© 2024 HMP Global. All Rights Reserved.

Postoperative wound infections, specifically prosthetic joint infections (PJIs) can pose significant challenges for wound care professionals. However, how does one proceed if the patient is not a surgical candidate? In the previous installment of this series, I discussed the basics of PJI. Now, let’s dive into this uniquely vulnerable patient population.

There is controversy as to how best to treat the nonsurgical candidate, such as the elderly patient with multiple comorbidities, the nonambulatory patient, the one with a limited life expectancy, or the patient who refuses operative intervention. With this patient population, providers must clearly outline and discuss expectations, noting that their clinical problem is complex, chronic, and incurable and that the proposed care is palliative. Treatment goals then typically aim at achieving a reasonable and satisfactory quality of life, a decrease in localized wound pain, maintaining a stable joint, avoiding progression of the underlying infection, preventing sepsis, and avoiding hospitalization. These goals can be successfully managed and maintained by periodic or as needed outpatient wound care.¹ In this patient group, “long-term or antibiotics for life suppression therapy” has been proposed¹ as the accepted treatment for the infected prosthesis, however, in my opinion, support for this approach has not been clearly documented.

When analyzing “long-term antibiotic treatment or antibiotics for life,” the optimal guidelines and benefits have not been fully established. Few randomized trials have been published, most, with small patient sampling and without controls. The supportive data for this treatment approach is vague, fragmented and based on low evidence results.² 

In reviewing many articles dealing with this topic, I observed a lack of significant data, and inconsistencies within the available data, as outlined here.  

1) there is no standard criteria for evaluating the efficacy and patient outcomes 

2) there is a lack of specific data regarding the choice of antibiotic used 

3) dosing with single vs combination drugs was often not stated 

4) no conclusion as to the benefits of oral vs intravenous route administration 

5) the optimal dosage and length of treatment were often unclear 

6) how to address bacterial resistance and a negative culture 

7) drug interactions and biofilm formation were also not examined 

8) a detailed wound description, including the wound base and edge, the amount and type of wound exudate, the state of the periwound, were not elaborated. Additionally, the  presence of a sinus tract,  exposed bone and or hardware are significant findings affecting treatment outcomes. 

9) details on the types of debridement, dressing choices and frequency of treatment 

10) the impact of the patient age, and related comorbidities and their influence on treatment outcomes

11) patient expectations and satisfaction with treatment outcomes 

12) patient adherence to treatment and their support systems

13) continuous and appropriate follow-up 

14) and finally, what if any clear predictors of treatment failure were established

One common conclusion was that antibiotic therapy alone, without wound debridement, is not recommended. It was also noted that the use of suboptimal antibiotics dosage has been routinely shown to cause resistance.³ Additionally, another study noted that most patients who discontinued antibiotic therapy did not exhibit a worsening clinical state.¹ This questions the value of initiating long-term therapy. An analysis of suppression antibiotic therapy (SAT) and debridement, antibiotics, implant (prosthesis) retention (DAIR], concluded a low probability of success when implementing SAT.³ 

Despite these strategies, there is limited data on patient outcomes, with bacterial resistance as a major concern.⁴ One 2022 5-year study noted “there is little known regarding the impact of long-term antibiotic therapy.”5 A piece in Clinical Infectious Diseases stated that there is low efficacy in the management of infected prosthesis utilizing suppression antibiotic therapy.⁶ 

What Factors Should Wound Care Professionals Consider?

In evaluating the overall palliative care results for these patients, I have found that their quality of life and treatment satisfaction becomes an important benchmark. Their responses are often personal and subjective.  Thus, interpreting their feedback, and formulating data for a treatment protocol can be difficult and inaccurate. Whether the patient is being treated for other significant medical conditions, lives at home with an adequate support system, resides in a nursing home, or has been recently hospitalized are important contributing factors to considered (and are rarely included in the literature). In my experience, an appropriate care plan should include routine follow-up appointments, performing debridement to remove devitalized tissue, maintaining open sinus tracts to promote drainage and utilizing appropriate dressings. Our clinic does not perform wet-to-dry dressing changes nor utilizes gauze as a primary dressing, as these will not adequately absorb wound exudate, ofteb adhere and dry out the wound, are and painful to remove. We treat sinus tracts with insertion of medicated foam. We do not pack with iodoform gauze which we find desiccates, and prevents egress of fluid. The patients in our practice are seen as outpatient and have had no issues with wound maintenance, diffuse cellulitis, sepsis, or intractable pain and have remained stable with an acceptable quality of life by the patient's and family's own reports.

Our clinic has analyzed a series of 11 patients, 2 of which underwent two-stage hip replacement, one successful, and the other complicated by a wound dehiscence. Two infected knee prostheses which had treatment with surgical debridement and irrigation and a shoulder prosthesis which is pending a two-stage repair. The remaining 6 patients have been followed for over 3 years and include 2 hip, 3 knee wounds, and 1 shoulder. Four of our patients have been seen monthly, had their wounds debrided, utilizing moist wound care without antibiotic therapy, while 2 patients are still on long-term low-dose oral antibiotics per their orthopedic and infectious disease physicians, who indicated to the patients that failure to take continuous antibiotics could result in sepsis and death.  Both groups have remained stable and in comparison, there has been no differences in wound appearance, condition or patient quality of life. 

There has been ongoing research evaluating the negative aspects of long-term antibiotics. Aside from resistance, and the possible development of C. difficile colitis, there is data suggesting that changing the gut flora alters the body’s microbiome balance and composition, which is associated with the chronic inflammatory responses. This has been linked to the possible development atherosclerotic disease by stimulating macrophage associated proliferation along with hypertension.⁷

In Conclusion

The use of long-term antibiotic therapy to treat infected prosthetic joints, is in my opinion not indicated as long as the patient is followed routinely at a wound care center. This allows for debridement and appropriate dressing changes. The concept of long-term antibiotic therapy, I believe, resulted from a lack of wound care knowledge and training by initial treating providers, a reluctance to debride, the concerns for hemostasis, and discrepancies in routine follow-up for these patients. Further, I feel that an element of fear has been falsely perpetuated by the original treating provider by telling the patient that, “without antibiotics they could become septic and die.” I have heard this phrase on multiple occasions which is incorrect and without evidence-based merit. What is difficult in medicine is not initiating new ideas and treatments, but discontinuing and abandoning old protocols.

References

1. Lau JSY, Korman TM, Woolley I. Life-long antimicrobial therapy: where is the evidence?, J Antimicrob Chemother. 2018;73(10):2601–2612.

2. Cobo J, Escudero-Sanchez R. Suppressive Antibiotic Treatment in Prosthetic Joint Infections: A Perspective. Antibiotics (Basel). 2021;10(6):743. 

3. Le Vavasseur B, Zeller V. Antibiotic Therapy for Prosthetic Joint Infections: An Overview. Antibiotics (Basel). 2022;11(4):486

4. Tsang SJ, Ting J, Simpson AHRW, Gaston P. Outcomes following debridement, antibiotics and implant retention in the management of periprosthetic infections of the hip: a review of cohort studies. Bone Joint J. 2017;99-B(11):1458-1466

5. Kiss C, Connoley D, Connelly K, et al. Long-term outcomes in patients on life-long antibiotics. A five-year cohort study. Antibiotics. 2022;11(1):62.

6. Cortes-Penfield N, Krsak M, Damioli L, et al. How we approach suppressive antibiotic therapy following debridement, antibiotics, and implant retention for prosthetic joint infection. Clin Infect Dis. 2024;78(1):188-198.

7. Rashid S, Sado A, Afzel MS, et al. Role of gut microbiota in cardiovascular diseases - a comprehensive review. Ann Med Surg (Lond). 2023;86(3):1483-1489.

Additional Reference

Wolcott RD, Ehrlich GD. Biofilms and chronic infections. JAMA. 2008;299(22):2682-2684.