Outcomes After Pseudomonas Prosthetic Joint Infections

Billy I Kim; Andrew M Schwartz; Colleen M Wixted; Isabel P Prado; Breanna A Polascik; Jessica L Seidelman; Thorsten M Seyler

doi:10.5435/JAAOS-D-23-00704

Outcomes After Pseudomonas Prosthetic Joint Infections

J Am Acad Orthop Surg. 2024 Feb 13. doi: 10.5435/JAAOS-D-23-00704. Online ahead of print.

Authors

Billy I Kim¹, Andrew M Schwartz, Colleen M Wixted, Isabel P Prado, Breanna A Polascik, Jessica L Seidelman, Thorsten M Seyler

Affiliation

¹ From the Department of Orthopaedic Surgery, Duke University, Durham, NC (Kim, Schwartz, Wixted, Prado, Polascik, and Seyler), and the Division of Infectious Diseases, Duke University, Durham, NC (Dr. Seidelman).

PMID: 38354412
DOI: 10.5435/JAAOS-D-23-00704

Abstract

Background: Pseudomonas species are a less common but devastating pathogen family in prosthetic joint infections (PJIs). Despite advancements in management, Pseudomonas PJIs remain particularly difficult to treat because of limited antibiotic options and robust biofilm formation. This study aimed to evaluate Pseudomonas PJI outcomes at a single institution and review outcomes reported in the current literature.

Methods: All hip or knee PJIs at a single institution with positive Pseudomonas culture were evaluated. Forty-two patients (24 hips, 18 knees) meeting inclusion criteria were identified. The primary outcome of interest was infection clearance at 1 year after surgical treatment, defined as reassuring aspirate without ongoing antibiotic treatment. Monomicrobial and polymicrobial infections were analyzed separately. A focused literature review of infection clearance after Pseudomonas PJIs was performed.

Results: One-year infection clearance was 58% (n = 11/19) for monomicrobial PJIs and 35% (n = 8/23) for polymicrobial PJIs. Among monomicrobial infections, the treatment success was 63% for patients treated with DAIR and 55% for patients treated with two-stage exchange. Monotherapy with an oral or intravenous antipseudomonal agent (minimum 6 weeks) displayed the lowest 1-year clearance of 50% (n = 6/12). Resistance to antipseudomonal agents was present in 16% (n = 3/19), and two of eight patients with monomicrobial and polymicrobial PJIs developed resistance to antipseudomonal therapy in a subsequent Pseudomonas PJI. Polymicrobial infections (55%) were more common with a mortality rate of 44% (n = 10/23) at a median follow-up of 3.6 years.

Conclusion: Pseudomonas infections often present as polymicrobial PJIs but are difficult to eradicate in either polymicrobial or monomicrobial setting. A review of the current literature on Pseudomonas PJI reveals favorable infection clearance rates (63 to 80%) after DAIR while infection clearance rates (33 to 83%) vary widely after two-stage revision.