Lortat-Jacob A, Nourissat G, Heym B
Service de Chirurgie Orthopédique, Hôpital Ambroise-Paré, Université Paris Ile de France-Ouest, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt.
Rev Chir Orthop Reparatrice Appar Mot. 2003 Jun;89(4):297-303.
Treatment of an infected arthroplasty is always a delicate task. Multidisciplinary management involving surgeons, clinicians, bacteriologists, and the patient may be long and not always successful. Rare re-infections caused by a bacterial strain different from the initial strain may be a cause of failure. We analyzed cases of re-infection with a different strain in search of an explanation.
We reviewed 13 cases of re-infection in 12 patients with 7 hip and 5 knee arthroplasties. The causal germ had been clearly identified by the bacteriology laboratory during the first infection. The antibiotic regimens were confirmed by the medical team. All patients underwent surgery in our unit. At the time of the second infection, the implant had been removed, had been left in place, or had been changed. We recorded the new strains isolated and studied their antibiotic susceptibility profile. Treatment protocols and biological and functional results were analyzed.
A mean 27 months after the re-infection, clinical and biological success had been achieved in 7 cases. The failures more frequently corresponded to cases where the first infection was caused by an aggressive germ and where the second germ was found during reimplantation.
Theoretically a change in the causal germ could be explained by an insufficient initial biological analysis with an unrecognized or masked germ, by peroperative contamination subsequent to the difficulties observed in these hospitalized patients, and finally by secondary contamination. We recall the criteria of secondary infection (free interval, distant infectious focus, time sequence), measures taken to prevent peroperative infections, and conditions for optimal bacteriological sampling. If no resistance emerges after the first antibiotic treatment, there could nevertheless be a selection of conditions enabling growth of germs infrequently encountered. We stress that re-infection should not be considered necessarily as a failure of initial management but can, in certain cases, be considered as a de novo infection, and treated as such.
治疗感染性关节成形术始终是一项棘手的任务。涉及外科医生、临床医生、细菌学家和患者的多学科管理可能耗时较长且并非总能成功。由不同于初始菌株的细菌菌株引起的罕见再感染可能是治疗失败的原因。我们分析了不同菌株再感染的病例以寻求解释。
我们回顾了12例患者的13例再感染病例，其中髋关节置换术7例，膝关节置换术5例。首次感染期间细菌学实验室已明确鉴定出致病微生物。抗生素治疗方案由医疗团队确认。所有患者均在我们科室接受手术。第二次感染时，植入物已被取出、保留原位或已更换。我们记录了分离出的新菌株并研究了它们的抗生素敏感性谱。分析了治疗方案以及生物学和功能结果。
再感染平均27个月后，7例患者取得了临床和生物学成功。治疗失败更多地发生在首次感染由侵袭性微生物引起且再植入时发现第二种微生物的病例中。
理论上，致病微生物的变化可以用以下原因解释：初始生物学分析不足，存在未识别或被掩盖的微生物；这些住院患者手术中出现困难后发生的术中污染；以及最终的二次污染。我们回顾了二次感染的标准（无感染间隔、远处感染灶、时间顺序）、预防术中感染采取的措施以及最佳细菌学采样的条件。如果首次抗生素治疗后未出现耐药性，但仍可能会选择有利于罕见微生物生长的条件。我们强调，再感染不一定应被视为初始治疗的失败，在某些情况下，可以被视为一次新的感染并进行相应治疗。
