The orthopaedic surgery patient is becoming increasingly aware of the risk of infection and its severe impact on the results of an operation that, more often than not, is functional. Yet the part played by risk factors linked to the patient himself is still debated owing to the widely publicised « nosocomial » risk in hospitals. Identifying the risk factors linked to the patient, and above all, assessing their importance, must take place early on, as soon as surgery is recommended, in order to correct their possible impact during and after surgery.

A multidisciplinary, medical/surgical team plays a key part as of this early stage. Coordination of assessment by the anaesthetist reinforces the quality of pre- and post-operative medical care and correction of these infection-inducing factors. Informing the patient of the patient-related risk of infection must be part of the overall discussion of the benefit-risk of the operation during the customary appointment between patient and anaesthetist.

Infection-related complications affecting cardiac and vascular valve prostheses remain a major problem. The consequences may be disastrous. One can distinguish between surgical and hematogenic infections. The latter spring from a focus of infection some distance from the prosthetic valve. They may occur any time after the operation and are due to foci of infection located elsewhere in the body : oral/dental infection (but also urinary, ENT or skin). The aim of this presentation is to identify oral/dental etiology and to propose precise therapeutic rules. We will address dental foci of infection prior to valve replacement and dental treatment for patients who have already received a prosthetic valve separately.

• Anatomical consequences
• Psychological consequences

Surgical site infections (SSI) are the most common complications in surgery. The magnitude of the problem can be summed up in 2 figures: 6.5 million patients are operated on every year in France, with an overall SSI rate of 2%. The repercussions of these SSIs can be assessed on three levels: the patient (and entourage), health professional (and health establishment), and society.

An economic evaluation is complexe in two respects: what is meant by evaluation (definition) and how can it be measured (methodology). Three main components must be borne in mind: direct costs (medical and non medical), indirect costs (loss of production) and intangible costs (diminished well-being and quality of life). Three methods, which each comprise avantages and limitations, are worth noting: the difference between planned and actual hospitalization, the unmatched comparison between infected/non infected patients and the comparison between infected – non infected patients after indirect adjustment. Mindful of the differences linked to the methods used, publications report that the length of hospitalization is increased by a factor of 2 (average 4.5 to 9) and additional costs by a factor of 3 (1,500 to 5,000 dollars). Cost calculation methods may overestimate the figure, and failure to take account of other factors (like, for example, non-hospital costs) may lead to an underestimation.

From an economic stance, the frequency of these SSIs should be set against their prevention, for it is estimated that 35% can be prevented through the introduction of a suitable programme and validated measures. The cost of these infections should therefore be compared with the cost of prevention (cost-benefit, cost-efficiency). In a recent report, the CDC estimated the benefits of prevention to be between 5.7 and 6.8 billion dollars when nosocomial infections (whatever the site) are reduced by 20%.

Preparing the skin is probably one of the most important stages in the fight against infection. Everyone involved must meticulously prepare. Indeed, preparation applies equally to all concerned.

Of course, the patient lies at the heart of this procedure; however, orderlies and nurses must subject their own skin to the same rules of hygiene if patient skin preparation is to be truly effective. Similarly, chief operating room nurses, auxiliary nurses, anaesthetists and surgeons also have to prepare properly before preparing the patient, putting him to sleep and operating. While a patient who fails to respect the rules can be viewed as irresponsible or poorly informed, a health professional is negligent and culpable.

In elective surgery, the first stage in skin preparation consists in informing the patient how to prepare for the operation. The patient must know what he cannot do, by explaining to him the role of the skin and the development of staphylococci. He must therefore pluck or sheer the region to be operated on, but not shave it under any circumstances. He must cut his nails but not tear the skin. He must remove, and not rip off, any body piercing jewelry!

A prospective national audit of skin preparation practices among patients due to undergo surgery was proposed in France in 2007 in all health establishments offering surgery or interventional radiology. The goal was to measure differences between practices recommended by the 2004 SFHH Consensus Conference and practices observed.
50.8% of health establishements participated, providing 41,188 observations for 1, 479 surgical departments. In 97.6% of these departments, there is a skin preparation protocol for patients. Information on pre-operative showering is given to patients in 88.2% of cases. Compliance with showering is better when the patient is duly informed, as opposed to not informed (75.8% v. 35%). Bodily hair management complies with recommendations in 91.5% of cases. The recommendation on cleaning followed by extensive disinfection of the surgical site is properly followed in 62% of cases. Finally, traceability differs depending on whether it concerns patient information (35.6%), pre-operative hygiene (82.3%) or surgical site disinfection (71.7%).

The main messages of the consensus conference have basically been assimilated, but efforts remain to be made to further improve practices.

Measurement, a crucial step in any quality improvement activity, can be a challenge when developing a program for the OR/OT setting. Strict adherence to multifaceted infection control best practices is inherent to the operation of any surgical facility and the performance of any operation, regardless of magnitude or risk. Semmelweis' hypothesis, that there was only 1 cause of infection and that all that mattered was cleanliness, was extreme at the time and was widely rejected (and ridiculed). One might say that there is clear evidence that it is still being rejected.

In fact, a recent survey of Ambulatory Surgery Centers (ASC) in US found that 68% of ASCs had a lapse of infection control practices noted under direct observation (18% in ≥3 domains). More than 19% had observed lapses in hand hygiene and use of personal protective equipment (e.g., gloves). Similar findings were reported from Netherlands in which there was only a 2% adherence to HH on entering the OT and 4% on leaving the OT.

Observation, the gold standard for monitoring hand hygiene compliance, cannot be easily adapted to the OR setting due to bias, Hawthorne effect and cost-effectiveness. Therefore, we developed and evaluated in both acute care OR setting and ASC, monitoring of HH compliance by product usage and patient/procedures and use feedback. Results from 17 ASC, 20 OR/OT in hospital setting showed that compliance continues to be lower than expected but can be increased when effective measurement and feedback is  conducted. This session will present the model for measuring and feedback that can be applied to the OR/OT setting.

At all times in the history of infection control, the implementation of existing, effective prevention measures has been difficult. Despite all the research, studies and experiences, and especially in spite of knowledge about the effectiveness of hand hygiene, the disinfection measures became easier and better whereas compliance is today often little better than at the age of Semmelweis and Lister, etc.
The reasons are variable; the most important factor is, however, the lack of time among medical and nursing healthcare workers in the care of patients.
Observation and analysis of the disinfection performance, combined with training and the use of different hand disinfectant dispensers, including touch-less as well as "feedback" giving Wi-Fi / WLAN-based dispenser systems may sustainably cause an increase in compliance. The use of dispensers with integrated counter functions also permits, in addition to recording the number of disinfections at each site, a selective review of compliance with its assessment of disinfection performance and, finally, to implement additional strategic measures.

37% of gowns used during routine hospitalised patient’s examination are contaminated by multi-resistant bacteria (Infect Control Hosp Epidemiol 2001:560-4), while surgical gowns contamination rate, at the end of a surgical procedure, has been reported to range from 8.6% to 34.3% in hip and knee prosthetic surgery (J Hosp Infect, 2006;62(2): 174-80).

An original research has been performed in our Institute to show how a patented anti-bacterial finishing of commonly used hospital gowns and textiles may significantly prevent multi-resistant nosocomial bacterial contamination of hospital textiles both in vitro and in the clinical setting. This low-cost, effective technology may open new pathways to reduce the impact of nosocomial infections. 

Staphylococcus aureus (SA) is both a commensal and a pathogen responsible for various anatomical site infections in man. The link between nasal SA carriage and infection was first described by Danbolt in 1931 in a patient with furunculosis. In the last 20 years, it has been proven that high nasal SA carriers have a three to six times higher risk of infection than non-carriers or low level carriers, particularly dialysed patients. In surgical patients, SA is the pathogen most often responsible for surgical site infections (SSIs), particularly in clean surgery. The impact of nasal screening and SA carrier decontamination on the reduction of SSIs has been the subject of much clinical research in the past few years. We shall give a summary of results. Recent findings enable us to recommend the introduction of rapid screening for surgical patients, combined with nasal decontamination with mupirocin and daily showering with antiseptic soap for 5 days, in addition to antiseptic chlorhexidine mouthwash. These strategies appear relevant in clean surgery where SA is the pathogen most frequently linked to SSIs. However, while the impact of this strategy is proven in cardiac surgery, many questions remain pending in other forms of surgery, in particular orthopaedic surgery. While nasal SA carriage is linked to a significant risk of SA SSI, the impact of decontamination on the SA SSI rate is more difficult to prove owing to the lower SSI rate than in cardiac surgery, the longer time to SSI onset and probably the more important role of carriage in the gut. Furthermore, the use of vancomycin in prophylactic antibiotic treatment in MRSA+ surgical patients detected on admission, replacing or in addition to cephalosporins, probably plays a major part in the reduction of MRSA SSI rates.

In France, the 2004 consensus conference on management of the risk of infection in surgical patients, which only recommends screening and decontamination of SA carriers in the event of  an epidemic and after implementation of all the other preventive measures, needs to be revised to take account of recently published findings. However, rapid routine PCR screening for SA in most French hospitals is not easy to achieve. Targeted or even general decontamination of SA carriers raises organisational problems that have never been assessed on a large scale. In this context, it is important to recall the importance of (1) the quality of nasal swabbing, (2) triple decontamination (nose, skin and oropharynx) (3) a complete decontamination protocol (10 doses over 5 days), although we do not know the exact impact of post-operative decontamination and (4) monitoring of the emergence of resistance to mupirocin in the event of decontamination failure. Similarly, a screening/decontamination policy must comprise an evaluation of the emergence of resistance to mupirocin and factors linked to decontamination failures. To prevent the risk of recolonisation, certain authors propose repeating the decolonisation protocol every 3 weeks in the case of prolonged hospitalisation to prevent the risk of MRSA or MSSA. We do not see the point once the operation has taken place. This strategy, while effective, is only one of the measures that needs to be implemented to reduce the rate of endogenous SSIs, as some SA SSIs occur in patients not identified as SA carriers on admission.

Crises are now part of daily life in hospitals, and are a favourite topic for the media. A crisis is an unusual event that upsets the normal functioning of the establishment. It calls for the implementation of emergency measures and may harm the reputation of the establishment.

This event may concern people (patients, visitors, health professionals), medical devices, equipment and material, or structures.

A certain number of situations involving care-linked infections that have to be reported (ARS/CCLIN) may trigger a crisis – for example, grouped infection (measles, whooping cough, tuberculosis, ERG, Carbapenemases, etc.). Forward planning in terms of outside and in-house communication will be required.

However, a crisis does not spring solely from the risk of infection, but also from any serious undesirable event in the establishment (risk of fire, iatrogenic events, emergency plan, etc.)
As information circulates ever more quickly (Web), it is of fundamental importance to set up an effective in-house warning system to anticipate and manage situations before they turn into a crisis.

The time is over when an operating theatre was a sacrosanct silo that imposed its pace on the entire medical establishment. New technologies, ever quicker innovation, new increasingly mini invasive approaches and new modes of patient management like out-patient care, which will become the norm, are bringing new users into the operating room – radiologists, cardiologists, endoscopists – who do not share the traditional surgical culture.

These interventional operators, whether doctors or surgeons, brought together as a multidisciplinary team, will provide mini invasive treatment for increasingly complex patients and pathologies, using sophisticated robots and computer-assisted equipment requiring considerable biomedical assistance. Large flows of patients will be admitted for short stays and information will have to be available in real time.

The standardisation of practices and patient management on an industrial scale, in a financially tight, competitive setting, will force structures to group together ; the whole chain of patient management will have to be taken into account instead of the each patient transfer from one totally independent silo to another.

These sea-changes will, in the short term, dictate a revolution in the architectural and functional design of the OR, which will become an interventional platform with a back office/front office type organisation that opens on to the establishment itself in addition to the outside world.

Of course, these strategic and operational upheavals will make it necessary to review OR management in order to solve new problems in terms of safety, personnel management and training based on new teaching techniques like simulation, the programming of procedures by different specialists, equipment maintenance and investment budgets.

The flooring performance requirements are higher in health care facilities than in almost any other area. Furthermore nosocomial infections (due to 99% to resistant bacteria) are considered in hospitals as one of the major risk facing patients in the 21-st Century: more than 10 million people are infected every year. That’s the reason why, on the top of Mastertop 1300 systems (1324, 1325/REG, 1326/REG), BASF Construction Chemicals developed a brand new innovative flooring system which meets the highest requirements in terms of hygiene: Mastertop 1325 AB. This bacteriostatic system is liquid applied, seamless when hardened, has a non-porous and easy to clean surface which results in low maintenance costs. Thanks to the monolithic adhesion to the substrate, there is no bacterial growth possible under the floor. The bacteriostatic effect of the surface avoids the bacterial growth, offering an additional protection between two cleaning cycles.

The bacteriostatic effect of this system is achieved through the last thin layer called top coat, in this case Mastertop TC 465 AB. As a result of one and a half year development, this polyurethane-based top coat (known for its durability) has been coupled with the Silver Technology and is therefore human and environmental friendly. The bacteriostatic efficacy has been proven through a series of scientific tests (ITECH certification, level 1) and continues to be effective for a long period of time and after regular cleaning and disinfecting cycles (ITECH certification, level 2). In practice, this means that not only the growth of bacteria but also contamination or cross-contamination from the flooring is prevented. The antibacterial effect can be restored by retopping the surface which contributes to preserve the earth without disposing automatically the floor.

Specific types of disinfection products are used for a certain level of disinfection, targeting certain groups of micro-organisms. More resistant organisms, most notably non-enveloped viruses and bacterial endospores, can only be killed by more harsh and more toxic disinfection products. This presentation will provide an overview of the current state of disinfection products and their spectrum of kill of microbes.

Mr. Bobbert will provide the audience with an overview of globally used disinfection products, their relevance and application in the European Union, and the associated safety profile and ecotoxicity of these disinfectants. A snapshot overview of the relevant laws and regulations, such as the Biocide Products Directive (98/8 EC), and its relevance to the use of certain active ingredients, and new research related to the resistance of microorganisms to certain biocides, will be presented. Specific attention will be given to new disinfectant products such as those based on activated Hydrogen Peroxide, their spectrum of kill, safety profile, hazard labeling and use benefits.

As the outcome of our Total Joint Surgical Site Infection Committee, we (UMASS) have implemented evidence based protocols to reduce SSI in Total joints which has been greatly successful.  The occurrence of SSI is a reportable event to our State Medical Board and the cost of treatment of SSI will soon be born by the institution should it occurr within one year of implant placement.

The high amount of false negatives associated with culturing and the low reproducibility of techniques in removing bacteria from biofilm in orthopaedic implant-related infections remain a challenging diagnostic problem. In this original study, different methods of pathogens detection in biofilms were tested both in vitro and in vivo. Polyethylene and titanium discs covered with biofilm formed by isolates of Pseudomonas aeruginosa and Staphylococcus aureus were treated with sonication, scraping, dithiothreitol and N-acetylcysteine, in order to remove adhered bacteria. The overall data demonstrated that the treatment with dithiothreitol was significantly more efficient than sonication, scraping and N-acetylcysteine in removing bacteria within biofilm (p<0.05). The in vitro testings were confirmed by in retrieved, infected hip and knee implants. Dithiothreitol treatment may open a new, low cost and easy way to diagnose implant-related infections.

The aim of our study was to evaluate Xpert MRSA/SA® SSTI RT-PCR assay (Cepheid®) directly on peri-operative osteoarticular samples. A retrospective analysis was first performed on 91 selected samples (MSSA, n=63; MRSA, n=9; negative, n=19) in order to validate the use of the assay (synovial fluid, n=24; bone, n=42; tissue biopsy n=25). Then, 135 samples from 105 patients (45 prosthetic joint infections, 3 spondylodiscitis, 14 acute septic arthritis, and 33 non infected controls) were tested prospectively. In all cases, molecular results were compared to microbial cultures.
Retrospective study: Se and Sp for the detection of SA, were 94.4% and 100%, respectively. All MRSA positive samples were detected.

Prospective study: Se, Sp, PPV and NPV for the detection of MSSA, MRSA and MRCNS in clinical specimens were 100%, 97%, 96% and 100%, respectively. The median of hands-on time for standard culture and Xpert MRSA/SA SSTI® assay were respectively 25 minutes vs 2 minutes, while the median turnaround-time from admission to notification of results were respectively 72 hours vs 72 minutes. Detection of methicillin resistance improved the antimicrobial therapy management as vancomycin could be avoided in many cases.

Xpert MRSA/SA SSTI assay is a rapid and accurate method for the detection MRSA, MSSA and MRCNS in peri-operative specimens. It can dramatically improve the clinical management of patients suffering from osteoarticular infections. Further studies must be conducted in order to evaluate the clinical and economical impact of such an assay.

The management of antibiotic resistance in patients admitted to hospital is of paramount importance for health professionals. In addition to covering a large number of markers, tests to detect resistances must be quick in order to contain the risk.

Genewave has developed a rapid, totally automated molecular diagnostic platform, GeneSpress, which can diagnose some fifty DNA markers in just two hours.

This presentation will detail the design process and functioning of the apparatus in addition to two of the rapid diagnostic tests, GeneVAP and GeneScreen, dedicated to resistance.

Has reporting of process and outcome measures related to healthcare-acquired infections made a difference in infection outcomes? The speaker will discuss reporting of process and outcome measures from the United States and European perspective.

I would like to discuss reporting healthcare-associated infections both in the United States and in Europe.  Reporting has made an impact in the UK in the reduction of C difficile infection and MRSA bacteremia.  I need to research additional reporting benefits identified. I would like to discuss the Unites States Health and Human Services Action Plan to reduce healthcare-associated infections: target goals, and the recent report citing a reduction of central line-associated bloodstream infection in the U.S. I can report on various state reporting measures to date with a focus on surgical site infection outcome data if available.

Has reporting of process and outcome measures related to healthcare-acquired infections made a difference in infection outcomes? The speaker will discuss reporting of process and outcome measures from the United States and European perspective.

I would like to discuss reporting healthHealth and management information systems are a tool to gather and process medical information for patient billing. In addition to their primary medical and economic role, they can serve to describe hospital epidemiology.

Patient infections can be directly or indirectly reported, with an indication of whether they are nosocomial or not. Publications on notifications of infections through health and management information systems conclude that such systems alone are not sufficiently sensitive. Recently, however, the economic impact of these events in the health and management information system has been reinforced and should enhance description.

The role of the health and management information system and those in charge of this sector can be strengthened by linking it to other information systems (in-house reporting of post-operative infections, bacteriological results), closer cooperation within the organisation (operational hygiene team, coordinating committees on nosocomial infection control, etc.) or meetings between key people (nursing care director, quality assurance manager, hygiene nurse). Reommendations in terms of coding rules and awareness-building among medical information personnel might also be envisaged to upgrade the description of nosocomial and other infection-related events and to broaden the role of the health and management information systems in the complex, sensitive context of post-operative infections.

In 2007, we conducted a study on the sensitivity and specificity of hospital information systems in the surveillance of surgical site infections, which is the leading cause of avoidable nosocomial infections.

This study by A. Hautemanière, A. Florentin, E. Albuison, H. Tronel, P. Hartemann from INSERM, Nancy teaching hospital, Henri Poincaré University in Nancy and the Faculty of Medicine of Nancy was designed to seek a method for automated surveillance of SSIs using hospital information system data.

The study highlighted:
° A simplification of patient inclusion and follow-up management
° A low-cost procedure that uses what is available and takes up little medical time
° Complete coverage of departments and more accurate bacteriological data compared with ISO-RAISIN surveillance.

Our first reaction was to build an in-house software for nosocomial computer files, rapid screening of patients carrying certain germs (highly resistant bacteria), warnings linked to patient investigations, screening in epidemics, cohort follow-up (SSI, central line, deaths, etc.), dashboards, etc.
The end-result is decisive: a system that works greatly assists the operational hospital hygiene team and significantly improves hygiene. However, an in-house software entails time-consuming maintenance and hinges on a single person, which is risky for the establishment.

Two hypotheses were studied: industrialisation of the tool and the search for a software package. NOTHING until we discovered ICNet, an off-the-shelf software package that fully meets our needs.

For the last three decades, surgical site infections (SSIs) have been considered a priority in nosocomial infection control programmes in North America and Europe. They represent approximately 15% of nosocomial infections that is between 100,000 and 150,000 patients operated on each year in France. Surveillance using national RAISIN network data shows a drop in excess of 30% in the incidence of these infections after certain clean surgical operations like total hip replacements or abdominal hernia repairs. These encouraging results obtained in a sample of volontary, motivated surgical centres should not cause efforts to lapse as in many centres, compliance with basic measures is not satisfactory. A more detailed analysis of risk factors, in particular those linked to the organisation of care and team behaviour, needs to be carried out. More or less compulsory measures to enhance compliance with the rules of prevention should be discussed.

How, today, can one fail to make practitioners and patients fully aware of the risk associated with a surgical procedure? Yet how far should one take the precautionary principle and thereby risk depriving many people of the benefits of a new technique or technology ?

Medicine, but also the automotive industry or air transport, is full of examples of high-performance technologies developed on bases that initially comprise levels of risk that would be unacceptable today.

Analysing the risks flowing from a given medical device design is one of the essential pillars of product certification. These methodologies are based on a thorough examination of the potential causes of failure, the means used to attenuate them, and the dangers to which users might be exposed if these failures actually occur. The definition of a residual risk level for each device makes it possible to weigh acceptability against the expected benefit.

For society and its legislators, the challenge is to position the residual risk acceptability threshold at a level that makes it possible to benefit from good health techniques while at the same time eliminating any potential risk.

The precautionary principle, invoked a posteriori to withdraw devices from the market following an accident, without clearly determining the benefit, therefore contradicts the principle of prevention, whereby it is possible, a priori, to build a device that incorporates the means of reducing the risk to an acceptable level while clearly identifying the conditions for obtaining the expected benefit.

Biologic fixation of implants by bone is the result of coordinated interaction of Osteoblasts with the implant surface at a microscopic level.  In this regard, a variety of surface enhancements including modification of implant topography and chemistry, have demonstrated utility as a means to enhance the rate and extent of implant osseointegration.  While effective, less is understood about the potential effect that changes in topography and chemistry have on colonization of the implant surface by bacteria.  This is of interest since implant infection is a persistent concern for both the patient and care provider.  In this talk, we will review and discuss various approaches that may provide short and long-term utility to reduce the incidence of implant associated infections.

The nosocomial infection rate linked to surgical sites and patient hospitalisation automatically plummets when out-patient surgery increases. International figures have been confirmed in France. The 2008 CCLIN report covering the Paris-North region shows, for example, a spectacular reduction in SSI rates, which dropped from 1,27% to 0.27%.  Strangely, however, two new problems may dampen the expected benefit. Out-patient care comprises major time constraints for professionals, fostering short-cuts, and this surgery is sometimes performed by interventional practitioners less versed in standard surgical practice.

This may lead to a drop in aseptic measures in care; indeed, the results of audits published in international reviews raise the spectre of this negative development in the general mindset. Furthermore, the national survey of undesirable events published in 2010 (ENEIS2) highlights another new risk : GPs manage infections earlier in the immediate post-op period and do not cure them well. Without training and without the help of infectiologists, they may be far less effective in the fight against infection. One can readily understand that this is a new challenge in infection control, which calls for a deep-seated change in techniques and usages in addition to the introduction of quality control.

Q&A IQuestions and Answer with the audience

Infection of a toal knee replacement is a dramatic situation for the patient, even more than in the case of total hip replacment.

Patients are older, the success rate lower whatever the therapeutic protocol proposed (excision-cleaning, one or two-step replacement, etc.) and the functional consequences far more serious. It is therefore important right from the outset, via the reference centre for the treatment of bone and joint infections (CRIOA), to set up optimal management circuits to try to minimise the consequences of infection.

The rate of infection after total knee has decreased over the last three decades.  Current rates are estimated to average between 1% to 2% for primary total knee arthroplasty.  Despite an improvement in its management, it remains a significant and difficult problem to manage.

Goals of Treatment

1. Eradicate the infection
2. Alleviate pain
3. Restore function of the affected limb. 

Treatment options

1. Antibiotic suppression
2. Debridement with retention of components
3. Resection arthroplasty with no reimplantation
4. Arthrodesis
5. Amputation
6. Removal of the prosthesis with reimplantation. 

Reimplantation offers the best chance for optimal functional outcome.  The two-stage approach In North America it is currently the treatment of choice for the chronically infected total knee arthroplasty. 
Advantages 2-stage: Second look/second debridement before reimplantation, reimplantation does not need to be an all-cement (to fill bony defects) implantation as the advocates of direct exchange recommend, Higher reported success rates.

Disadvantages 2 Stage: Time interval between the first and the second stage, the pain and limitation of function in between the stages, the stiffness encountered at the time of reimplantation and the possibility of soft tissue contractures which may occur during this time interval.

Controversies: Optimal duration in between stages, the optimal duration and route of antibiotic delivery, the efficacy of antibiotic spacers and bone cement, the role of spacer blocks/Prostalac on functional outcome, the optimal fixation at the time of reimplantation, and the use of allograft in the face of previous infection. 
Indications: good bone stock, adequate soft tissue envelope, an immunocompetent patient, and a sensitive organism. 

Contraindications of reimplantation include persistent infection, an immunocompromised host, extremely poor bone stock, and extremely poor soft tissues, i.e. extensor mechanism disruption. 

The first stage includes removal of sinus tracts, removal of prosthesis, removal of all cement, and extensive soft tissue and bony debridement, obtaining cultures and placement of an antibiotic spacer. The placement of a spacer has the advantages of local delivery of antibiotics as well as the maintenance of collateral ligaments.  Its disadvantages include the fact that it is a foreign body and that bone loss may occur around the spacer. We prefer and arthrodesis block. The typical dose for the spacer includes 3 to 4 gr of Vancomycin and 3.6 to 4.8 gr of Tobramycin per batch of cement.

The second stage or reimplantation should done once eradication of infection has been documented clinically, by normal or near normal infection labs and by frozen section and gross inspection of the joint at the time of surgery. It should be done with antibiotic loaded cement.  The typical dose for fixation with prosthesis include 1 gr of Vancomycin and 1.2 gr of Tobramycin per batch of cement. 

The results of infected total knee arthroplasty with the use of this two-stage reimplantation technique has provided good results at mid to long-term follow-up.  The Mayo Clinic Experience has been reported by Haleem et al (CORR, 2004).  Ninety-four patients, of which two had bilateral arthroplasties, were followed for 7.2 years.  Fifty knees required reoperation; nine knees required removal for a reinfection; and six knees required revision for loosening.  The two-stage reimplantation technique had a survivorship free from reinfection of 93.5% at 5 years and 85% at 10 years.

Total knee implant-related infection usually entails changing the prosthesis. Two-step reimplantation is considered the treatment of choice.

This technique has several advantages, at least in theory :
o double cleaning, at each step
o absence of a foreign body, fostering eradication of the infection
o eradication can be checked before reimplantation
o « right to make a mistake » during the first step

However, this approach implies two extensive operations with a difficult in-between time for the patient. For several years now, we have changed infected total knee implants using single-step surgery on a routine basis without selecting patients. This is only justified if the clearing of infection is not impaired.

We shall present a series of 48 patients who underwent a one-step procedure to change an infected total knee implant between 2004 and 2007. All the patients were followed up for a minimum of 2 years. The following points were assessed: clinical and functional results according to the Knee Society score, radiological results, complications and redos. The absence of infection was assessed using the customary clinical, biological and radiological parameters in addition to the absence of further surgery for infection.

88% of the patients were free of infection at the last follow-up. The average « knee » score was 80 points (ranging from 10 to 100 points). The average flexion angle was 97% (ranging from 10 to 120°). The average « function » score was 69 points (ranging from 10 to 100 points). The survival rate of infection eradication was 81% at 2 years.
The initial infection was not cured in 3 patients (6%), treated respectively with a new one-step change, a two-step change and suppressive antibiotic treatment. In three patients, the initial infection was cured but a new infection due to another germ developed. These three cases were treated respectively with debridement, iterative one-step change and suppressive antibiotic treatment.

The results of systematic one-step implant change in infected knee prostheses, without patient selection, are thus similar to the best results published for two-step reimplantations. The clinical and functional results are no doubt better and the patient avoids the difficult in-between period. Failures owing to infection are due in equal numbers to failed initial treatment of the infection and a new infection, no doubt acquired during the surgical procedure.
Systematic one-step reimplantation after removal of an infected knee prosthesis, without patient selection, appears to be a very attractive alternative devoid of any major risk of failure.

o Prescription of antibiotics in the absence of germs in the event of redness after an infection,
o Extended treatment of an implant-related open wound with a VAC system,
o The choice of a suitable antibiotic,
o Etc. 

In the event of total knee replacement, one or two-step surgery is often proposed according to a decision-making tree established by each team. Some clinical, anatomical or microbiological situations lie outside these protocols. What do our experts do in the event of rupture of the extensor apparatus, iterative infection, multi-resistant bacteria, major loss of cutaneous or bony substance, immunocompromised patients ? When should arthrodesis, amputation or palliative medical treatment be proposed ? A selection of these most complicated cases will fuel discussions among experts at the session.

Anatomical and psychological sequelae of infections

The sequelae of infections spring from the process of infection itself in addition to the curative surgery. All the anatomical tissues may be affected. The skin is impaired by iterative, unsightly scars, chronic ulcerations or ugly flaps. The muscles and tendons may be atrophied or torn, the nerves paralysed and vascularisation altered. The joints may become stiff or unstable. Bones go off-axis, are lengthened or shortened, sometimes amputated. These painful, often irreversible sequelae alter the functional result for the patient. They are particularly important when patients have experienced failures and undergone iterative surgery.

These failures owing to infection are a source of concern, incomprehension and mistrust for the patient. How can a patient who trusted the medical establishment and acquired an infection during functional surgery place his trust once again in medicine in the hope of achieving a cure ?

On the medical side, introspection is necessary in order to progress. Communication remains the key to re-establishing a trusting relationship with the patient in order, together, to implement an effective therapeutic programme

o What can we learn from discussions with orthopaedic surgeons
o Physiopathology : biofilm
o Can one keep the implant ?
o Antibiotic treatment

Mr Deshpande will present on Surgical Site Infections in Cardiothoracic surgery - the risks involved, the consequences to the patient and the hospital and what interventions can be made to help improve surgical outcomes. He will then focus on skin-prep and the impact that ChloraPrep as a single intervention has made on the surgical site infection rate within Kings College Hospital's Cardiothoracic Unit.

The frequency of post-operative infections in joint replacement surgery without antibiotic prophylaxis is 3 to 5%. Prophylactic antibiotic treatment can reduce this rate to under 1%. In primary arthroplasty, prescription of local antibiotic prophylaxis by means of commercially available antibiotic impregnated cement does not dispense with parenteral antibiotic administration.

Revision surgery

Revision surgery during the same hospital stay for a surgical reason other than infection (hematoma, dislocation, etc.) calls for a diffferent antibiotic prophylaxis. Revisions deemed septic should not be treated on the basis of probability. Deep cultures must be made. When vancomycin is prescribed, it must be combined with an antibiotic active against hospital negative gram bacillae.

Conversely, late revisions (within a year after surgery) for mechanical causes in out-patients do not call for any change in the initial antibiotic prophylaxis.
Target bacteria : S. aureus, S. epidermidis, Propionobacterium, Streptococcus spp, E.coli, K.pneumoniae 

Antibiotic impregnated bone cement is used both as a preventive and therapeutic initiative in orthopedic surgery. Controversy regarding the preventive role of antibiotic impregnated bone cement in primary and revision total joint replacement reflects the observation that the infection rate in those joints in which this type of cement is used may be lower than with conventional bone cement but the revision rate is as high or higher suggesting some loss of mechanical integrity in the cement as a consequence of adding the antibiotic.

Antibiotic impregnated bone cement has a recognized therapeutic role in the treatment of established infections particularly as an effective method of local delivery of antibiotic during one- or two-stage revision procedures. 

Despite systemic prophylaxis, infection rates after orthopedic surgery can reach more than 1%. A new HAP/TCP bone substitute loaded with 125 mg of gentamicin was designed for prophylactic use. Its aim was to enhance the efficacy of systemic prophylactic treatments by increasing the local antibiotic concentration. The release rate of gentamicin from the bone substitute was investigated after implantation in the femoral condyle of five sheep. In order to investigate the local and systemic gentamicin concentrations, synovial fluids and blood samples were assessed over a 5-day period.

The mean gentamicin concentration peak in blood was 4.2 μg/ml and the mean local concentration in synovial fluids during the first 8 hours was 305 μg/ml. After 48 hours, the concentrations in blood and synovial fluids were less than 0.5 μg/ml. No remaining gentamicin was detected in bone substitutes explanted after 8 days of implantation. The gentamicin release rate from the bone substitutes assessed corresponds to the recommendations for the prophylactic use of antibiotics: high local concentration but limited in time (less than 48 hours) not to select antibiotic-resistant bacterial strains. Our results indicated that this implant should be an effective prophylactic tool in orthopedic surgery in combination with systemic prophylaxis. 

Despite knowledge about concensus conferences of various learned societies, there is much negligence in the implementation of antibiotic prophylaxis protocols.

o In the pre-operative analysis of the risk of infection
o In compliance with protocols

As a result, new, potentially serious, disabling post-operative complications due to infection are developing. They could be avoided by strict application of clearly identified protocols for patient preparation in elective surgery.

Also, new invasive intra-articular endoscopic procedures should encourage us to enforce careful preparation, which must be “ecological and eclectic” in terms of skin preparation of the surgical site. 

Antibiotic therapy for bone and joint infections

Update on recommended clinical practice in implant-related bone and joint infections. Classification of infections.

°   Regimen/combinations
°   Duration
°   Mode of administration
°   Delivery of the molecule
°   New molecules 

o What do you do ?
o Duration
o Duration of intravenous administration
o Combinations
o Regimen
o Result 

This survey conducted among infectiologists in bone and joint infection reference centres and associated centres covered the length of antibiotic treatment (length of IV administration and total length), the mode of administration and the use of a combination of antibiotics (type, length) in the management of implant-related infections. It will provide data on current practices and fuel subsequent discussion on the subject (ME5.5);

The characteristics of certain antibiotics recently placed on the market provide for their possible use in implant-related bone and joint infections. Antibiotics must have many virtues to treat such infections, which limits the number of really useful molecules in this context.

The first requirement is the ability to disseminate within the infected tissue, comprising compact and cancellous bone, the surrounding tissues and the biofilm when the infected hardware has not been removed or surgical debridement was not complete ; continued activity on growing bacteria present in the basal zones of the biofilm is an interesting pre-requisite for considering the use of an antibiotic in such situations.

Antibiotic action against multiresistant bacteria is increasingly useful owing to the growing prevalence of these bacteria, in particular negative coagulase staphylococci and multi-resistant negative gram bacilli. Some old molecules are being viewed with renewed interest owing to their impact on these bacteria despite major limitations mainly linked to the fact they are difficult to use. It has not been proven that bacteriocidal activity is an advantage in implant-related bone and joint infections. Finally, in light of the population treated, oral administration, long-term tolerance and the absence of interaction with other drugs are important criteria in decision-making.

This presentation will discuss the use of linezolid, daptomycin, tigecyclin, fosfomycin and colimycin in the treatment of implant-related bone and joint infections. 

WHICH APPROACH ?

The best method for medium or long-term antibiotic administration has been open to debate for many years. Implantable chambers have been widely adopted, using tunneled Hickman or Groshong type catheters.

These vascular approaches have, however, displayed limitations, and sometimes lead to complications and patient discomfort.

Catheters have now been greatly improved in order to preserve the vascular system and improve patient comfort :

o Use of Polyurethane (long-term)
o Ultrasound guided puncture
o Use of a « Maximum barrier » kit guaranteeing total asepsis and compliance with CDC regulatory directives

Infection-induced osteitis can now be treated using a simple approach, with a clear drop in the risk of infection and thrombosis: the PICC line – peripheral insertion central catheter. 

After several decades of rash antibiotic use, we are entering an era of risk and shortage, characterised by the advent of highly resistant bacteria (in particular, ESBL-producing enterobacteriaceae and, more recently, carbapenemase-producing enterobacteriaceae) for which we have few or no antibiotics. Furthermore, very few new products are expected in the next ten years. An acute public health problem is looming for man and the animal kingdom.

Therapeutic failures with major clinical consequences are already occurring and will increase in the coming years, owing to infections that used to be benign……thanks to antibiotics ! It is currently estimated that antibiotic resistance will cause at least 25,000 deaths per annum in Europe, no doubt an underestimate. Antibiotic resistance is strongly correlated to antibiotic use. Despite some short-lived progress (the CNAM « antibiotics are not automatic » programme), France basically remains a huge prescriber for man and beast (two times greater than the European average, three times greater than the Scandinavian countries). It is high time to react.

The World Health Organisation dedicated its world health day on April 7th to antimicrobial resistance. An article co-signed by 14 scientists from around the world published the same day in The Lancet called for strong international mobilisation on the theme. In France, health system users, 320 scientists including 60 leading foreign doctors, and 37 learned societies or specialist colleges have decided to group together and create a « Global Alliance against the Development of Multi-resistant Bacteria « (AC-de-BMR). This alliance is made up of a broad range of French and foreign professionals in human and veterinary health, environmental experts and parliamentarians. Citizens are represented by LIEN and CISS and are deeply involved. 

The continual evolution of antimicrobial resistance poses a dilemma in the management of orthopaedic infections. Lengthy antibiotic therapy, coupled with the inherent difficulties in managing such infections, contributes to the emergence of resistant microbial subpopulations. We highlight the mechanisms of resistance and its orthopaedic implications by focusing on vancomycin-intermediate and daptomycin-resistant Staphyloccus aureus. Recommendations include increased awareness of resistance patterns, earlier specialized screening and narrow-spectrum antibiotic usage. Where possible, prolonged antibiotic use should be avoided and implicated hardware should be removed early to achieve adequate source control.

Given the difficulties currently encountered with antibiotic treatment, other solutions need to be found. Phagotherapy is an anti-bacterial treatment that uses the lytic activity of bacteriophages, a special virus, to combat bacteria. This principle, discovered in 1915-17, was widely used for therapeutic purposes as of 1919, up until to the discovery of antibiotics. In the ‘40s, owing to very variable results, phagotherapy was abandoned.

Bacteriophages specifically destroy the target bacteria, whether resistant to antibiotics or not. They multiply in the course of treatment in the presence of the « target » bacteria, and disappear once the patient is cured. Phagotherapy can be used independently or at the same time as antibiotics. We shall describe the advantages and disadvantages of phagotherapy, our personal experiences and the conditions for re-introducing phagotherapy.

o What is the purpose of bone and joint infection centres ?
o Current status and results
o Prospects in 2012