Perioperatives Management bei Endoprotheseninfektionen des Rheumapatienten

Zusammenfassung

Hintergrund: Infekte bei Endoprothesen des Rheumapatienten verlangen eine rasche systematische Reaktion mit Keimbestimmung und operativer Sanierung durch 2-zeitigen Implantatwechsel mit lokaler (Zementspacer) und systemischer Antibiose.

Problematik: Die erforderliche Pause der immunsuppressiven Therapie kann zum Auftreten einer rheumatischen Schubsituation führen, die den Verlauf der Infektsituation erschweren kann. Vor Replantation sind Laborparameter zu evaluieren und erhöhte Werte auch im Hinblick auf das Vorliegen einer Schubsituation zu analysieren. Gelenkspunktion und Gewebsbiopsie können vor Replantation hilfreiche Zusatzinformation vermitteln.

Methodik: Die Antibiose soll im Idealfall etwa 14 Tage vor Replantation pausiert werden, wodurch einerseits persistierende fehlende Entzündungsparameter Sicherheit der Vorbehandlung geben können, andererseits die Wertigkeit der bei der Replantation gewonnenen Abstriche zunimmt. Wesentlich ist eine ausreichend lange Prävention postoperativ die aus bis zu 6 Monaten Antibiose bestehen sollte und absolut durch den Verlauf der Entzündungsparameter beeinflusst ist.

Schlussfolgerung: Beim immunsupprimierten Patienten mit Endoprotheseninfekt im Rahmen einer Rheumatoiden Arthritis ist ein systematisches Vorgehen mit 2-zeitigem Wechsel und ausreichend langer Antibiose auch bei Vorliegen vieler Komorbiditäten in hohem Maße zielführend.

Abstract

Background: Infections of a rheumatic's endoprosthesis demand a quick, systematic reaction with ascertainment of the gems and operative reconstruction with a 2-phase change of the implant with a local (cement spacer) and systemic antibiosis.

Problematics: The necessary interruption of the immune suppressive therapy can lead to the development of a rheumatic attack, which can aggravate the course of the infection. Before re-implantation the laboratory parameters have to be evaluated and elevated readings have to be analysed in the light of the existence of an attack. Joint puncturing and tissue biopsies can provide helpful additional information before re-implantation.

Methods: In an ideal case the antibiosis should be interrupted about 14 days before re-implantation, whereby on the one hand the persisting absence of inflammation parameters can give assurance of the pre-treatment, on the other hand, the quality rating of the obtained swabs during re-implantation increases. It is important that an adequately long postoperative prevention period should be taken into account consisting of at least 6 months of antibiosis and should be influenced by the progress of the inflammation parameters.

Conclusion: For a rheumatoid arthritis patient with immune suppression and an infection of the endoprosthesis a systematic approach with a 2-phase change and adequate antibiosis is reasonable even though there may be many disadvantages.

Schlüsselwörter

Protheseninfekt - Rheumatoide Arthritis - Antibiose - Prothesenexplantation

Key words

prosthesis infection - rheumatoid arthritis - antibiosis - prosthesis explantation

Literatur

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