Guidelines for prevention, diagnosis and management of orthopaedic infections

at UHA / RLUH / BGH

1. Preoperative screening

2. Intra-operative sampling, including -defensin testing (Synovasure)

3. Antibiotic prophylaxis

4. Antibiotic cement

5. Empirical antibiotic choices

6. Diabetic foot infection

7. Accessing orthopaedic infection services, and principles for dealing with positive microbiology results at the

clinical authorisation stage

1. Preoperative screening and decolonisation treatment

MRSA screening before elective surgery

Obtain Screening Swabs:

Nose, Groin, Wounds/Ulcers

and CSU if catheterised

Positive Result Negative Result

Patient to be supplied with

skin antiseptic, nasal ointment

and instructions to start

decolonisation 5 days pre-

operatively

Usual Admission Procedure

Skin conditions eg psoriasis or

severe eczema notify a

member of the infection

control team

If patient to be admitted

within less than 5 days,

contact a member of the

infection control team for

further advice

Patient operation with anti-

MRSA antibiotic prophylaxis

(in addition to normal

prophylaxis) given by

anaesthetist at induction of

anaesthetic. Patient at end of

list if practical and safe to do

so.

Continue skin antisepsis (body

wash) until discharge or for 10

days post-operatively.

MRSA screening of patients admitted acutely for orthopaedic surgical procedures

CPE screening

Indication for CPE screening:

- any admission to hospital within preceding 12 months

CPE-positive result:

- isolation on admission with enhanced barrier nursing precautions (discuss with Infection Control in advance of

admission where possible)

Urine testing

Pre-operative urinalysis (dipstick testing) and urine culture, in patients without symptoms of urinary tract infection,

has not been shown to be beneficial and should not be performed1,2 even in patients with indwelling urinary

catheters.

References: (1) Sousa, R et al. (2014). Is Asymptomatic Bacteriuria a risk factor for prosthetic joint infection? Clinical Infectious Diseases

59(1):41-7. (2) Duncan, RA (2014). Prosthetic joint replacement: should orthopedists check urine because it’s there? Clinical Infectious

Diseases 59(1):48-50

2. Intra-operative sampling (including -defensin testing)

Samples for Microbiology:

Send tissue samples for culture and sensitivity testing if:

- there is clinical suspicion of infection, or

- there has been any previous orthopaedic surgery at the same site (e.g. metal work in situ)

Histology:

Histology is not necessary when there are overt local signs of infection (e.g. purulence, chronic sinus)

Otherwise, tissue should be sent for histology whenever intra-operative tissue samples are sent for microbiological

culture, including all cases of revision surgery for presumed aseptic loosening.

Sampling procedure:

Obtain 5 tissue samples using separate blades and forceps. Samples may be divided for culture and histology, when

histology is indicated

For implant debridement or revision surgery, the following sites are suggested for sampling:

1x Fascia

2x joint capsule

2x tissue from underneath or around prosthesis, and

Any necrotic or other suspicious tissue

Each sample should be placed into an individual pot and immediately sent off for extended culture (and histology if

applicable)

Synovial fluid sampling is not necessary in addition to the above, and need not be sent to the laboratory at the time

of joint revision surgery

Please send samples for Microbiological investigation in universal containers, either dry or in a small amount of

sterile saline (not in formalin). Tissue samples in formalin are not suitable for culture.

-defensin testing (Synovasure):

This is not currently recommended in any setting.

Its use may be considered on an individual case basis, through the orthopaedic infection MDT

3. Antibiotic prophylaxis for orthopaedic surgery

No allergy Penicillin-allergic1 MRSA-positive

Non-implant surgery No antibiotic prophylaxis

Primary arthroplasty Cefuroxime 1.5g IV Teicoplanin 800mg IV Teicoplanin 800mg IV

Compound fracture [assess tetanus risk and consider need for immunisation or Immunoglobulin]

Co-amoxiclav 1.2g IV (alone) every 8 hours, or Cefuroxime 1.5g IV every 8 hours plus Metronidazole 500mg IV every 8 hours

Clindamycin 600mg IV every 6 hours. Add Ciprofloxacin 400mg IV every 8 hours (or PO 750mg BD), after gunshot injuries or if very extensive or contaminated wound

Add Teicoplanin 800mg IV 12 hourly for 3 doses, to one of the other recommended regimens

Hemiarthroplasty / fractured neck of femur, and Revision surgery for indications other than infection

Teicoplanin 800mg IV, plus Cefuroxime 1.5g IV

Teicoplanin 800mg IV, plus Gentamicin 5mg/kg IV

Teicoplanin 800mg IV, plus Cefuroxime 1.5g IV

Revision surgery for infection

Discuss with Microbiology or Orthopaedic infection team: choice of agent depends on whether infecting organism is known preoperatively2

Antibiotic prophylaxis for patients undergoing spine surgery

No allergy Penicillin-allergic1 MRSA-positive

Open surgery without instrumentation

Cefuroxime 1.5g IV Teicoplanin 800mg IV Plus Gentamicin 5mg/kg

Teicoplanin 800mg plus Cefuroxime 1.5g IV

Open surgery with instrumentation

Cefuroxime 1.5g IV, plus Vancomyin powder applied locally (If Vancomycin powder is not used, give Teicoplanin 800mg in addition to Cefuroxime)

Gentamicin 5mg/kg IV, plus Vancomyin powder applied locally (If Vancomycin powder is not used, give Teicoplanin 800mg in addition to Gentamicin)

Teicoplanin 800mg plus Cefuroxime 1.5g IV, plus Vancomyin powder applied locally

Minimally-invasive surgery

Teicoplanin 800mg plus Cefuroxime 1.5g IV

Teicoplanin 800mg plus Gentamicin 5mg/kg

Teicoplanin 800mg plus Cefuroxime 1.5g IV

Notes:

1Penicillin allergy: Patients with a history of angioedema, anaphylaxis, or severe skin reaction to any -lactam

antibiotics should not receive prophylaxis with Cefuroxime. Patients with a history of only minor or delayed rash

after penicillin, may receive Cefuroxime

2When the organism is known preoperatively, additional antibiotic cover for other potential pathogens may

nevertheless need to be provided at the time of surgery. All such cases should be discussed at the MDT (or with a

Consultant Microbiologist if no opportunity for discussion at the MDT exists), and regimens for both prophylaxis and

treatment agreed in advance.

Duration of prophylaxis: Antibiotic prophylaxis must not be continued beyond the peri-operative period (usually

only one dose at the time of induction or 30-60 minutes before surgery). Antibiotic treatment for suspected or

confirmed infection is reasonable however, pending culture results.

For open fractures, continue prophylaxis for 48 hours, or for 24 hours beyond the time of soft tissue closure

(whichever is sooner)

Please note that patients receiving antibiotics for treatment of presumptive infection rather than prophylaxis,

should be treated according to section 5 (“Empirical antibiotics for treating orthopaedic infections”)

Repeat doses:

An additional dose during the operation is indicated if:

there is major intra-operative blood loss blood loss of > 1500 ml during surgery. (In this case, additional dose of the prophylactic antibiotic should be given after fluid replacement)

haemodilution up to 15ml/kg

surgery has lasted for more than 4 hours (Cefuroxime only - this does not apply to Gentamicin or Teicoplanin)

Urinary catheterisation:

Patients undergoing implant surgery should receive antibiotic prophylaxis (Gentamicin 160mg, one dose) at the time

of urinary catheterisation or catheter removal, if catheterised during the perioperative period. However prophylaxis

at the time of catheter removal is unnecessary.

Patients undergoing urinary catheterisation at the time of surgery whose surgical prophylaxis requires Gentamicin

according to the above table, should receive the higher dose (5mg/kg).

4. Choice of antibiotic cement

Indication Cement

Primary arthroplasty Gentamicin

Revisions (no infection) Vancomycin plus Gentamicin

Hemiarthroplasty Gentamicin1

Septic revisions (including 1- and 2-stage revisions)

Discuss with Microbiology / orthopaedic infection service2

1. Currently under review

2. Choice of antibiotic cement for infected revisions must be agreed in advance of surgery

5. Empirical antibiotic choices for treating orthopaedic infections (not prophylaxis)

Please note that this does not apply to cases in which diagnostic microbiology results have already been obtained

1st line 2nd line comments

Acute native osteomyelitis or septic arthritis

Flucloxacillin 2g QDS (IV) (+/- Gentamicin 5mg/kg if systemic upset due to sepsis)

Teicoplanin (+/- Gentamicin 5mg/kg if systemic upset due to sepsis) (The Teicoplanin dose is 12mg/kg BD for 48h then 12mg/kg OD with therapeutic drug monitoring (trough level on day 4)

Withhold antibiotics pending appropriate microbiological sampling (e.g. synovial fluid aspirate [except in severe sepsis], blood cultures [all cases]). In cases of possible septic arthritis, refer to local guidance for management of the “hot joint”

Chronic osteomyelitis

No antibiotics – discuss with Orthopaedic infection service

Prosthetic joint infection or Spinal implant infection:

Acute

Withhold antibiotics unless patient is systemically unwell Discuss with Microbiologist (on call Microbiologist if out of hours) and orthopaedic infection service Give Teicoplanin (12mg/kg BD for 48h then 12mg/kg OD with therapeutic drug monitoring (trough level on day 4)) + Gentamicin if systemically unwell with signs of severe sepsis

Prosthetic joint infection or Spinal implant infection:

Chronic

Withhold antibiotics unless patient is systemically unwell Discuss with Microbiologist (on call Microbiologist if out of hours) and orthopaedic infection service

Postoperative antibiotics, for implant-related surgery pending Microbiological diagnosis (may be initiated immediately after intra-operative sampling)*

IV Teicoplanin 12mg/kg BD for 48h then 12mg/kg OD with therapeutic drug monitoring (trough level on day 4) + IV Ciprofloxacin 400mg TDS (may be changed to PO Ciprofloxacin 750mg BD as soon as patient is able to take medication orally) (may be changed to PO Linezolid 600mg BD + PO Ciprofloxacin 750mg BD if suitable for early discharge on oral therapy, with appropriate arrangements for review with C&S results)

Native spine infections (suspected discitis, vertebral osteo- myelitis, epidural abscess)

Withhold antibiotics unless patient is systemically unwell, in which case treat as for acute native osteomyelitis or septic arthritis (above) Discuss with Microbiologist on call and with orthopaedic infection service

Acute, severe diabetic foot infection

Piperacillin-tazobactam 4.5g TDS (add Teicoplanin if known colonisation with MRSA)

IV Teicoplanin 12mg/kg BD for 48h then 12mg/kg OD with therapeutic drug monitoring (trough level on day 4), plus Ciprofloxacin PO 750mg BD or IV 400mg TDS, plus Metronidazole IV 500mg TDS (or PO 400mg TDS)

Add Gentamicin 5mg/kg if signs of severe sepsis

Notes:

Teicoplanin dosage for treatment of suspected or confirmed infection (as opposed to prophylaxis): 12mg/kg BD for

48h then 12mg/kg OD with therapeutic drug monitoring (trough level on day 4)

Duration of antibiotic therapy:

Orthopaedic infections are usually treated for 6 weeks from the time of definitive surgery.

It may be reasonable to convert antibiotics from intravenous to oral administration within that time however,

depending upon patient factors, the bacterial pathogen and the availability of agents with good oral bioavailability

for treating it.

Treatment durations of greater than 6 weeks may be considered in certain circumstances, but should be agreed on a

case-by-case basis through the MDT

6. Diabetic foot infection

Empirical antibiotic choices for diabetic foot infection without osteomyelitis

Clinical manifestations

Severity

(IDSA grade)

Suggested empirical antibiotics

(adapt if necessary based on microbiology results /

recent antibiotic treatment)

Suggested duration

No purulence or manifestations of

inflammation

Uninfected

No antibiotic treatment

-

Presence of ≥2 of purulence/

erythema/pain/tenderness/warmth/

induration, but cellulitis extends

≤2cm, only skin/superficial soft

tissues involved, no local

complications, not systemically

unwell

mild

Antibiotic naïve and infection of recent (<3 weeks)

onset:

Flucloxacillin 1g QDS PO (consider adding

metronidazole if anaerobic infection suspected),

or

Clindamycin 450mg QDS PO (If Penicillin

allergic) – check that Staphylococci and

Streptococci have previously been sensitive to

macrolides (Ery-/Clarithromycin)

If MRSA-positive: Doxycycline 100mg BD

1-2 weeks

Infection as above and systemically

well but cellulitis extends >2cm,

lymphangitis, spread beyond

superficial fascia, gangrene,

involvement of muscle/tendon/joint/

bone

Moderate

[may be limb-

threatening]

Antibiotic naïve and recent (<3 weeks) onset:

(consider adding metronidazole if anaerobic

infection suspected),

Flucloxacillin 1g QDS PO (2g QDS IV), or

If Penicillin-allergic: Clindamycin 450/600mg QDS

PO/IV

Not antibiotic naïve, or chronically infected:

(consider seeking specialist advice from Med

Micro/ID)

Co-amoxiclav (1.2g TDS IV or 625mg TDS PO),

or

Clindamycin 450/600mg QDS PO/IV plus

Ciprofloxacin 750/400mg PO/IV BD

For more extensive infection, and infections in

MRSA-carriers: treat as severe

2-4 weeks (see also “diabetic foot

osteomyelitis”)

Systemic toxicity or metabolic

instability, or patients admitted

acutely to hospital because of diabetic

foot infection (with or without

suspected osteomyelitis)

Severe

[may be life-

threatening]

IV Piperacillin/tazobactam (Tazocin) 4.5g TDS

(Add Teicoplanin if known colonisation with

MRSA, and consider a single dose of Gentamicin

5mg/kg if there is evidence of systemic upset due to

sepsis), or

If Penicillin-allergic: IV Teicoplanin plus

Ciprofloxacin 400mg TDS (IV)/750mg BD (PO),

plus IV/PO Metronidazole. Consider single dose of

Gentamicin 5mg/kg in addition, if systemic upset

due to sepsis

2-4 weeks

1. Onset in the community and no prior antibiotic treatment and no systemic upset due to sepsis:

Empirical antibiotic choices for the treatment of Diabetic foot infection without osteomyelitis

Notes: Patients admitted acutely for intravenous antibiotic treatment should usually be treated as “severe” in the first instance

Clindamycin and Ciprofloxacin have excellent oral bioavailability and should be given by the oral route if possible.

Oral step down for moderate to severe infections should be discussed with Microbiology and based on culture/susceptibility results where possible

1. Onset in the community and no prior antibiotic treatment and no systemic upset due to sepsis:

Flucloxacillin 2g QDS (IV) or 1g QDS (PO) +/- Sodium fusidate 500 mg TDS PO

If penicillin allergic: Clindamycin 450mg TDS (PO) or 600mg QDS (IV)

2. Onset in hospital or failure of prior antibiotic therapy or known or suspected colonization with antibiotic-

resistant organisms

Discuss with Medical Microbiology

3. Acutely unwell patients with systemic upset due to sepsis (Send blood cultures and do not delay initiation of

antibiotic treatment pending tissue sampling)

IV Piperacillin/tazobactam (Tazocin) 4.5g TDS plus a single dose of Gentamicin 5mg/kg

(Add Teicoplanin if known colonisation with MRSA)

If Penicillin-allergic: IV Teicoplanin plus Ciprofloxacin 400mg TDS (IV)/750mg BD (PO), plus Metronidazole. Consider single

dose of Gentamicin 5mg/kg IV in addition, in severely unwell patients

Empirical antibiotic choices for diabetic foot infection associated with osteomyelitis

Empirical antibiotic choices for patients with osteomyelitis associated with diabetic foot infection

Note: The subsequent choice of antibiotics, after initiation of empirical therapy, should be discussed with a

Microbiologist in all cases

7. Accessing orthopaedic infection services

Reference values (guidance only)

Specimen Type Value

Native Joint WCC >40,000/mm3 may be crystal or septic arthritis >100,000/mm3 typical of septic arthritis

Prosthetic Joint WCC >1700/mm3 and >65% Neutrophils

Principles for dealing with positive microbiology results at the clinical authorisation stage

Referral to diabetic foot infection services:

Referral pathways are in the process of being developed

J. Folb, J. Fountain, N. Feasey, S. Montgomery, A. Santini

V5 (final) June 2017

STERILE Tissue Fluid

Microscopy Check the Gram stain – does this tally with the organism grown? For discrepant Gram stain result consider adding comment to this effect using hotkey “RM”

See below for normal values Presence of organisms on Gram stain should be considered significant

Significant pathogens

Any isolate should be considered a potential pathogen however clinical judgement is required. Skin flora in limited specimens with no white cells or clinical details of infection may be considered a contaminant.

Authorisation Principles

Specific notes

- It is recommended NOT to interpret number of positive specimens i.e. 1 of 6 positive etc. at the authorisation stage. Release with comment SR (“Sensitivities available on request”). Consider suggesting referral to Bone & Joint Infection MDT using comment “BJIG”. - Positive culture results will not be followed up by the clinical lead unless specifically agreed, even once they have been informed of the result. Please consider whether the patient would be most appropriately dealt with through telephone advice or by a ward review by the Consult Service