Ferry Tristan, Batailler Cécile, Brosset Sophie, Kolenda Camille, Goutelle Sylvain, Sappey-Marinier Elliot, Josse Jérôme, Laurent Frédéric, Lustig Sébastien
Service des Maladies Infectieuses et Tropicales, Hospices Civils de Lyon, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - CIRI - Centre International de Recherche en Infectiologie, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ. Lyon, 69007 Lyon, France.
Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - Service de Chirurgie Orthopédique, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France.
SICOT J. 2020;6:26. doi: 10.1051/sicotj/2020021. Epub 2020 Jul 7.
PJI is the most dramatic complication after joint arthroplasty. In patients with chronic infection, prosthesis exchange is in theory the rule. However, this surgical approach is sometimes not desirable especially in elderly patients with multiple comorbidities, as it could be associated with a dramatic loss of function, reduction of the bone stock, fracture, or peroperative death. We propose here to report different approaches that can help to maintain the function in such patients based on a pathophysiology-, multidisciplinary-, and an experience-based approach.
We describe the different points that are needed to treat such patients: (i) the multidisciplinary care management; (ii) understanding the mechanism of bacterial persistence; (iii) optimization of the conservative surgical approach; (iv) use of suppressive antimicrobial therapy (SAT); (v) implementation of innovative agents that could be used locally to target the biofilm.
In France, a nation-wide network called CRIOAc has been created and funded by the French Health ministry to manage complex bone and joint infection. Based on the understanding of the complex pathophysiology of PJI, it seems to be feasible to propose conservative surgical treatment such as "debridement antibiotics and implant retention" (with or without soft-tissue coverage) followed by SAT to control the disease progression. Finally, there is a rational for the use of particular agents that have the ability to target the bacteria embedded in biofilm such as bacteriophages and phage lysins.
This multistep approach is probably a key determinant to propose innovative management in patients with complex PJI, to improve the outcome.
Conservative treatment has a high potential in patients with chronic PJI for whom explantation is not desirable. The next step will be to evaluate such practices in nation-wide clinical trials.
人工关节感染（PJI）是关节置换术后最严重的并发症。对于慢性感染患者，理论上应更换假体。然而，这种手术方法有时并不理想，尤其是在患有多种合并症的老年患者中，因为它可能会导致功能严重丧失、骨量减少、骨折或围手术期死亡。我们在此提出报告不同的方法，这些方法基于病理生理学、多学科和经验性方法，有助于维持此类患者的功能。
我们描述了治疗此类患者所需的不同要点：（i）多学科护理管理；（ii）了解细菌持续存在的机制；（iii）优化保守手术方法；（iv）使用抑制性抗菌疗法（SAT）；（v）使用可局部靶向生物膜的创新药物。
在法国，法国卫生部创建并资助了一个名为CRIOAc的全国性网络，以管理复杂的骨与关节感染。基于对PJI复杂病理生理学的理解，提出保守手术治疗如“清创、抗生素和保留植入物”（有无软组织覆盖），随后进行SAT以控制疾病进展似乎是可行的。最后，有理由使用具有靶向生物膜中细菌能力的特定药物，如噬菌体和噬菌体裂解酶。
这种多步骤方法可能是为复杂PJI患者提出创新管理以改善结果的关键决定因素。
对于不适合进行假体取出的慢性PJI患者，保守治疗具有很大潜力。下一步将在全国范围内的临床试验中评估此类做法。
