Implementation of Outpatient Parenteral Antimicrobial Therapy (OPAT) in Patients with Complicated Periprosthetic Joint Infections

Abstract

Introduction

Periprosthetic joint infections (PJI) are a serious complication of arthroplasty with high morbidity. With growing bacterial resistance and limited disposability of oral antibiotics with sufficient bioavailability, the need for intravenous antibiotic application is raising. This causes long-term hospital stays and rising costs. In the course of transferring procedures into an outpatient setting as well as coping with pressures on hospital capacity, outpatient parenteral antimicrobial therapy (OPAT) can build a bridge for the treatment of such infections.

Methods

In a single centre analysis, 47 cases treated with OPAT were studied in relation to pathogen, antimicrobial resistance, indication for OPAT and follow up. Furthermore, the patients received an anonymised questionnaire with 4 clusters of interest in terms of internal quality assessment on the success and evaluation of this therapeutic procedure. Special attention was paid to the descriptive analysis of patients with periprosthetic joint infections (n = 30).

Results

Between May 2021 and October 2022 out of 47 patients with OPAT, 30 cases with periprosthetic joint infections were identified. For infected hip- and knee arthroplasties, a remarkable spectrum of pathogens was found. In hip infections highly resistant strains of Staphylococcus epidermidis and Enterococci were detected. In knee infections, the pathogens were more susceptible, but however highly virulent Staphylococcus aureus and Streptococci. Difficult to treat, mixed infections were found in both locations. The indication for OPAT was based in half of the cases on the high level of antimicrobial resistance, with availability of only parenteral applicable antibiotics. Further indications were mixed infections and difficult to treat pathogens, with flucloxacillin therapy as well as OPAT as the last therapeutic option. The questionnaire showed 96% patient satisfaction in terms of organisation and acceptance of this kind of therapy. Complications or unexpected outpatient/ hospital treatments were very rare in connection with OPAT. Two thirds of patients reported completion of the treatment. In the clinical follow up (average of 5.7 months), 96.6% of cases were declared free of infection. In one patient the infection persisted.

Discussion

OPAT is a safe and reliable therapeutic option for outpatients to continue parenteral antimicrobial treatment in joint infections. Due to increasing pressure on hospitals in terms of costs and capacity, this therapy offers an alternative to inpatient treatment. The indication for OPAT should be set individually, risk adjusted and not generalised for all patients. The outpatient sector needs financial and structural support for comprehensive roll-out of this treatment in Germany. A further focus should be on the prevention of periprosthetic joint infections. With the knowledge of the expected pathogens and the surgical resources, the standards should be adapted. The choice of the antibiotic should be specified and the intervals of application be shortened, according to the surgical course, in order to yield high levels of agent concentration in the surgical area. Further investigations are required to test the superiority of OPAT versus the oral administration of antibiotics in long-term observations as well as to define the necessary duration of OPAT.

Keywords

OPAT - PJI - bacterial resistances

Publication History

Received: 27 December 2022

Accepted after revision: 12 March 2024

Article published online:
27 May 2024

• Literatur

• 1 Gehrke T, Alijanipour P, Parvizi J. The management of an infected total knee arthropasty. Bone Joint J 2015; 97-B (10 Suppl A): 20-29
• 2 Lazic I, Scheele C, Pohlig F. et al. Treatment options in PJI – is two-stage still gold standard?. J Orthop 2021; 23: 180-184
• 3 Izakovicova P, Borens O, Trampuz A. Periprosthetic joint infection: current concepts and outlook. EFORT Open Rev 2019; 4: 482-494
• 4 Leta TH, Lygre SH, Schrama JC. et al. Outcome of Revision Surgery for Infection After Total Knee Arthroplasty: Results of 3 Surgical Strategies. JBJS Rev 2019; 7: e4
• 5 Kurtz S M, Lau EC, Son MS. et al. Are We Winning or Losing the Battle With Periprosthetic Joint Infection: Trends in Periprosthetic Joint Infection and Mortality Risk for the Medicare Population. J Arthroplasty 2018; 33: 3238-3245
• 6 Natsuhara KM, Shelton TJ, Meehan JP. et al. Mortality during total hip periprosthetic joint infection. J Arthroplasty 2019; 34 (7S): S337-S342
• 7 Parvizi J, Tan TL, Goswami K. et al. The 2018 Definition of Periprosthetic Hip and Knee Infection: An Evidence-Based and Validated Criteria. J Arthroplasty 2018; 33: 1309-1314.e2
• 8 Li R, Song L, Quan Q. et al. Detecting periprosthetic joint infection by using mass spectrometry. J Bone Joint Surg 2021; 103: 1917-1926
• 9 Renz N, Trampuz A. Pro-Implant Foundation. Pocket Guide to Diagnosis & Treatment of Periprosthetic Joint Infection (PJI). Version 9. 2019. Accessed May 02, 2024 at: www.pro-implant.org
• 10 Neufeld ME, Lanting BA, Shehata M. et al. Prevalence and outcome of unexpected positive intraoperative cultures in presumed aseptic revision hip arthroplasty. J Bone Joint Surg 2021; 103: 1392-1401
• 11 Klasan A, Schermuksnies A, Gerber F. et al. Development of antibiotic resistance in periprosthetic joint infection after total knee arthroplasty. Bone Joint J 2021; 103-B (6 Supple A): 171-176
• 12 Hu L, Fu J, Zhou Y. et al. Trends in microbiological profiles and antibiotic resistance in periprosthetic joint infections. J Int Med Res 2021; 49: 3000605211002784
• 13 Ravi S, Zhu M, Luey C. et al. Antibiotic resistance in early periprosthetic joint infection. ANZ J Surg 2016; 12: 1014-1018
• 14 Frieler S, Hanusrichter Y, Bellova P. et al. Facing multidrug-resistant pathogens in periprosthetic joint infections with self-administered outpatient parenteral antimicrobial therapy- A prospective cohort study. J Orthop Res 2021; 39: 320-332
• 15 Ibrahim MS, Ryan S, Seyler T. et al. Infection in Arthroplasty: The Basic Science of Bacterial Biofilms in Its Pathogenesis, Diagnosis, Treatment, and Prevention. Instr Course Lect 2020; 69: 229-242
• 16 Boese CK, Lechler P, Frink M. et al. Kostenanalyse stationärer und ambulanter intravenöser Antibiotikatherapie periprothetischer Gelenkinfektionen. Eine Simulation. Orthopade 2021; 50: 150-158
• 17 Trampuz A, Zimmerli W. Diagnosis and treatment of implant-associated septic arthritis and osteomyelitis. Curr Infect Dis Rep 2008; 5: 394-403
• 18 Holinka J, Windhager R. Management von Protheseninfektionen. Orthopade 2016; 45: 359-373
• 19 Premkumar A, Kolin DA, Farley KX. et al. Projected Economic Burden of Periprosthetic Joint Infection of the Hip and Knee in the United States. J Arthroplasty 2021; 36: 1484-1489.e3
• 20 Ochsner PE, Borens O, Bodler PM, Broger I, Eich G, Hefti F, Maurer T, Nötzli H, Seiler S, Suvà D, Trampuz A, Uckay I, Vogt M, Zimmerli W. Infektionen des Bewegungsapparates – Grundlagen, Prophylaxe, Diagnostik und Therapie. 2. Grandvaux: Swiss Orthopaedics und Swiss Society for Infectious Diseases; 2016
• 21 Schulz-Stübner S. Antibiotic Stewardship im Krankenhaus. Berlin: Springer; 2021
• 22 von Eiff C. Staphylococcus aureus small colony variants: a challenge to microbiologists and clinicians. Int J Antimicrob Agents 2008; 31: 507-510
• 23 Sendi P, Rohrbach M, Graber P. et al. Staphylococcus aureus Small Colony Variants in Prosthetic Joint Infection. Clin Infect Dis 2006; 43: 961-967
• 24 Bundesinstitut für Arzneimittel und Medizinprodukte (BfARM). Accessed December 04, 2022 at: www.bfarm.de/DE/Arzneimittel/Arzneimittelinformationen/Lieferengpaesse
• 25 Erba A, Beuret M, Daly ML. et al. OPAT in Switzerland: single-center experience of a model to treat complicated infections. Infection 2020; 48: 231-240
• 26 Briquet C, Cornu O, Servais V. et al. Clinical characteristics and outcomes of patients receiving outpatient parenteral antibiotic therapy in a Belgian setting: a single-center pilot study. Acta Clin Belg 2020; 75: 275-283
• 27 Stegemann M, Hagel S, Lehmann C. Antibiotikatherapie (2): Ambulante parenterale Gabe. Dtsch Arztebl 2019;
• 28 Stegemann M, Hagel S, Lehmann C. K-APAT – Ambulante parenterale Antibiotikatherapie in der Kölner Metropolregion. Laufende Studie seit 2020. Accessed March 26, 2024 at: https://www.infektiologie-netzwerk-koeln.de/projekte/studien/k-apat/
• 29 Bernard L, Arvieux C, Brunschweiler B. et al. Antibiotic Therapy for 6 or 12 Weeks for Prosthetic Joint Infection. N Engl J Med 2021; 384: 1991-2001