Knee Infection A question about antibiotics after an infection

[ziggy99]

Hi all. Had my knee replaced 2/1/2017. Everything went smoothly and I was back to full activity (which is a fair amount of activity. I walk/jog about 30 miles in an average week, 50-60 miles in busy ones, ride a bike, swim) within ten weeks and things were going fine.

On 12/27/17 I developed an infection in my knee - group b strep, as it turned out. Caught it very early according to the surgeon, so he just debrided it and replaced the liner. First they put me on Ceftriaxone (infusion via a PICC line) but I developed a reaction to something (my liver went crazy and I ended up back in the hospital) after a couple of weeks, so we stopped all meds except aspirin and switched to Vancomycin in place of the Ceftriaxone. That went fine and I am coming to the end of an 8 week course of treatment with the IV antibiotics.

The knee itself is a little sore, but fine. I am still a little tired from the infection and complications, but otherwise I am not limited in my activity. I know I am pushing the limits of the knee with my activity level but that is very much why I did this - I want to be active and enjoy my life. In this rehab I am focusing on range of motion, so a lot of stretching in addition to walking and some other strength work. So far, so good - 8 weeks in, I can flex around 120 degrees, quite a bit more than after my first rehab, and walk as far as I like.

Was reading some studies online and the numbers I found were that the two stage replacement of the prosthetic is successful in eliminating the infection over 90% of the time, while what I had done only works about 25% of the time. I was not in any shape to make that decision, and I think I would have gone with the less invasive choice anyway if the surgeon (who I like a lot in terms of the results of the surgeries) had consulted me.

So I guess I understand why the Infectious Disease doctor tells me I will be on penicillin for the rest of my life. The bacteria is probably still lurking around. I am curious if others have had different treatment for similar infections (group b strep caught early and treated with the debridement and liner replacement). Should I get a second opinion? I try to avoid taking drugs to the degree possible but the infection was miserable and since it sounds like there is a 75% chance some bacteria are still around, I will take the antibiotics. Just want to be sure it is the right treatment.

Also curious to hear about others who might be as active as me, including light jogging on soft surfaces, mostly grass and artificial turf (I referee soccer games). I am definitely overweight which was surely a factor in the wear on my knee but the surgeon told me I could do light jogging on soft surfaces after the replacement.

Any early wear on the knee, or other complications in similar situations?

My first year went so well that before the infection I was planning to increase my activity level.

Thanks in advance,
z

 

[Pumpkin]

Ziggy99,
Welcome to BoneSmart glad you joined us!
Sorry to hear you have been through so much. @KarriB had a smilier procedure, and is doing well. She is on a lifetime antibiotic, she will tell you more about her situation when she responds to my tag.

We have many members who are very active after joint replacement, you will do better to wait until your knee has healed before increasing your activity to previous levels.

I am going to give you the recovery guidelines, you are only a 6 weeks out from your most recent procedure, and are still in the early days.

Here are the recovery guidelines, the articles are short and will not take long to read.

Knee Recovery: The Guidelines
1. Don’t worry: Your body will heal all by itself. Relax, let it, don't try and hurry it, don’t worry about any symptoms now, they are almost certainly temporary
2. Control discomfort:

rest
elevate
ice
take your pain meds by prescription schedule (not when pain starts!)
don't overwork.​

3. Do what you want to do BUT
a. If it hurts, don't do it and don't allow anyone - especially a physical therapist - to do it to you
b. If your leg swells more or gets stiffer in the 24 hours after doing it, don't do it again.
4. PT or exercise can be useful BUT take note of these

the BoneSmart view on exercise
BoneSmart philosophy for sensible post op therapy​

5. At week 4 and after you should follow this

Activity progression for TKRs​

The Recovery articles:
The importance of managing pain after a TKR and the pain chart
Swollen and stiff knee: what causes it?
Energy drain for TKRs

Elevation is the key
Ice to control pain and swelling
Heel slides and how to do them properly

Chart representation of TKR recovery
Healing: how long does it take?
Post op blues is a reality - be prepared for it
Sleep deprivation is pretty much inevitable - but what causes it?

There are also some cautionary articles here
Myth busting: no pain, no gain
Myth busting: the "window of opportunity" in TKR
Myth busting: on getting addicted to pain meds


We try to keep the forum a positive and safe place for our members to talk about their questions or concerns and to report successes with their joint replacement surgery. While members may create as many threads as they like in a majority of BoneSmart's forums, we ask that each member have only one recovery thread. This policy makes it easier to go back and review history before providing advice.

 

[liam2015]

how awful to have an infection 10 months after your replacement. do you have any idea or did your doctor suggest how you may have got the infection? other than that, you had an amazing recovery and even after the infection, you've had a good recovery in terms of range of motion and activity level. wishing you all the best in dealing with the aftermath of infection and antibiotic therapy.

 

[pdx]

It sounds as if you'd be more comfortable getting a second opinion, so maybe think of it that way? So sorry you went through the infection -- let's hope it's gone, gone, gone.
As for exercise, running was the only thing I was counseled not to do. But I don't know if the advice changes depending on the type of implant. Like you, I walk, bike and swim without issues. Luckily I never much liked running anyway!

 

[KarriB]

Welcome, Ziggy! Our stories are very similar, except my infection occurred 4 weeks post op and I THINK I had group A strep. At 4 weeks I had yellow pus streaming from a closed incision which resulted in emergency surgery Thanksgiving Eve. Going in I knew there was a chance they’d take the knee out, but my revision OS felt a washout/spacer exchange would do the trick. My knee continued to seep for about 3 after that surgery, even with PICC line and oral antibiotics from my ID. I was also in an immbolizer at that time because my dr didn’t want any bending because the soft tissue was so compromised by the infection and washout. After 4 weeks the seeping stopped, at 6 weeks my white cell count was so low the ID took me off all antibiotics until my body recovered from the barrage of meds (I only ever took thyroid medication before) and when the white count came up I went on 200mg of doxycycline.

I do take 100mg doxycycline daily along with a good probiotic and still see my ID annually for blood work to Ben sure all is well. After slowly working on ROM I now purposely walk a few miles a day, ride 8-10 miles on my exercise bike and swim 20 laps in the summer. I’m actually more active now than before my TKR, but I’ve never been a runner.

My OS wanted me to take things slowly in the beginning, not forcing any bending. When I left PT at 5-6 months my ROM was 109, so your 120 is great!

 

[Josephine]

I'm sorry for your bad luck, Ziggy. But I think it depends upon which authors you read concerning one or two stage revisions for infection. So far as I've read, it's about 50/50 in success rates. I do know surgeons who swear by each method and each get very good results. It's really difficult to be specific about these things.

As for what causes the infection, that's almost impossible to say but this article might give you some insight Peri-prosthetic infection - also known as late onset infection.

Certainly the bio-film usually has more than a little to do with it but the big question is WHY? As yet, nobody has been able to define what it is that kick-starts the juvenile bugs in the biofilm to start growing and reproducing. Opinions abound but facts are pretty scarce!

 

[ziggy99]

Hi to all of you kind folks.

First to the Admins - I made a typo. My TKR was 2/1/2016, not 2017. The date for my infection is correct. Now let me see if I can reply to everyone in order.

Josephine, thank you for all the info. I really appreciate the infection info. I acknowledge the wisdom of much of the rehab stuff, though it is definitely not what I did after the TKR, nor what I am doing for this recovery. I suppose my disagreement is two-fold. First, I dislike pain meds. When something hurts it is because my body is telling me something and I need to listen. So for the last 4 years before my TKR I almost completely stopped taking pain meds, and I also stopped taking them as soon as was comfortable after my TKR and then after my recent debridement. I pay attention to the pain, let it tell me what should and should not do.

Second, I want to be active and have what I consider to be reasonable ROM. And I am a little bit impatient, perhaps a bit driven, which may be why I wore out my knee. To get where I want to be, and particularly to get to the ROM that is my main goal this time, I feel I need to push a little harder than you indicate. I did not push for ROM the first time and was unhappy with the results, so I am trying to fix that this time. On the other hand, because of the impact of the infection and treatment for it, I am going a lot slower as far as my overall activity level this time, though still faster than you indicate. Let's just call it fast, as opposed to crazy. But crazy worked okay for me after the TKR (despite my PT telling me I was nuts), so I think fast is probably okay this time. And my orthopedic surgeon is aware of and supportive of my choices.

But I definitely get that this is a personal choice, very much dependent on my fitness and activity level pre-surgery, and would not work for everyone.

Thanks for the kind wishes, liam. On the whole I am pretty happy with the TKR (though I did not always feel that way during the infection). No, no one has any idea how I got the infection. The bacteria is common, in 30% of all adults, so I may well have infected myself. But I will never know for sure.

Hi pdx. Yes, I really am not supposed to run and at my age I really do not run. I do jog in brief bursts, tho, and the doctor said that is okay so long as it is not on a hard surface. My research suggests that I am definitely going to wear out my implant faster by doing that, so I am torn between trying to do continue to do what I love (referee soccer) and doing what is best for my knee. Which is pretty much what got me here, anyway. I was happy with the line I walked (so to speak) last year, so I plan to continue along that line. But I am sort of deluding myself about that since the ill effects will not show themselves until the wear becomes apparent later.

Thanks for sharing your story Karri. Aside from when our infections happened, it does sound like our experiences are pretty similar. I am going on oral penicillin tomorrow (as the ID doc said, group B strep is easily treated, no fancy antibiotics), 500mg 3 times a day. So glad to have the picc line out! As I noted above, the OS and PT both had me take it easy on bending after the replacement and I was not happy with my ROM in the end, so I (my choice here) am being more aggressive this time. It does hurt some, but I am very careful about how much I push it. And I am not taking any pain meds, so I am very clear about how much it hurts. In fact, I was unhappy with how sore my knee was last week (I think I did a little too much weight work) and took a couple of days off of everything except walking (tho I walked a lot) and the ROM decreased to about 115 degrees. Feeling better now, but still taking it a little easier with weights and ROM work. It sounds like you are also on antibiotics forever?

Bottom line, I am thinking I will just plan on the oral antibiotics being a permanent thing, but review it with the ID Doc each time I see him/her.

Thanks again to all of you.

 

[Josephine]

To get where I want to be, and particularly to get to the ROM that is my main goal this time, I feel I need to push a little harder than you indicate. I did not push for ROM the first time and was unhappy with the results, so I am trying to fix that this time.

ziggy, perhaps you missed my point that pushing hard for ROM is counter-productive as it creates more swelling and pain and thus a stiff leg which is what impedes ROM progress. All too often, we hear and see members thinking or being told that to rectify this, the hapless patient needs to push harder! NOT a good idea!

Bottom line, I am thinking I will just plan on the oral antibiotics being a permanent thing, but review it with the ID Doc each time I see him/her.

If your infection has been mostly proven then I'm sorry to be a downer but this also is not a good idea. It's not like having to or trying to live with the pain of arthritis but this is more malicious and can be destructive to the bone.

(end of lecture!)

 

[Beckadeez]

Glad you got your infection taken care of. Good luck with your recovery.

 

[shelli22]

@ziggy99 I have just read your post and I’m interested as you seem to have a similar story to me. I would just like to know what you mean by your liver went crazy and what caused it as my LFTs were out of whack, my heart rate sits at 110-125 at rest but I only had one culture come back positive which they say could be a contaminant. Just wondering whether I’m in the same boat as you perhaps

 

[SusieShoes]

Infection aside, because that’s not in anyone’s plan, it sounds like you have your recovery well in hand. Pushing harder works for some people. If you’re paying close attention to your knee and are only pushing as far as your knee is saying is all right, you’re doing fine. Other people might think you’re crazy, but plenty of people think those who don’t push their knees are crazy, too.

As for wearing out your knee sooner... it’s your knee. What’s the good of having a new knee, and all that trouble, if you can’t enjoy it? Use it. Plenty of members here have gone on to play sports, like soccer or hockey, and live really active lives. We get these new knees so we can live a little, so go out there and have fun!

 

[pdx]

Hey, if you want to referee soccer, go for it!

 

[bill4]

Hi all. Had my knee replaced 2/1/2017. Everything went smoothly and I was back to full activity (which is a fair amount of activity. I walk/jog about 30 miles in an average week, 50-60 miles in busy ones, ride a bike, swim) within ten weeks and things were going fine.

On 12/27/17 I developed an infection in my knee - group b strep, as it turned out. Caught it very early according to the surgeon, so he just debrided it and replaced the liner. First they put me on Ceftriaxone (infusion via a PICC line) but I developed a reaction to something (my liver went crazy and I ended up back in the hospital) after a couple of weeks, so we stopped all meds except aspirin and switched to Vancomycin in place of the Ceftriaxone. That went fine and I am coming to the end of an 8 week course of treatment with the IV antibiotics.

The knee itself is a little sore, but fine. I am still a little tired from the infection and complications, but otherwise I am not limited in my activity. I know I am pushing the limits of the knee with my activity level but that is very much why I did this - I want to be active and enjoy my life. In this rehab I am focusing on range of motion, so a lot of stretching in addition to walking and some other strength work. So far, so good - 8 weeks in, I can flex around 120 degrees, quite a bit more than after my first rehab, and walk as far as I like.

Was reading some studies online and the numbers I found were that the two stage replacement of the prosthetic is successful in eliminating the infection over 90% of the time, while what I had done only works about 25% of the time. I was not in any shape to make that decision, and I think I would have gone with the less invasive choice anyway if the surgeon (who I like a lot in terms of the results of the surgeries) had consulted me.

So I guess I understand why the Infectious Disease doctor tells me I will be on penicillin for the rest of my life. The bacteria is probably still lurking around. I am curious if others have had different treatment for similar infections (group b strep caught early and treated with the debridement and liner replacement). Should I get a second opinion? I try to avoid taking drugs to the degree possible but the infection was miserable and since it sounds like there is a 75% chance some bacteria are still around, I will take the antibiotics. Just want to be sure it is the right treatment.

Also curious to hear about others who might be as active as me, including light jogging on soft surfaces, mostly grass and artificial turf (I referee soccer games). I am definitely overweight which was surely a factor in the wear on my knee but the surgeon told me I could do light jogging on soft surfaces after the replacement.

Any early wear on the knee, or other complications in similar situations?

My first year went so well that before the infection I was planning to increase my activity level.

Thanks in advance,
z

same story here, very active 20 months out and came down with strep. 6 weeks picc line then 4 months amoxicillin antibiotics. the OS put internal sutures in that resist infection. These sutures been in 12 months with no signs of infection. nor sure how long they last. back to the OS in Decwmber

 

[Chillimac]

For the past 8 years I've struggled with firstly my left knee, as soon as I got that one done I thought, great, I can finally get back to my former active lifestyle........... Wrong! Then the right knee starts to break down. I had that one replaced a month ago and literally cannot wait for it to settle down so I can put some exercise in. I'm an ex rugby player, always trained in the gym and boy have I missed not being able to do any aerobic work. As soon as I'm healed enough I'll be right at it.
If you have no more complications after your infection then within reason I'd be using your new knee as it was intended to be used. As Susie says, enjoy it, the reason for having it done is to get back to as much of a semblance of your life before you started to suffer with it as you can. I'm not planning on going squatting 350lb barbells in the future but I'm certainly going to see how far I can go.
Good luck and enjoy your exercise.