1. Dr Savita Gossain Heart of England NHS Foundation Trust
Educational Workshops 2013
Bone and Joint Infections
An oozy wound
Dr Savita Gossain Heart of England NHS Foundation Trust

2. Case History
77Y F with background of Type II diabetes; Hypertension; Previous SVT & Osteoporosis
March 2008: Fractured Left NOF, Dynamic hip screw
Oct 2009: Pain in Left hip; at rest & on walking
Nov 2009: DHS revised to gamma nail, satisfactory recovery
12 Dec 2009: Left total hip replacement following failed gamma nail; post-operative anaemia, otherwise uneventful recovery. [ASA 2/3, BMI ~ 35 ]

3. Day 15 post-op THR 27 Dec 2009: Readmission Pain & erythema hip wound
Wound oozing serous fluid
Systemically well
WCC 7.5; CRP 16
X-ray hip : NAD

4. WHAT WOULD YOU ADVISE?

5. Facilitator Slide
Would this situation lead to a consult in hospitals that participants work in?
Discuss whether this is a superficial wound infection or suggestive of Early PJI
Remember that Early infections often will present with local signs of cellulitis, erythema, swelling, pain, drainage, and delayed wound healing and may or may not have systemic symptoms such as fever and chills
IDSA guidelines: “Suspect PJI in patients with any of the following (B-III): A sinus tract or persistent wound drainage over a joint prosthesis....”
Discussion about value of early sampling - aspiration/ debridement.
IDSA guidelines: “A diagnostic arthrocentesis should be performed in all patients with suspected acute PJI unless the diagnosis is evident clinically and surgery is planned and antimicrobials can be safely withheld prior to surgery”
Could also discuss differential cell counts in aspirate – see IDSA guideline
Other investigations - USS? Nucleotide scans?
Antibiotics – ?start now or wait until after samples as she is clinically stable. Using antibiotics now may jeopardise further microbiology results. See above recommendation from IDSA guideline

6. 1 Jan 2010: Discharged home 4/7 later on oral Flucloxacillin 7days (No micro/ID consult)
4 Jan 2010: T&O clinic review (D23 post-op)
Wound erythematous & indurated with mucky discharge
Temp 380C but otherwise well
CRP 91

7. WHAT WOULD YOU ADVISE NOW?

8. Facilitator Slide
Deep infection more likely now and she is febrile although otherwise stable.
Sampling of joint required – open or arthroscopic?
Antibiotics ? – now or wait till after theatre. Ideally, would be after specimens taken.
Choice of Abx?
Various options but initially would be intravenous e.g. Meropenem + Teicoplanin ; Tazocin + Vancomycin or Ciprofloxacin or alternative(s) alone/combination
Samples from theatre – how many? How should they be taken? Also discuss about sending samples for histology
IDSA guidelines: “At least 3 and optimally 5 or 6 periprosthetic intra-operative samples or the explanted prosthesis itself should be submitted for aerobic and anaerobic culture at the time of surgical debridement or prosthesis removal to maximize the chance of obtaining a microbiological diagnosis”
Also see: Atkins et al (1998) J.Clin. Micro.

9. Commenced on IV Benzylpenicillin +Flucloxacillin
5 Jan 2010 (Day 24): Open washout
30-40ml purulent fluid oozed from joint
Samples sent for micro (fluid & tissue)
Wound packed – layers not closed as plan to take back to theatre in 48hrs

10. 7 Jan 2010 (Day 26) E.coli grown from fluid samples x2
Tissue not received (!)
Changed to iv ciprofloxacin + stat gentamicin in theatre (Microbiology advice)
Back to theatre
“most tissues appeared healthy & viable. Three tissue samples taken (superficial, deep & capsule). Further debridement to healthy tissue. Washout of hip joint, 6 litres saline with pulsed lavage”

11. 9 Jan 2010: All tissue samples from 7/1/10 grew E
9 Jan 2010: All tissue samples from 7/1/10 grew E.coli as previously, ciprofloxacin continued.
E.coli = fully sensitive (Ampicillin, Gentamicin, Ciprofloxacin, Cefuroxime, Meropenem..)

12. What would you advise for further management ?

13. Facilitator Slide
No published randomized trials to address optimal management strategy – surgical decision with input from infection specialist, plastics etc.
Dependent on many factors including patient factors e.g. Surgical risk & patient preference; whether prosthesis well fixed or loose; duration symptoms; infecting pathogen susceptibility; quality of peri prosthetic soft tissue.
Well fixed prosthesis and early infection (within 30d of implantation) so in this case, could be considered for Debridement and implant retention (DAIR) strategy
Joint exchange strategy could also be used (1 or 2 stage)
Other options are resection arthroplasty, arthrodesis, amputation.
Antibiotic options dependent on surgical plan/ pathogen

14. Antibiotic treatment
Picc line inserted 11/1/10 & Ceftriaxone 2g od commenced by ID Consultant. Plan for 4-6/52 iv to be continued as OPAT and then prolonged oral course of antibiotics (Ciprofloxacin) to eradicate the infection.

15. Liver function tests 7 Dec 2009 6 Jan 2010 12 Jan 2010 ALT (0 – 33) 11
211
Alk Phos
( ) 76 83
627
Bilirubin
(0 – 17) 5 3 4

16. Cause of deranged LFTs? What would you advise?

17. Facilitator Slide Possible cause of deranged LFTS:
?Ceftriaxone (but commenced on 11/1/10)
?Flucloxacillin (from 5/1/10 - 7/1/10)
?Ciprofloxacin (from 7/1/10 – 11/1/10)

18. It was thought that rise may be related to ciprofloxacin as raised 12 hours after switch to ceftriaxone.
However liver SEs much more common with ceftriaxone so planned to closely watch LFTs over next few days....

19. Liver function tests 7 Dec 2009 6 Jan 2010 12 Jan 2010 14 Jan 16 Jan
ALT
(0 – 33) 11 10
211
106 52 16 14
Alk Phos ( ) 76 83
627
507
369
210
172
Bilirubin
(0 – 17) 5 3 4

20. Further progress
Following debridement & washout – wound oozing serous fluid for few days. Clips were removed 20/1/10 (Day 13 post debridement)
22/1/10: temperature spike and ?rigors. Septic screen and paired BC advised & to remove line if further spike temperature. Wound ooze settling.

21. Cultures:
W/S mixed skin flora
MSU : 13 WBC, 15 RBC, culture not indicated
BC x 2: Negative
CRP 15
However, continuing ooze from wound (serous)and few spikes of temperature over next few days (still on ceftriaxone)

22. WHAT WOULD YOU ADVISE?

23. Facilitator Slide
Possibility of another infection source – however infection screen negative
Continuing fevers and wound oozing suggestive of continuing infection/sinus
Further management ideally should be decision made as part of MDT and also determined whether prosthesis is well-fixed
If well fixed could consider further debridement and excision sinus tract or a 2 stage revision. See IDSA guidelines

24. ID consult
Wound not settled post debridement although inflammatory markers down
Wound not cellulitic. Continued ooze suggests sinus tract
Consider USS to see if superficial collection
If joint secure – further w/o & debridement, excision sinus tract & and replacement of any exchangeable components
If joint loose – 2 stage revision
Alternative of long term suppression with antibiotics less useful with E.coli as more resistant strains may emerge during treatment

25. USS on 4/2/10 (D28 post debridement): No collection, no effusion in joint.
Temperature settling, mobilising, pain better
T & O consultant: “as improving and CRP coming down and no collection on USS, does not want to do 2 stage revision at this time”
Wound continued to ooze : no cellulitis, small discharging sinus middle wound

26. WHAT ARE THE OPTIONS?

27. Facilitator Slide
Sinus tract now present (?failed DAIR) & Surgeon decision against joint revision now
Use of Ceftriaxone vs. Ciprofloxacin – IDSA guideline: “For patients with non staphylococcal PJI treated with debridement and retention, the panel agrees on using an induction course of intravenous antimicrobial therapy or highly available oral therapy as outlined in Table 2 based on in vitro sensitivity testing. The use of quinolones after debridement and retention for susceptible aerobic gram-negative PJI may improve the outcome.” Refs Martinez-Pastor et al (2009) & Legout et al (2006)
In this case, ciprofloxacin was not used – not quite clear from notes why
Chronic Suppression with antibiotics – choices of agent??

28. 19/2/10 Completed 6/52 IV Ceftriaxone
?Unsuccessful attempt at cure by DAIR
Discharging chronic sinus
No plan for revision
Discharged home on po Amoxycillin 500mg qds & review in 1 month whether to continue
If deterioration hip function , may require revision
Discharged home 1/3/10 (D53 post debridement)

29. April 2010: Clinic Review
Systemically well
No cellulitis over wound
Sinus over the wound healed
Normal WCC & CRP 10
Continued Amoxicillin 500mg tds, suppressive treatment
Patient made aware of CDI risk, chronicity of infection.

30. July 2011 & July 2012:
No problems with the hip.
Xray hip: NAD
Wound healed.
Continuing suppressive Amoxycillin

31. SUMMARY Case of early infection THR (<30d post surgery)
Delayed wound healing/ ooze may represent early infection +/- systemic symptoms
Managed as DAIR initially – IDSA guidelines (A-II recommendation for early infection, well fixed prosthesis)
?Failed DAIR – sinus developed , but no further surgery planned
Suppressive antibiotics continuing