Periprosthetic joint infections (PJIs) are dreaded complications of total joint arthroplasties. The risk of developing PJIs is likely to be influenced by several patient factors such as sociodemographic characteristics, body mass index (BMI), and medical and surgical histories. However, the nature and magnitude of the long-term longitudinal associations between these patient-related factors and risk of developing PJIs are uncertain. Objective To conduct a systematic review and meta-analysis to assess the associations between several patient-related factors and PJI. Data Sources MEDLINE, EMBASE, Web of Science, Cochrane Library, and reference lists of relevant studies from inception to September 2015. Study Selection Longitudinal studies with at least one-year of follow-up for PJIs after total joint arthroplasty. Data Extraction and Synthesis Two investigators extracted data on study characteristics, methods, and outcomes. A consensus was reached with involvement of a third. The relative risk (RR) with 95% confidence intervals was used as the summary measure of association across studies. Study-specific RRs with 95% confidence intervals were meta-analysed using random effect models and were grouped by study-level characteristics. Results Sixty-six observational (23 prospective cohort and 43 retrospective cohort or case-control) studies with data on 512,508 participants were included. Comparing males to females and smokers to non-smokers, the pooled RRs for PJI were 1.36 (1.18–1.57) and 1.83 (1.24–2.70) respectively. There was no evidence of any significant associations of PJI with age and high alcohol intake. Comparing BMI ≥ 30 versus < 30 kg/m2; ≥ 35 versus < 35 kg/m2; and ≥ 40 versus < 40 kg/m2; the pooled RRs were 1.60 (1.29–1.99); 1.53 (1.22–1.92); and 3.68 (2.25–6.01) respectively. Histories of diabetes, rheumatoid arthritis, depression, steroid use, and previous joint surgery were also associated with increased risk of PJI. The results remained similar when grouped by relevant study level characteristics. Conclusions Several potentially modifiable patient-related factors are associated with the risk of developing PJIs. Identifying patients with these risk factors who are due to have arthroplasty surgery and modulating these risk factors might be essential in reducing the incidence of PJI. Further research is however warranted to assess the potential clinical utility of these risk factors as risk assessment tools for PJI. Systematic Review Registration PROSPERO 2015: CRD42015023485

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Antibiotic prophylaxis in total hip arthroplasty: effects of antibiotic prophylaxis systemically and in bone cement on the revision rate of 22,170 primary hip replacements followed 0-14 years in the Norwegian Arthroplasty Register.

Stein Lie, Lars B Engesæter, Stein Emil Vollset … (2003)

We studied the effects of antibiotic prophylaxis, systemically and in bone cement, on the revision rate of cemented total hip arthroplasties (THAs) in data from the Norwegian Arthroplasty Register during the period 1987-2001. To have comparable groups, only THAs performed because of primary osteoarthritis, using cemented implants with documented good results, and high-viscosity cement were included. If systemic antibiotic prophylaxis had been given, only operations with cephalosporin or penicillin were selected. Cox-estimated survival relative revision risks (RR) are presented with adjustment for differences among groups in gender, age, cement brand, type of systemic antibiotic prophylaxis, type of prosthesis, type of operating room, and duration of the operation. Of 22,170 THAs studied, 696 THAs (3.1%) were revised, 440 (2.0%) for aseptic loosening and 102 (0.5%) for deep infection. We found the lowest risk of revision when the antibiotic prophylaxis was given both systemically and in the cement (15,676 THAs). Compared to this combined regime, patients who received antibiotic prophylaxis only systemically (5,960 THAs) had a 1.4 times higher revision rate with all reasons for revision as endpoint (p = 0.001), 1.3 times higher with aseptic loosening (p = 0.02) and 1.8 times higher with infection as the endpoint (p = 0.01). With the combined antibiotic regime, the results were better if antibiotics were given 4 times on the day of surgery (2,194 THAs), as compared to once (1,424 THAs) (p < 0.001), twice (2,680 THAs) (p < 0.001), or 3 times (5,522 THAs) (p = 0.02). Those who received systemic prophylaxis a single day 1, 2 or 3 times, as compared to 4 times, had a revision rate 1.8-3.5 times higher with all reasons for revision as endpoint, 1.5-3.1 times higher with aseptic loosening, and 2.7-6.8 times higher with infection. When we compared systemic prophylaxis 4 times in 1 day, no further improvement resulted in those given systemic prophylaxis for 2 days (1,928 THAs) or 3 days (717 THAs). In a subset of data including only the Charnley prosthesis, we obtained similar results. This observational study shows that the best results were recorded when antibiotic prophylaxis was given both systemically and in the bone cement, and if the systemic antibiotic was given 4 times on the day of surgery.

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Journal

Journal ID (nlm-ta): EFORT Open Rev

Journal ID (iso-abbrev): EFORT Open Rev

Title: EFORT Open Reviews

Publisher: British Editorial Society of Bone and Joint Surgery

ISSN (Electronic): 2058-5241

Publication date Collection: November 2019

Publication date (Electronic): 5 November 2019

Volume: 4

Issue: 11

Pages: 633-639

Affiliations

[1 ]Research Department of Orthopaedics and Musculoskeletal Sciences, University College London, London, UK

[2 ]Department of Microbial Diseases, UCL Eastman Dental Institute, University College London, London, UK

[3 ]MSK Lab, Imperial College London, London, UK

Author notes

[*]Alexander D. Liddle, MSK Lab, Imperial College London, 7 ^th Floor, Charing Cross Campus, St Dunstan’s Road, London, W6 8RP, UK. Email: a.liddle@ 123456imperial.ac.uk

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Publisher ID: 10.1302_2058-5241.4.180095

DOI: 10.1302/2058-5241.4.180095

PMC ID: 6851527

SO-VID: 085683fa-a668-4717-b1a5-514b65f0c89f

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This article is distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence ( https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed.

Implant materials and prosthetic joint infection: the battle with the biofilm

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UCL: UN SDG 03 Good Health and Well-Being

Most cited references 48

Biofilm bacteria: formation and comparative susceptibility to antibiotics.

Patient-Related Risk Factors for Periprosthetic Joint Infection after Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

Antibiotic prophylaxis in total hip arthroplasty: effects of antibiotic prophylaxis systemically and in bone cement on the revision rate of 22,170 primary hip replacements followed 0-14 years in the Norwegian Arthroplasty Register.

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