procedure was associated with the best outcome
and highlighted that not using antimicrobial
impregnated cement was associated with risk
of re-infection. 7 For all the reasons mentioned,
the risk of re-infection of the prosthetic joint is
unsurprisingly higher in patients with RA-up to
25% compared with 5% in the general population
in both of these studies even with a two-stage
procedure. Both studies showed contrasting
results with regards to immunosuppressive
therapies and the influence on outcomes, leaving
this an area for future research. Ultimately any
non-randomised control study looking at surgical
outcomes in this field is limited by the fact that
patients undergoing a two-stage procedure are
more likely to have favourable joint anatomy and
have fewer comorbidities. This reflects the fact
that the final operative management rests with
the surgical team.
With regards to medical or antimicrobial
therapy of PJI infections this is highly
individualised by the micro-organisms and their
susceptibilities. Every patient with PJI should be
reviewed by an infection specialist. The IDSA 10
recommends two to six weeks of pathogen
specific therapy in combination with oral
rifampicin in susceptible isolates with follow-on
oral therapy for three months in total hip
replacement and six months in total knee
replacement. It also states that IV therapy should
go on for four to six weeks if rifampicin cannot be
used, but evidence is lacking and this is not our
local practice. Lifelong suppressive antimicrobials
may be considered if removal or further revisions
cannot be performed. With regards to a patient
with RA and PJI, the specific medical management
might also be affected by drug interactions with
immunosuppressive therapy and decisions must
be made within a skilled specialist
multidisciplinary team.
Other important medical management
considerations in PJI infection in RA is the
discontinuation of immunosuppressive therapy in
elective patients admitted for revision arthroplasty.
This should be performed in conjunction with
a rheumatologist, especially when considering
stopping long-term corticosteroids due to the
risk of developing acute adrenal insufficiency. The
international consensus meeting on peri-prosthetic
joint infections defined timings based on half-lives
for stopping immunomodulatory therapy for
elective joint replacement. This remains an area
for research in patients with PJI. The decision
to stop, reduce or continue with the current
immunosuppression will require an individualised
risk vs benefit analysis.
As with diagnosis, follow up and response
to medical and surgical of PJI in RA can be
challenging. The joint might be inflamed and
biomarkers may be persistently raised due to
the patients underlying inflammatory condition
rather than persistent infection.
Conclusions
PJI infection in RA remains more common than
in the general population and is challenging to
diagnose and manage. Treatment should be
individualised under a multidisciplinary team in
a specialised centre. Areas of future research to
provide a better evidence base include the effect
of RA and immunomodulatory therapies on the
newer specific bacterial biomarkers and the effect
of immunosuppressive therapies on recovery
from PJI infection.
16
HHE 2019 | hospitalhealthcare.com
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