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Posted on October 15, 2018 by sabine - Uncategorized

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INFECTION PREVENTION & MANAGEMENT
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Is 6 Weeks the Gold Standard for PJI Treatment?
What factors influence your decision making on how long to keep patients on IV therapy following DAIR treatment? (check all that apply)
- Pathogen responsible for PJI
- Type of PJI (acute, chronic, hematogenous)
- Calculation of Prognosis scores (e.g. KLIC, CRIME-80)
- Patient comorbidities (can influence renal or hepatic function)
- Monitoring labs (resolving ESR, CRP)
- Physical findings (resolution of pain/warmth/erythema)
- Other
Which of the following statements are true regarding keeping patients on IV antibiotics following DAIR treatment (check all that apply)?
- I routinely try to utilize rifampin as part of the IV antibiotic treatment when possible
- Patients routinely receive IV antibiotic treatment for 2 weeks or less
- Patients routinely receive IV antibiotic treatment for 4 weeks or less
- Patients routinely receive IV antibiotic treatment for 6 weeks or less
- Patients routinely receive IV antibiotic treatment for 12 weeks or less
- I do not have a routine duration for IV treatment following DAIR
For your typical DAIR patient, how long do you keep them on oral antibiotic therapy after stopping IV treatment?
- I do not routinely prescribe oral therapy following IV treatment
- Oral therapy is prescribed for 3 months or less
- Oral therapy is prescribed for 3-6 months
- Oral therapy is prescribed for 6 -12 months
- Oral therapy is prescribed for over 12 months
Who do you think won the debate?
- 6 weeks of IV is the gold standard (Matt Squire)
- IV plus oral is enough (Nemandra Sandiford)
Will you change your practice because of this debate?
- Yes
- No
Do you have any questions on this topic that you’d like to submit?
If you would like an answer to your question, please provide your contact information:
Name
First Last
Email
Phone

Use of High-Dose Spacers
When making a PMMA spacer, which type of PMMA do you utilize before manually adding antibiotics?
- Plain Cement
- Antibiotic-loaded Bone Cement
What brand of bone cement do you use when constructing a spacer?
- PALACOS®
- Simplex®
- SmartSet®
- Cobalt®
- Other
What types of Antibiotics do you use when constructing a spacer? (please check all that apply)
- No
- Yes, I usually utilize an aminoglycoside (gentamycin/tobramycin) in the spacer
- Yes, I usually utilize vancomycin (or teicoplanin) in the spacer
- Yes, I usually utilize another antibiotic in the spacer
Do you add any of the following in your antibiotic spacer? (please check all that apply)
- Methylene blue or other dyeing agent
- Porogen agent to improve porosity
- Other
When battling a fungal PJI, how do you adjust your spacer cocktail? (please check all that apply)
- I still utilize an aminoglycoside and/or vancomycin in my spacer
- I do not utilize an aminoglycoside and/or vancomycin in my spacer
- I add an antifungal in my spacer
- I add antifungal powder in the surgical wound
Which of the following factors lead to you to modify antibiotic dosing of your spacer? (please check all that apply:)
- Pathogen resistance profile
- Presence of a sinus tract
- Impaired host renal status
- Host risk factors for failure (obesity, smoking, etc)
- None of the above
- Other
Who do you think won the debate?
- Higher dosing is required (Matt Dietz)
- Lower dosing mitigates toxicity while enabling satisfactory cure (Tim Tan)
Will you change your practice because of this debate?
- Yes
- No
Do you have any questions on this topic that you’d like to submit?
If you would like an answer to your question, please provide your contact information:
Name
First Last
Email
Phone

Best Alternative to Two Stage Revisions
Over the past year, what percent of your chronic PJI cases have been managed with a 1/1.5 stage approach?
- More than 50%
- More than 33%
- Under 33%
- Under 5%
- I do not utilize this approach in my practice
- I don’t manage PJI cases in my practice
Which of the following techniques do you utilize when performing a debridement as part of a DAIR (please check all that apply)?
- In knees, perform a radical synovectomy back to healthy bleeding tissue
- In hips, perform a radical capsulectomy
- Utilize methylene blue or another dyeing agent to mark tissue to debride
- Resect the skin edges of the previous incision
- Insert a deep drain
- Routinely utilize calcium phosphate beads as an antibiotic delivery vehicle
- Routinely apply vancomycin powder in the wound for sensitive organisms
- Routinely utilize negative pressure dressing for wound coverage
What is your preferred type of articulating spacer when performing a two-stage KNEE revision?
- Premade commercial spacer
- Spacer made intraoperatively in a commercial mold
- Primary components fixed with antibiotic cement
- Handmade spacer
What is your preferred type of articulating spacer when performing a two-stage HIP revision?
- Premade commercial spacer
- Spacer made intraoperatively in a commercial mold
- Primary components fixed with antibiotic cement
- Handmade spacer
What pre-operative conditions influence you choosing between 1/1.5 and 2 stage revision? (Select all that apply)
- Presence of absence of pathologen (Culture positive versus culture negative)
- Type of pathogen (e.g. staphylococcal, fungal, enterococcal)
- Presence of antibiotic resistance
- Presence of a sinus tract
- Host status
- Perceived patient compliance
- Other
Who do you think won the debate?
- The 1 stage (Endoklinik) protocol (Thorsten Gehrke)
- The 1.5 stage (Destination spacer) protocol (Mark Spangehl)
Will you change your practice because of this debate?
- Yes
- No
Do you have any questions on this topic that you’d like to submit?
If you would like an answer to your question, please provide your contact information:
Name
First Last
Email
Phone

Criteria for Reimplantation
What tests do you perform to help decide when to perform the second stage reimplantation? (Check all that apply)
- Duration of time since first stage
- CRP / ESR
- D-dimer/fibrinogen
- Synovial Aspiration (Cell count, differential)
- Synovial Aspiration (Leukocyte Esterase)
- Synovial Biopsy
- Imaging results
- Culture results
- History and physical
What factors influence your decision regarding the optimal time to perform second stage reimplantation? (Check all that apply)
- Host status
- Preoperative test results
- Bad pathogen: Resistant pathogen, Polymicrobial infection
- Atypical pathogen (fungal, mycobacteria)
- Soft tissue status (previous sinus tract, fragile wound)
How long of an antibiotic holiday do you give patients when you believe it’s time to reimplant?
- 0 days - I do not routinely perform an antibiotic holiday
- 1 – 7 days
- 8 – 14 days
- 15 -21 days
- More than 21 days
How often do you perform an interim spacer exchange?
- Less than 5% of cases
- 5 – 14.9% of cases
- 15 – 24.9% of cases
- 25 – 35.9% of cases
- In 35% or more of cases
Who do you think won the debate?
- We have enough markers for reimplantation. (Tom Bradbury)
- We don’t have enough markers for reimplantation. (Carlos Higuera)
Will you change your practice because of this debate?
- Yes
- No
Do you have any questions on this topic that you’d like to submit?
Name
First Last
Email
If you would like an answer to your question, please provide your contact information:

DNA Sequencing
How you often have you used DNA sequencing in the past year?
- Never
- 1 – 9 times
- 10 – 25 times
- More than 25 times
In what clinical situations would you use DNA sequencing? (Check all that apply)
- All patients
- Patients meeting MSIS criteria for PJI who have negative cultures
- Patients whose history and presentation does not match the culture grown
- Patients who fail two-stage exchange
- Patients whose health would prevent multiple revision surgeries
- None of the above
If you do use DNA sequencing, how to do you decide your treatment strategy?
- I treat all detected pathogens
- I treat the detected pathogens that are known causes of PJI
- I treat the most dominant detected pathogen
- Other strategy
- Not applicable
Who do you think won the debate?
- DNA sequencing can be used more broadly. (Javad Parvizi)
- DNA sequencing should be used in only culture negative patients. (Wayne Moschetti)
Will you change your practice because of this debate?
- Yes
- No
Do you have any questions on this topic that you’d like to submit?
If you would like an answer to your question, please provide your contact information:
Name
First Last
Email

Alpha Defensin and D-dimer
Which comment below best represents your use of Alpha Defensin in establishing the diagnosis of PJI?
- I use it routinely to help diagnose PJI
- I rely other test results first, then use alpha defensin only if necessary
- I have access to it, but I do not use it as I do not find it helpful
- I do not have access to alpha defensin, but wish I did.
- I do not have access to alpha defensin, and do not seek its use at this time
What type of alpha defensin test does your institution have?
- ELISA (Send to a Lab)
- Lateral Flow
- Both
- Neither
- I Don’t Know
What type of D-dimer test does your institution have?
- Serum d-dimer
- Plasma d-dimer
- Both
- I Don’t Know
Who do you think won the debate?
- These tests should be used in all patients. (Elie Ghanem)
- These tests have limited utility with added costs. (Chris Pelt)
Will you change your practice because of this debate?
- Yes
- No
Do you have any questions on this topic that you’d like to submit?
If you would like an answer to your question, please provide your contact information:
Name
First Last
Email
Phone

Antibiotic Loaded Bone Cement
How often do you currently use antibiotic-loaded bone cement in primary TKA?
- Routinely, in over 75% of patients
- Commonly, in 25 – 75% of patients
- Rarely, often in high-risk patients only
- Never
If you performed cemented hip arthroplasty / hemiarthroplasty, how often do you use antibiotic-loaded bone cement?
- Routinely, in over 75% of patients
- Commonly, in 25 – 75% of patients
- Rarely, often in high-risk patients only
- Never
- I do not utilize cement in hip replacement surgery
How often do you currently use antibiotic-loaded bone cement in aseptic cemented revision surgery?
- Routinely, in over 75% of patients
- Commonly, in 25 – 75% of patients
- Rarely, often in high-risk patients only
- Never
Do antibiotic elution kinetics factor in to your selection of a bone cement?
- Yes
- No
What antimicrobial or antimicrobial combination would you most like to see in a commercially available antibiotic loaded bone cement? (select all that apply)
- Daptomycin
- Gent/Tobra + Vancomycin
- Gent/Tobra + Clindamycin
- Gent/Tobra + Amphotericin B
- Other (please write out)
Other
Who do you think won the debate?
- PRO - Should be used in more than 30% of patients (Mike Reed)
- CON - Should be used in less than 30% of patients (Antonia Chen)
Will you change your practice because of this debate?
- Yes
- No
Do you have any questions on this topic that you’d like to submit?
If you would like an answer to your question please provide your contact information
Name
First Last
Email

How often do you currently use an antiseptic solution during primary total joint arthroplasty?
- Routinely in all patients
- In high-risk patients only
- On rare occasions
- Never
What antiseptic solution do you use most often?
- Betadine (povidone-iodine) from a sealed, sterile pack
- Betadine (povidone-iodine) from a bottle
- Diluted Chlorhexidine (Irrisept)
- Proprietary formulation (Bactisure, Prontosan)
- Dakin’s Solution
- Other (Please write out)
Other
What volume of fluid do you use for lavage?
- Less than 1 L
- 1 – 2 L
- 2 – 4 L
- More than 4 L of fluid
Do you use locally delivered antibiotics during primary surgery? (select all that apply)
- Yes, I add antibiotics (polymyxin, bacitracin) to the intraoperative irrigation
- Yes, I do administer topical vancomycin powder routinely
- Yes, I do administer topical vancomycin powder, but in high-risk patients only
- No, I do not use locally delivered antibiotics routinely during primary surgery
Who do you think won the debate?
- PRO - Antiseptic solutions should be used in all patients (Thorsten Seyler)
- CON - Antiseptic solutions should be used in high-risk patients only (Daniel Kendoff)
Will you change your practice because of this debate?
- Yes
- No
Do you have any questions on this topic that you’d like to submit?
If you would like an answer to your question please provide your contact information
Name
First Last
Email

Admixing Antibiotics
For primary joint replacement procedures, do you currently manually mix-in antibiotics into bone cement?
- Yes, routinely
- Yes, occasionally (e.g. adding vancomycin when a patient is an MRSA carrier)
- Yes, but on rare occasions
- Never
If you have been manually mixing tobramycin into bone cement, how are you dealing with the shortage across the United States?
- I have started using commercial antibiotic loaded bone cement
- I have started mixing in another antibiotic into bone cement
- I have began using topic vancomycin powder
- I have utilized another strategy not listed here
- Not applicable – I am not affected by the shortage or don’t routinely manually mix in antibiotics
Were you aware that liquid antibiotics could not be mixed into bone cement?
- Yes
- No
Were you aware that orthopedics surgeon assume product liability when antibiotics are manually mixed into bone cement?
- Yes
- No
Who do you think won the debate?
- PRO – Mixing antibiotics into cement is cost-saving and effective (Derek Amanatullah)
- CON – The risks of manually mixing antibiotics into cement outweigh the possible benefits (Jason Webb)
Will you change your practice because of this debate?
- Yes
- No
Do you have any questions on this topic that you’d like to submit?
If you would like an answer to your question please provide your contact information
Name
First Last
Email

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