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18 Prevention ofPostoperative Infections
261
theatre, often in collaboration with nurses [52,
53]. This interdisciplinary approach aims to
enhance various aspects of surgical practices and
outcomes. Notably, epidemiological studies have
identied noise generated by the operating staff
as an independent risk factor for SSI [54].
Recognizing and addressing factors such as noise
pollution within the operating room may contribute to a better understanding of the dynamics
inuencing SSI rates and lead to improved strategies for infection prevention.
18.3.3 Postoperative Measures
18.3.3.1 Postsurgical Wound Care
The literature on surgical wound care and SSI
prevention currently faces a paucity of information. Specically, there is a lack of data regarding
the proportion of SSIs acquired postoperatively
on the ward through direct inoculation. While
experts suggest that this proportion may be as
high as 10%, there is currently no empirical evidence to support this estimate.
A Cochrane review aimed to assess the effectiveness of various dressings and topical agents
on surgical wound healing and infection prevention. However, the review concluded that the
quality of the available trials was insufcient to
determine any superiority of one protocol or topical agent over another [55]. Similarly, other randomized studies comparing occlusive dressings
versus gauze dressings also failed to detect superiority in terms of reducing SSIs or promoting
wound healing [56–58]. This lack of conclusive
evidence underscores the need for further
research and robust clinical trials to better understand and improve surgical wound care practices
for SSI prevention.
18.3.3.2 Postoperative Antibiotics
Prolonging antibiotic prophylaxis beyond
24 hours is deemed ineffective in reducing the
rate of SSI. Additionally, this practice carries
various drawbacks, including increased hospital
costs, heightened risk of systemic toxicity and
colitis caused by C. difcile, and negative effects
on both individual and community microora,
thereby promoting the development of pharmacological resistance.
In orthopedic trauma cases, the general consensus is that antibiotic medication should not be
administered for more than 24hours for grade I
and II fractures [59]. The recommended minimum duration for grade III fractures varies, ranging from 1 day to several weeks. However,
guidelines based on expert opinion and common
sense typically recommend a maximum duration
of 48hours or 72hours in such cases [60, 61].
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Periprosthetic Joint Infection: General Aspects
Ferdinando DaRindeLorenzo andJavadParvizi
19
Periprosthetic joint infections (PJI) represent one
of the most important surgical complications, so
much so that in America, and specically in
Philadelphia, scientic meetings organized by
Dr. Parvizi and Dr. Gerhke were held in 2013 and
2018, to try to create guidelines to address this
issue [1] The rst meeting addresses the issue of
periprosthetic infections of the hip and knee
while in the following meeting, all other subspecialties in orthopedics were included. Both meetings was attended by the world’s leading experts
and discussions centered around prevention,
diagnosis, and treatment of orthopedic infections.
The issue of PJI continues to take center stage as
the number of arthroplasties being performed
around the world continues to increase (Fig.19.1)
[2] It is estimated that more than 1.5 million hip
arthroplasties are performed per year, of which
300,000 are done in the United States. Italy is
among the European countries where the highest
number of hip replacements are carried out, out
of approximately 700,000 THA performed every
year in Europe, over 100,000 are done in Italy,
which is surpassed only by Germany (250,000)
and France (130,000) and precedes the United
F. Da Rin de Lorenzo (*)
National Reference Center for the Diagnosis and
Treatment of Bone Infections, Codivilla-Putti
Institutes, Cortina d’Ampezzo, Italy
J. Parvizi
Orthopedic Surgery, Acibadem University,
Istanbul, Turkey
Kingdom (90,000) and Spain (70,000) [3] The
number of implants increases by 5% every year
and that expenditure of one billion three hundred
million euros corresponds to 1% of the National
Health Fund. To this gure must be added the
over 500 million euros spent on rehabilitation
following the intervention (Figs.19.1b and 19.2a,
b) [2] It is now not uncommon to operate on 30 or
40-year-olds and every year 20,000 prostheses
are implanted in people under 65, 5000 are
inserted in people under 50.
The new ceramics can therefore guarantee
superior durability and resistance, at a relatively
higher cost, we are talking about a few hundred
euros more on implants that normally cost
between 3000 and 4000 euros. The data regarding prosthetics of the knee are based on approximately 500,000 implants per year in Europe and
with a trend of greater increase in the hip, of
6–8% per year. The infection rates of a prosthesis
are variable as can be seen from (diagram 1) [2]
Va also considers that in the case of a PJI, these
are mostly elderly patients with frequently associated other pathologies (diabetes, heart disease,
etc.) [4, 5] Furthermore, the prolonged use of
antibiotics produces side effects, such as kidney
disease and liver disease. The patient falls on the
family and on volunteers, as the children have
little time to dedicate to their elderly parents. In
65% of cases, hip replacement concerns women,
and the percentage rises to 75% if the implant is
subsequent to an osteoporotic fracture. Patients
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
P. Ruggieri et al. (eds.), Bone and Joint Infections, https://doi.org/10.1007/978-3-031-96383-4_19
265
266
a
Fig. 19.1 (a) The
projected increase in
infections in hip and
knee replacements [2].
(b) The proportional
increase in costs [3]
F. Da Rin de Lorenzo and J. Parvizi
b
carrying a periprosthetic infection undergo many
operations and sometimes with a resurgence of
the pathology, therefore mistrust in the healthcare
system. It should be considered that even after
many operations, amputation can result and the
patient himself and himself are at risk, as in all
chronic illnesses, requires psychological
support.
For the healthcare system, commitment is
very important, as these are patients with long
stays, there are no safety areas, and there may be
contamination of other patients. This surgery
requires protected surgical, resuscitation, and
hospitalization areas. Furthermore, the purely
surgical situation presents considerable technicaldecision- making difculties given the chronicity
of the disease, the general conditions of the
patient and the condition of the local bone stock.
Now, as you can well imagine, these data led the
specialists to the meeting described which led,
for the rst time, to give indications on the basis
of the evaluations made.
We report the percentage of infections in
America and Europe (Scheme 19.1) [6, 7].
Therefore, based on the data reported, the prevention of these pathologies becomes fundamental. Before delving into the preventive aspects, it
is useful to try to give a denition of what is diagnosed as PJI (Periprosthetic Joint Infection). The
Philadelphia Consensus has dened parameters
within which we can say that we are faced with a
periprosthetic infection [7]. The European School
(EBJIS) has given another denition, both similar [8]. Other working groups have given a
Primary
T
a
b
Staf
Staf
OR costs
D
Clinical ma
Wa
Mat
Diagnostic t
Medication
Antibiotics
ICU st
T
T
Aseptic
DAIR
Two-stage
T
Staf
Staf
OR costs
Clinical materials (including the prosthesis)
Wa
Mat
Diagnostic t
Medication
Antibiotics
ICU st
T
T
1393
3,664 [5,358*]
1,093
5,648
19 Periprosthetic Joint Infection: General Aspects
267
otal costs
otal hospital stay
f
rd costs
erials
ests
(excluding antibiotics)
ay
otal operating room
f
terials (including prosthesis)
AIR - Debridement, Antibiotics and Implant Retention
otal costs
otal hospital stay
f
rd costs
erials
ests
(excluding antibiotics)
ay
otal operating room
f
Fig. 19.2 (a) Economic Data on 488 TKA cases (average cost per patient in euros) [3]. (b) Economic Data on 293
THA cases (average cost per patient in euros) [3]
Arthroplasty
(n = 459)
3,168
1,024
521
262
78
62
83
4
14
2,594
277
237
2,080
Primary
Arthroplasty
(n = 256)
3,230
1,307
624
407
94
95
36
6
45
1,923
238
292
Revisions
(n = 13)
7,985
1,289
405
151
409
126
6,696
306
413
5,977
Aseptic
Revisions
(n = 22 [4*])
6,089 [7,840*]
1,728 [1,739*]
773
151 [162*]
404
248
48
10
94
4,361 [6,101*]
305 [351*]
392
94
19
85
(n = 8)
4,009
2,677
1,120
135
661
553
1,332
204
334
794
DAIR
(n = 8)
5,528
3,923
1,802
291
1,028
317
99
287
87
1,605
304
208
78
78
52
Revision
(n = 8)
13,793
4,388
1,944
1,141
252
433
108
239
271
9,405
621
451
8,333
Two-stage
Revision
(n = 7)
11,415
4,584
1,772
1,026
274
703
293
243
273
6,831
464
719
268
F. Da Rin de Lorenzo and J. Parvizi
Scheme 19.1
Periprosthetic infection rates are hovering:
In America: Hip 1.99–2.18%
In Europe: Hip 2.05–2.48%
In Europe:
Revision prosthesis 5–20% (***)
Shoulder 0.8–1.5% (****)
Elbow 3.3% (*****)
*Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi
J.Economic burden of periprosthetic joint infection in the
United States. J Arthroplasty. 2012;27:61–65.e61. https://
doi.org/10.1016/j.arth.2012.02.022
**Nordic Arthroplasty Register Association
***Tandea AJ, Patel R.Prosthetic Joint Infection. Clin
Microbiol Rev. 2014;27(2):302–45
****Singh JA, Sperling JW, Schleck C, Harmsen W,
Coeld RH.Periprosthetic infections after shoulder hemiarthroplasty. J Shoulder Elbow Surg. 2012;21:1304–9
*****Voloshin I, Schippert DW, Kakar S, Kaye EK,
Morrey BF.Complications of total elbow replacement: a
systematic review. J Shoulder Elbow Surg. 2011;20:158–68
The percentage of periprosthetic hip infections is 1.5–4%.
Periprosthetic infections represent from 0.5% to 3% of all
implanted prostheses and of those revised it can even
reach 20%
Periprosthetic infection rate
*[2]
Knee 2.05–2.18%
**
Knee 2.30–3.18%
denition and in the following diagram the set of
all these denitions reported by the WAIOT scientic society (Fig.19.3) [9].
“Prevention” As can be seen, it is necessary
to ensure that periprosthetic infections are, in
percentage, reduced to a minimum. Studies on
the prevention of infections mainly concern two
sectors:
A. The patient’s risk factors and all the aspects
that can be modied during the pre-intra and
post-operative process, to avoid an infection
[10–17].
B. The characteristics of the prostheses to be
implanted. On the latter, multiple operations
were carried out considering the defensive
properties of the prostheses against any bacterial load, let’s say “possible” because the
infection is not yet underway but everything
would serve to prevent it. First of all, the
patient must be evaluated when a prosthesis
is to be performed, in fact, some conditions
must lead to using more restrictive measures
before accessing a prosthesis, for the modiable risk factors, while for others it is a matter
of applying them routinely. All conditions are
evaluated in depth in relation to a probable
infection. Furthermore, knowledge of risk
factors also allows for a greater relationship
between doctor and patient [9] Both oncological orthopedic prosthesis and traumatology are excluded but can be included, at least
for their general characteristics, which however have peculiar situations not covered in
this chapter.
e
19 Periprosthetic Joint Infection: General Aspects
269
IDSA 2013 [4]ICM 2013 [5]ICM 2018 [7] Proposed EBJIS 2018 [8]
3–5 Possibly infected
(˝Consider further molecular diagnostics
1 of the 2 Major CriteriaORMinor criteria scoring 6 Infected
3 of 5 Minor Criteria*
1 of the 2 Major Criteria
OR
1 Positive Criteria
such as next-generation sequencing˝)
<3 Not infected*
l
tissue reaction, crystal deposition disease,
slow growing oranisms"˝
*˝Proceed with caution in: adverse loca
t
*˝PJI may be present withou
meeting these criteria,( ... ).˝
˝
1. Pur ulence around the prosthesis or sinus
tract
2. Increase synovial fluid leukocyte count
communication to the joint or
Major:
1. Sinus tract with evidence of
1. A sinus tract communicating with
the joint
Major
(>2,000 cells/mL or >70 % granulocytes)
3. Positive histopathology
4. Confirmatory microbial growth in synovial
fluid, periprosthetic tissue, or sonication cultur
visualization of the prosthesis
2. Two positive growths of the same
organism using standard culture
methods
2. Two positive periprosthetic
cultures with phenotypically
identical organisms,
(˝Confirmatory microbial growth in
periprosthetic tissue: if positive in 1 specimen
units/mL of sonication fluid.˝)
vilulent pathogens; sonication culture
considered positive if >50 colony-forming
in highly virulent organisms or 2 in low
ug/L for chronic infection) (score 2)
Minor:
Minor:
(a) Elevated ESR (>30 mm/hr) and
(b) Elevated ESR (no role for acute
(a) Elevated CRP (>100 mg/L for acute
infections; >10 mg/L.. for chronic
infections) or D-Dimer (unknown
threshold for acute infection; >860
count (>10,000 cells/mL for acute
infections; >3,000 cells/mL for
CRP (> 100 mg/L for acute
infections; >10 mg/L for chronic
infections)
(b) Elevated synovial fluid WBC
evated synovial WBC count (>10,000
(c) El
cells/mL for acute infections; >3,000
cells/mL for chronic infections) OR
(score 3)
Leukocyte Esterase (++ for acute and
infections) (score 1)
on leukocyte esterase test strip
chronic infections) OR Positive alphadefensin
(c) Elevated PMN% (>90% for acute
infections; >80% for chronic
infections)
(d) Positive histological analysis of
periprosthetic tissue (> 5
neutrophils per high-power field
infections; >30 mm/hr for chronic
chronic infections) or ++ change
(score 3)
acute infections; >70% for chronic
infections) (score 2)
(e) Single positive culture (score 2)
(f) Positive histology (score 3)
(g) Positive intraoperative purulence
(d) Elevated synovial PMN% (>90% for
tions of the Open Access Creative Commons Attribution (CC BY) license (http://
creativecommons.org/licenses/by/4.0/))
in five high-power fields
observed on periprosthetic tissue
at ×400 magnification)
(e) A single positive culture
MSIS 2011 [1]
Source
Definition
1 Positive Criteria*
1 of the 2 Major Criteria
OR
criteria are not met ( .. .)
*˝The presence of PJI is possible even if the above
4 of 6 Minor Criteria*
*˝PJI may be present if fewer than
four of these criteria are met˝
Scoring
system
2 intraoperative cultures or combination of
preoperative aspiration and intraoperative cultures
prosthesis
3. Acute inflammation seen on histopathological
examination of the periprosthetic tissue
the prosthesis;
2. A pathogen is isolated by culture
from at least two separate tissue
yielding an indistinguishable organism (the growth of a
4.
virulent microorganism (e.g., Staphylococcus aureus) in
a single specimen of a tissue biopsy or synovial fluid is
or fluid samples obtained from
the affected prosthetic joint
Minor:
(a) Elevated ESR (>30 mm/hr) and
also considered as indicative of a PJI]
CRP (>10 mg/L) concentration
1. Sinus tract communicating with the prosthesis
2. Purulence without other etiology surrounding the
Major:
1. Sinus tract communicating with
(b) Elevated synovial leukocyte
count
(c) Elevated PMN%
(d) Purulence in the affected joint
(e) Isolation of a microorganism in
one culture of periprosthetic
tissue or fluid
Criteria
(f) Greater than five neutrophils
per high-power field in five
high-power fields observed
from histologic analysis of
periprosthetic tissue at ×400
magnification
Fig. 19.3 Comparison of the diagnostic criteria, adopted in ve peri-prosthetic
joint infection (PJI) denitions, in the differents guidelines, published from
2011 to 2018. (Reproduced from Romanò etal. [9] under the terms and condi-
270
F. Da Rin de Lorenzo and J. Parvizi
19.1 “General” Patient Risk
Factors [11, 13, 14, 16,
18–21]
• History of previous surgical interventions [18,
22, 23].
• The age of the patient.
• Poorly controlled diabetes mellitus (blood
sugar >200mg/L or HbA1C>7%) [4, 5].
• Malnutrition [24, 25].
• Obesity (BMI>40/m2) [26].
• An active liver disease [27, 28].
• A chronic kidney disease [29, 30].
• Excessive smoking (>1pack per day) [31, 32].
• Excessive alcohol consumption (>40units per
week) [33].
• Intravenous drug abuse [34].
• A recent hospitalization.
• An extended stay in a rehabilitation center.
• A severe immunodeciency [34].
• Previous transfusions.
19.2 “Local” Patient Risk Factors
in creating a periprosthetic infection if we do not
pay due attention and do not correct the modiable risk factors. These considerations generally
apply to all major surgery such as traumatology,
for example, or pelvic and spinal surgery.
Furthermore, they are reported without a logical
sense because there is no standard scheme in
evaluating these factors but it would be good for
this to happen to be careful not to forget any of
them, a protocol must be made which must be
followed to the letter.
19.4 The Factors That Concern
theRisks That Can
BeControlled andApplied
Have Been Divided into
Factors
• Presurgical
• Intra-surgical
• Postsurgical
• History of previous surgical interventions at
the site of surgery.
• Associated extra-osseous structure lesions.
• The diagnosis of a previous post-traumatic
arthritis.
• An inammatory arthropathy (AR).
• A previous surgical procedure in the joint to
be operated on.*
• Skin lesions such as furunculosis or
impetigo.
(*) such as inltration [35–38].
19.3 Risk Factors Related
tothePerioperative Phase
andSurgery
In addition to the patient’s risk factors, other risk
factors that are outside the patient but which
affect the patient himself must be evaluated. We
have divided all those aspects that can intervene
19.4.1 Presurgical
For suspicion of a urinary infection [39–41],
more typical in women, the attitude varies:
Treatment before prosthetic surgery
if:
Acute urinary infection Asymptomatic
Bacterial count >1×10/ml
Symptomatic infection
Therefore, only symptomatic forms should be
treated and In the case of a full-blown form, it
will also be necessary to consider the germ and
the antibiogram of the urinary infection that will
be treated.
Another factor to consider is the suspension of
an immunological treatment in place before the
operation (Fig.19.4) [42, 43].
Another factor to be evaluated is the decoloni-
zation of the nasal site [44] if both methicillin-
resistant and methicillin-susceptible
Staphylococcus aureus are found, it should be
done, with nasal application, in the short term,
No treatment
if:
19 Periprosthetic Joint Infection: General Aspects
271
Fig. 19.4 Table listing
medications, their
half-lives, and
recommendations for
discontinuation before
surgery
Medication Half Life * Recommendation
Nonsteroidal Antiinflammatory Drugs(NSAIDs)
Methotrexate 0.7–5.8 hoursDiscontinue therapy within 1week
Sulfasalazine
Azathioprine
Leflunomide ~2 weeksHoldfor 6weeks priortosurgery
Hydroxychloroqine Continue therapyuptoand
Biological Response
Modifiers
Etanercept
Infliximab
Golimumab
Tocilizumab
Abatacept
Adalimumab
Certolizumab
Rituximab
Gout agents
Allopurinol
Colchicine
Probenecid
2–17 hours
5hours
7.6hours
1–2 months
4.3days
8–10 days
12–14 days
21 days
1–2 hours
26–32 hours
26–32 hours
Discontinuetherapy within 1week
priortosurgery
priortosurgery
Continue therapy2weeksafter
surgery
(Patientswithrenal dysfunction,
hold 2weeks priortosurgery)
Discontinuetherapy priorto1week
before surgery
includingthe dayofsurgery
Hold foratleast 1.5weeks priorto
surgery
Hold for3weeksprior to surgery
Hold for1monthprior to surgery
Hold for2months priortosurgery
Discontinuetherapy within 1week
priortosurgery
with mupirocin, but not all authors are agreement, perhaps due to the lack of uniformity in
study designs (retrospective vs prospective)
[45–47].
Preoperative skin cleansing should be done
with chlorhexidine gluconate (CHG). If CHG
sensitivity is present, or when CHG is not available, an antiseptic soap is appropriate. It is recommended to start cleansing the skin at least the
night before a prosthesis operation. Furthermore,
after bathing, patients are advised to sleep in
clean clothes and clean bed linen, without the
application of any topical products. It would be
useful for the patient to be hospitalized the day
before the operation to be able to clean the body
properly [48–50].
Another very important step is shaving [51–53],
not recommended by hand (clipping), but better
with the motorized one (shaving). It must be performed close to the operation and the skin incisions
must take into account the presence of eczema,
psoriasis, furunculosis, or previous traumatic scars.
The guidelines for trichotomy are as follows:
• Shaving should only be carried out by expert
personnel
• Wear gloves to carry out this procedure
• Make sure that the lighting is sufcient
• Never undress the patient for no reason
• Set up an environment in which privacy is
maintained
• Shaving must not take place more than twice
hours before the procedure This ensures that