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Prevention of InfectionStrategies that Work

Javad Parvizi, MD, FRCS Professor of Orthopaedic SurgeryRothman Institute at Thomas Jefferson University

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RESEARCH SUPPORT:• NIH

• OREF

• Stryker Orthopedics

• Depuy

• Zimmer

• Baxter

• 3M

• Biomemetics

• Ceramtec

• Smith and Nephew

CONSULTANT:• Zimmer

• Smith and Nephew

• Convatech

• TissueGene

• Ceramtec

• Emovi

• 3M

• Cadence

INTELLECTUAL PROPERTY/ROYALTY:/OWNERSHIP

• SmarTech

• Elsevier

• Wolters Kluwer

• Slack

• Hip Innovation Technology

• CD Diagnostics

• Jaypee publishers

• Datatrace

Disclosures

� Board Member/Adviser� Journal of Arthroplasty� Philadelphia Orthopaedic Soc� Eastern Orthopedic Assoc.� United Healthcare� 3M� JBJS-A� Bone and Joint Journal (British)� Muller Foundation

Implants Today

1890 THEMISTOKLES GLUCK

…. ailments of human joints will be treated by artificial

materials…….

Periprosthetic Joint Infection

1976S SIR JOHN CHARNLEY

…joint sepsis will be the major hurdlein our way in the future..

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THA Infection: Medicare Data

TKA Infection: Medicare Data

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Infected Revisions: 1990-2003

0

1,000

2,000

3,000

4,000

5,000

6,000

1990 1992 1994 1996 1998 2000 2002 2004

No

. o

f In

fect

ed

Re

vis

ion

s

Infected THA

Infected TKA

Kurtz, S, Parvizi J JOA 2008

Infected Revisions 2001-20: Burden

Kurtz, S, et al JOA 2012

Cost 2009$600 Million

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Periprosthetic Joint Infection

� PREVENTION

� DIAGNOSIS� TREATMENT

Periprosthetic Joint Infection

� PREVENTION OF SSI GUIDELINES ARE IN DEVELOPMENT

Medicine is an Art

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Innovators

Medicine Has Evolved

Sir James Paget1814 - 1899

Sir James Paget1814 - 1899

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Evidence Based Pyramid

True Model of EBM

International Consensus MeetingPhiladelphia, August 2013

� 400 delegates� 52 countries

� >100 societies

� 22 translations

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International Consensus GroupStep 6: Assemblage

� Editorial in BJJ, CORR� Full publication in JOA� 15,000 copies of book� Translation to 21 languages� Numerous society websites

International Consensus GroupStep 8: Publication

Prevention of PJI

� OPTIMIZE HOST

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Diabetes

� Control of glucose

� HbA1C <7%

� glucose <180

� Ulcerations

� Neuropathy

Control Nidus

� GI/GU (urine)

� Skin/nails

� No role for routine dental clearance

Rheumatoid Arthritis

� Disease modifying agents (antimonoclonal antibodies)- Stop 4 weeks before and 8 weeks after

� Steroids (taper)

� Skin (ensure there is no ulcers)

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Preoperative Optimization

� malnutrition

� obesity

� skin (psoriasis, eczma, ulcerations)

� vascular insufficiency ??

� smoking

Peri-operative Factors

� Skin prep

� Gloves

� Draping

� Room

� Antibiotics

� Exposure

� Bleeding control

� Closure

� Dressing

ANTIBIOTICS

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PROPHYLACTIC ANTIBIOTICS

Prevention of PJI Antibiotics

� Vancomycin (needs 1 hour)

� MRSA carriers

� Remote or recent MRSA Infection

� Institutionalized patients

� Healthcare workers

Skin Prep

� Starts at Home

Preoperative Optimization

SKIN DECONTAMINATION

� Betadine shower

� Chlorhexidine wipes/showers

� Shaving (save until the OR)

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SKIN PREP•9 step

Matar W, et al JBJS 2012

Skin Prep

SKIN PREP•Most important agent is ALCOHOL

Skin Prep� Contamination of skin during

draping

� May repeat skin prep

Drapes� Skin recolonizes

� Adhesive draping

Johnston DH, et al: Br J Surg 74:64, 1987

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OR Environment

LACK OF ADEQUATE SCIENCE

� Laminar flow

� Space suits

� Size/volume

OR EnvironmentWOUND CONTAMINATION •Direct Fall-out

•Gloves Or Instruments

THE PRIMARY SOURCE OF BACTERIA

IN OR IS OR PERSONNEL

OR EnvironmentPEOPLE SHED UP TO

10,000 BACTERIA/MIN.

“DISPERSERS”

•13% of Men

•5% of Post-menopausal Woman

•1% of Pre-menopausal Women •Traffic--- terrible

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Gloves

� Puncture all cases > 3 hrs

� Cotton outer gloves reduce risk

� Change every 2 hrs

OPTIMAL SOLUTION NOT KNOWN

Wound Irrigation

Wound Complications

�Drainage

�Hematoma

�Cellulitis

Treat Aggressively

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Hips do not lie

Risk Factors for PJI� RHEUMATOID ARTHRITIS

� STEROID THERAPY

� DIABETES MELLITUS

� PRIOR SEPTIC ARTHRITIS

� PRIOR ARTHROPLASTY

� MALIGNANCY

� LYMPHOCYTE <1.5X109

� MORE THAN 4 HOSPITAL DAYS PRIOR TO TJR

� HOMOLOGOUS BLOOD� DURATION OF

HOSPITALIZATION� DECUBITUS ULCERS� NINS>1� SUPERFICIAL WOUND

INFECTION� WOUND DRAINAGE� WOUND HEMATOMA� WOUND DEHISCENCE

Berbari EF, et al; Clin Infect Dis, 27:1247, 1998

Pulido L et al CORR 2009

Approach

� Old scars

� Undermining

� Gentle handling

� Expeditious surgery

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Hematoma� Serious Event

� Soft tissue ischemia/necrosis

� Prevents antibiotic access

Nelson CL, et al: Clin Orthop 147:167, 1980

Hematoma� Associated with the

administration of anticoagulation

� Increases risk of PJI

Parvizi J, et al: J Arthoplasty 2008

� Serious event

� Soft tissue ischemia/necrosis

� Prevents antibiotic access

Anticoagulation

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Hematoma� Low threshold for I & D if

associated with drainage� “Large”� Active

Drains� Hadden, J arth 1990

� Beer, JBJS 1991

� Acus, orthop 1992

� Ritter, JBJS 1994

� Niskanen, J arth 2000

� Hallstrom, orthop rev 1992

Cochrane database

•No difference in hematoma

formation

•Higher blood loss

Surin et al. JBJS-B, 1984 Brown et al.JBJS-B, 1996.

DrainageHIPS WITH H/O DRAINAGE AFTER OPERATION HAVE 3 – 4X

GREATER RISK OF INFECTION THAN THOSE

THAT HEAL NORMALLY

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Prevention of Wound Drainage

WOUND OPTIMIZATION� Meticulous closure

� Sealed dressing� Infrequent dressing changes� Watchful eye

Surgical Dressing Protocol

� 1st dressing change at 7 days� No environmental wound exposure

� Reduces pain associated with dressing changes

� Ease for family/caretaker

� Excessive drainage evaluated via strikethrough

� Patients may shower immediately post operatively

Screening and Decolonization?

SSI caused by MRSA

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� One time application

� One hour before surgery

� 12 hour effect

� 99% eradication

� Lowers SSI

Phillips MS et al . IDSA 2012

Decolonization

Screening� It appears that screening and decolonization

reduces the incidence of SSI

� Logistic issues

� How to implement

� Perhaps most important is identifications

� Appropriate antibiotics

� Isolation

Stay tuned

Questions?