Periprosthetic Joint Infections on the Rise?!

Researchers from Mount Sinai in New York have new research which seems to indicate that the national rate of periprosthetic joint infection (PJI) has increased from 13% of all joint revisions to more than 16%—this, despite huge efforts to prevent infection.

Calin Moucha, M.D., chief of adult reconstruction and joint replacement surgery at Mount Sinai Hospital in New York, with colleagues, presented their results at the recent meeting of the American Association of Hip and Knee Surgeons.

Dr. Moucha told OTW, “Next to the economic burden of primary arthroplasties, revision surgeries are a major driver of overall costs, which may be further inflated by periprosthetic joint infection (PJI).”

“Previous studies have assessed this burden either using a combined primary/revision arthroplasty cohort or state-specific cohorts. Given limited recent national information we aimed to assess PJI and associated trends and costs regarding hospitalizations for hip arthroplasty revisions done specifically for infection. We used the most recent national data from The National Inpatient Sample (2003-2013; n=497,035).”

“Trends in PJI and associated total inpatient cost regarding PJI revision (expressed in January 2013 U.S. dollars) were stratified by the following parameters: (a) Hospital teaching status and (b) Hospital bed size.”

“PJI was the indication for 15.1% of all revisions and we showed an increasing trend from 13.0% in 2003 to 16.3% in 2013. Infection cost also significantly increased over time. While the increase in the number of revisions for infection was not surprising (more primaries translates into more revisions) I was surprised by the percent increase.”

“The lowest PJI burden was in rural hospitals (12.5%) and highest in urban, teaching hospitals (16.4%). Infection case rates increased significantly over the study period for all hospital types and there were no significant trends in cost (not charges, like some previous studies) between hospital types. PJI burden was comparable in hospital sizes, with increasing rates in medium and large hospitals. Costs in large hospitals significantly increased. In essence, increasing trends in revisions done for infection and associated costs are seen in all types of hospitals.”

“This data should serve as a good platform for further investigations as to why we are seeing increasing trends in PJI infection risk. Specifically, we plan on looking at other more comprehensive databases to evaluate whether these are early or late revisions for infections. Trying to better understand why we are seeing these trends is obviously the next step.”

“The big question now, of course, is to figure out why this is happening.”

“Are we more vigilant in diagnosing infections or are our methods of diagnosis too sensitive with too many false positives?”

“Are we optimizing patients as best we can and should we be more restrictive as to who receives a joint replacement like they are now doing in England and other places, where morbidly obese patients and smokers cannot undergo elective surgery until they prove they have at least tried to address these issues?”

“Is the trend towards outpatient surgery as safe as we think it is?”

“Are we using the most appropriate prophylactic antibiotics and paying attention to local antibiograms?”

“Are we using the most appropriate skin preps, irrigation methods, airflow technologies, and patient warming methods or can we do better?”

“Infections should never be called a ‘never event’ for as long as we continue to operate we will forever have infections. The key is to try to prevent infections as best possible and when they do happen diagnose them in a timely manner and treat appropriately. Regional centers for the treatment of infections are probably key to obtaining the best results but there have to be systems in place that to not overburden these centers financially.”