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Infection: peri-prosthetic infection - also known as late onset infection

Josephine

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Some questions asked about joint replacement and infections:
Which injuries do I need to worry about with a joint replacement?
What is the purpose of prophylactic antibiotics before dental work and why don't I need them when I floss or clean my teeth?
My surgeon says I’m to have antibiotics if I have a dental cleaning but my dentist doesn’t agree.
I often get cystitis and I am worried about having had my hip replaced. Would my hip be in danger when I get an infection?
Well, there is a lot of confusing information about dental work and infection when you’ve had a joint replacement. There are so many different opinions between the surgeons/dental organisations and in different countries. One says antibiotics 2 days prior and several days after, another says just one dose 1-2 hours prior. Some say forever, another says for the first 2 years. Some people also include other things like colonoscopy, colonoscopic biopsies or polypectomies and even PAP smears while others say those are not a hazard. It's a right royal muddle and no-one seems to have any specific data to back up their own point of view so at the moment that's pretty much all we have to go on - people's points of view.

But truth to tell, most of those who have a late stage infection in their joint replacement have no idea where it came from. Or how many had prophylactic antibiotics that worked or didn't work.

The first thing you need to do is stop thinking of this as a 'normal' or regular kind of infection because it's not.

Almost all medical implants acquire a 'biofilm' which fall under the radar of the body's immune system, due both the inertness of the implant and the biofilm itself.

Biofilm (BF) is a microbial community film created by cells (bacteria) and is attached to a foreign body such as a surgical implant. The organisms have a very unique structure in BF, evolving from a simple single cell structure to a complex structure where organisms communicate in a manner not unlike DNA. This makes them very difficult to eradicate for although various single organisms can be destroyed, the over-all structure of the BF remains and can reproduce. This is the substance that is most problematic when treating these infections.

It has become evident that whilst the basic BF takes a mere 72 hours to mature into this complex structure, removing it is more of a problem. But it has been discovered that in the presence of aggressive chemo-therapy, the BF can be converted to a ‘normal’ structure which can be eradicated.

The biggest problem with BF is in the way it attaches itself to foreign bodies and also in the manner of cell production. Before the BF fully matures, it appears that though antibiotics will succeed in killing off the immature surface cells the ‘persister cells', being invisible to the white blood cells, remain impervious to the drugs.

However, after a period of time, it becomes possible to convert the mature BF into a ‘normal’ substance that can be eradicated. This can take some months and therefore knowledgeable surgeons will not touch new cases until sufficient time has passed for this process to at least be under way. This also allows any cellulitis to have resolved and treatment should not begin until a good period has passed since they last had antibiotics.

Therefore my advice to anyone with this issue is to try and accept that this is going to be a long term condition, much on a par with psoriasis or fibromyalgia. It's going to be part of you for quite some time and you can't keep letting it dog your dreams.

On the plus side, once these bugs colonise an implant and set up a biofilm, they are unlikely to proliferate to a point where they could cause gross infections or even septicaemia. The worst that could happen is that the biofilm will cause implant loosening and maybe a sense of unwellness in the patient. Just don't think it's the end of the world or a harbinger of doom if that does happen.

A surgeon who is taking this subject further than any other I have yet heard about is Dr Gerhard Maale of Plano, Texas.


Some articles of interest
Evidence insufficient to recommend prophylactic antibiotics for dental procedures
Periprosthetic infection: Mayo Clinic study shows that dental procedures are not a risk factor
 
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Josephine

Josephine

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Transcript of an interview on ABC News June 25th 2013 (Australian Broadcasting Company) compliments of Poppet

Breakthrough in fight against infections on medically implanted devices

TONY EASTLEY: Scientists have made a breakthrough that could help prevent life-threatening infections forming on medically implanted devices.
The infections are caused by drug-resistant bacteria like Golden Staph and are notoriously difficult to treat.
Researchers from Sydney's University of Technology have discovered how the bacteria behaves and why it spreads so quickly. They say they’ve come up with a novel solution.
As Jane Norman reports, their research has just been published in the prestigious US journal Proceedings of the National Academy of Sciences.

JANE NORMAN: In the war against superbugs, knowing how your enemy works is the key to success.
For a team of researchers from Sydney's University of Technology, that enemy is the bacteria that causes infections on devices implanted in the body like catheters, pace makers and joint replacements.
And Associate Professor Cynthia Whitchurch says they've made a breakthrough.

CYNTHIA WHITCHURCH: We understand something new about how bacteria works, how whole populations of bacteria work and we might be able to use that knowledge to control them in ways we hadn't considered before.

JANE NORMAN: The bacteria forms what's known as 'biofilm'. It's fast moving and resistant to both antibiotics and the body's natural immune defences.

CYNTHIA WHITCHURCH: Bacterial infections of medical devices are thought to account for about half of all hospital acquired infections, which can lead to enormous health care costs. It's estimated in US alone that it can cost somewhere in the vicinity of $5 billion a year.

JANE NORMAN: Using a sophisticated imaging system, the scientists were able to study how the bacteria behaved. They found it secreted a DNA, which acted as a glue, binding hundreds of the cells together.
Those cells then became a kind of bulldozer, gouging tiny furrows, or trails, as they moved along the surface.

CYNTHIA WHITCHURCH: So really what we found is that bacteria are able to build their own sort of road network, and that they can manage traffic flow throughout that road network to enable really rapid expansion of their biofilms across surfaces.

JANE NORMAN: Cynthia Whitchurch says she's now trying to find a unique solution and it may lie in sabotage.

CYNTHIA WHITCHURCH: One of the things we're thinking of doing for example is, instead of allowing the bacteria to create their own furrows, now that we know they like to get guided by furrows, that we create our own furrows in say the surface of a catheter, where we inhibit their ability to run up the catheter of their own accord and we can direct them into, for example, futile circles so that their rate of migration along the catheter is significantly inhibited.

JANE NORMAN: Potentially a new development in the arms race.
 

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