1 00:00:05,000 --> 00:00:09,940 Sara Dong: Hi everyone, welcome to Febrile, a cultured podcast about all things infectious disease. 2 00:00:10,565 --> 00:00:15,875 We use consult questions to dive into ID clinical reasoning, diagnostics, and antimicrobial management. 3 00:00:16,285 --> 00:00:19,325 I'm Sara Dong, your host and a MedPeds ID doc. 4 00:00:19,795 --> 00:00:22,645 Welcome to our next Febrile StAR episode. 5 00:00:23,095 --> 00:00:27,934 Again, these are featuring topics and authors from the CID Journal State of the Art Reviews. 6 00:00:28,424 --> 00:00:33,365 I encourage you to listen to episode number 97 to get a quick introduction from the editors. 7 00:00:33,835 --> 00:00:38,235 And this is now our third of four straight weeks of STAR episodes to kick off the series. 8 00:00:38,614 --> 00:00:41,030 So, I'll introduce our guest stars today. 9 00:00:42,265 --> 00:00:42,625 Dr. 10 00:00:42,625 --> 00:00:51,884 Sandra "Sandy" Nelson is an ID physician at Massachusetts General Hospital and an assistant professor at Harvard Medical School in Boston, Massachusetts. 11 00:00:52,495 --> 00:00:59,384 She serves as the Associate Clinical Director of the Division of ID and oversees the ID inpatient service and OPAT program. 12 00:00:59,955 --> 00:01:03,885 Her academic interest is in the care of patients with musculoskeletal infections. 13 00:01:04,375 --> 00:01:12,624 At MGH, she directs the Program in Musculoskeletal Infectious Diseases, which is actively engaged in clinical care, educational efforts, and research. 14 00:01:13,034 --> 00:01:14,335 Sandy Nelson: Hi, I'm Sandy Nelson. 15 00:01:14,610 --> 00:01:14,990 Sara Dong: Dr. 16 00:01:15,320 --> 00:01:21,270 Jodian "Jodi" Pinkney is an ID physician at Massachusetts General Hospital in Boston. 17 00:01:21,570 --> 00:01:29,640 She is interested in health equity and maternal health and is wholeheartedly dedicated to eliminating maternal deaths related to vaccine preventable diseases. 18 00:01:30,050 --> 00:01:37,350 She is currently enrolled in the MPH program in health policy with a concentration in maternal and child health at the Harvard T. 19 00:01:37,360 --> 00:01:37,590 H. 20 00:01:37,600 --> 00:01:38,900 Chan School of Public Health. 21 00:01:39,384 --> 00:01:42,795 and is a fellow in the Commonwealth Fund Fellowship in Minority Health Policy. 22 00:01:43,655 --> 00:01:44,735 Jodi Pinkney: Hi, I'm Jodi Pinkney. 23 00:01:45,664 --> 00:01:45,995 Sara Dong: Dr. 24 00:01:45,995 --> 00:01:55,504 Antonia Chen is the Chief of Arthroplasty and Joint Reconstruction at Brigham and Women's Hospital and an Associate Professor of Orthopedic Surgery at Harvard Medical School. 25 00:01:55,855 --> 00:02:03,855 She specializes in hip and knee replacements, as well as in the care of complex patients who may require revision procedures for their previous hip and knee replacements. 26 00:02:04,245 --> 00:02:05,295 Antonia Chen: Hi, I'm Antonia Chen. 27 00:02:05,735 --> 00:02:06,095 Sara Dong: Dr. 28 00:02:06,105 --> 00:02:12,575 Aaron Tande is an infectious diseases consultant and professor of medicine at the Mayo Clinic in Rochester, Minnesota. 29 00:02:13,055 --> 00:02:22,154 He also serves as the associate division chair for outpatient practice, the chair of the orthopedic ID focus group, and physician co chair of antimicrobial stewardship. 30 00:02:22,335 --> 00:02:23,424 Aaron Tande: Hi, I'm Aaron Tande. 31 00:02:23,790 --> 00:02:24,260 Sara Dong: Awesome. 32 00:02:24,270 --> 00:02:25,740 Well, thank you guys for joining. 33 00:02:25,990 --> 00:02:31,850 Before we talk about your article, we're going to start with the general Febrile introduction. 34 00:02:32,120 --> 00:02:40,009 As everyone's favorite cultured podcast, we like to ask our guests to share a little piece of culture, really just something non medical that brings you joy. 35 00:02:40,189 --> 00:02:42,289 Antonia Chen: My favorite thing is my four pound Yorkie. 36 00:02:42,850 --> 00:02:44,840 She brings me a lot of joy and she's a lot of fun. 37 00:02:45,285 --> 00:02:54,675 Jodi Pinkney: I am a huge fan of reggae music and the new Bob Marley movie that just came out, because my dad is a reggae guitarist who played with Bob Marley back in the 70s. 38 00:02:55,575 --> 00:02:59,314 Aaron Tande: I've always been a fan of music and I'm excited this weekend I'm going to go see Jason Isbell. 39 00:02:59,314 --> 00:03:02,565 If anybody knows who he is, he's probably the best songwriter alive today. 40 00:03:03,035 --> 00:03:08,984 Sandy Nelson: I'm going to share that this year I started making my own kombucha, which is a piece of culture in more ways than one. 41 00:03:09,125 --> 00:03:10,665 Sara Dong: It's like the perfect piece of culture. 42 00:03:11,704 --> 00:03:14,984 Sandy Nelson: It is such the perfect hobby for the nerdy ID doc. 43 00:03:15,234 --> 00:03:18,274 And you get your fermented foods and a yummy drink all in one. 44 00:03:18,274 --> 00:03:19,795 It's really, really pretty cool. 45 00:03:19,834 --> 00:03:20,874 Antonia Chen: And it's good for your gut. 46 00:03:20,994 --> 00:03:21,454 Sandy Nelson: That's right. 47 00:03:21,454 --> 00:03:21,844 Yeah. 48 00:03:23,740 --> 00:03:26,970 Sara Dong: Well, I am so excited to have you guys here. 49 00:03:26,990 --> 00:03:36,590 We are partnering with CID to talk about these state of the art reviews, and you all authored a paper about periprosthetic joint infection current clinical challenges. 50 00:03:37,169 --> 00:03:40,979 I have a couple cases today for us to try and tackle. 51 00:03:40,980 --> 00:03:44,560 I may have added a few additional questions to get your thoughts. 52 00:03:44,780 --> 00:03:47,650 So I'll start with our first patient. 53 00:03:48,060 --> 00:03:57,450 He is a 70 year old male, has a history of hypertension and diabetes, and he had a left knee arthroplasty for severe arthritis two years ago. 54 00:03:58,060 --> 00:04:02,649 He comes in with left knee pain and stiffness over the past two to three months. 55 00:04:03,350 --> 00:04:10,030 He says he has no fevers at home, he hasn't really noticed any redness, any obvious swelling of that knee. 56 00:04:10,040 --> 00:04:12,730 He's really just generally feeling okay otherwise. 57 00:04:13,459 --> 00:04:17,209 On his labs, his CBC, ESR, and CRP are normal. 58 00:04:17,730 --> 00:04:29,220 And he undergoes a left knee arthrocentesis, which results with cloudy fluid with a white blood cell count of 2, 500, and the differential on that had 75 percent neutrophils. 59 00:04:29,870 --> 00:04:32,529 The gram stain and culture is negative. 60 00:04:33,130 --> 00:04:44,985 And so I want to pause here for a second because most of our Febrile audience are likely ID fellows or ID physicians, or at least medicine trained folks, and Antonia, we're really excited to have you here. 61 00:04:45,015 --> 00:04:48,984 Can you tell us a little bit about the surgical perspective at this moment? 62 00:04:49,015 --> 00:04:56,505 You know, what is the spectrum of options we have available for someone that we're wondering if they have suspected prosthetic joint infection? 63 00:04:56,830 --> 00:04:58,770 Antonia Chen: So, first of all, thanks for having me on here. 64 00:04:58,780 --> 00:05:08,020 I know that there's definitely contention between ID docs and orthopedic surgeons, so we appreciate you guys a lot, and we know we cause you guys a lot of stress, so thank you for having me here. 65 00:05:08,400 --> 00:05:09,410 That's the first thing. 66 00:05:09,739 --> 00:05:13,630 And this is the type of patient that we all typically see way too often in clinic, right? 67 00:05:13,630 --> 00:05:16,040 It's that in between gray zone that's the hardest person. 68 00:05:16,310 --> 00:05:21,040 So, the patient obviously has comorbidities like diabetes, which places an increased risk of infection. 69 00:05:21,350 --> 00:05:33,000 The surgery was two years ago, which is definitely considered chronic, you know, people debate if it's chronic is four weeks or three months, but two years puts past that timeframe, but the pain and stiffness is over the past two or three months. 70 00:05:33,350 --> 00:05:37,590 So that's a longer timeframe than most of us are comfortable with most of the time. 71 00:05:37,590 --> 00:05:40,680 So we consider it as probably pretty chronic at this point in time. 72 00:05:41,159 --> 00:05:47,320 You know, things like ESR and CRP, whenever I see a patient who comes in with a joint replacement, I always run that first. 73 00:05:47,460 --> 00:05:51,349 And typically that's elevated, when they're normal, that says, okay, now what do I do? 74 00:05:51,690 --> 00:05:57,590 If the patient still has persistent pain, especially swelling, I will likely take an arthrocentesis like this patient had. 75 00:05:58,010 --> 00:06:03,650 The cloudy fluid always makes me a little bit concerned, but you do have to worry about other things that can cause cloudiness to the fluid. 76 00:06:04,060 --> 00:06:10,490 And the cutoffs that are typically used in a diagnostic criteria are 3, 000 and then 65 percent neutrophils. 77 00:06:11,209 --> 00:06:16,150 So the problem is you're in this gray zone where it's a little bit below the white blood cell count, but a little bit above the neutrophils. 78 00:06:16,249 --> 00:06:20,099 So from a surgical perspective, it's one of those things, the gram stain and the culture are negative. 79 00:06:20,130 --> 00:06:27,340 This is not Sorry, not from a surgical perspective yet, from a diagnostic perspective, I would potentially consider doing something like next generation sequencing. 80 00:06:27,409 --> 00:06:31,509 And this is where I would call on my ID colleagues to say, is this something worthwhile doing or not? 81 00:06:31,859 --> 00:06:34,949 And then on top of it, adding things like other markers. 82 00:06:35,009 --> 00:06:41,679 So alpha defensin, leukocyte esterase, these are other things I would look at to try to see if we arrive at the same diagnosis of infection. 83 00:06:42,119 --> 00:06:44,484 So from a surgery perspective, I'm not jumping into surgery at this point. 84 00:06:45,094 --> 00:06:53,034 I think it's too premature, and I would consult my wonderful ID friends to see what they would say before undergoing any surgical management. 85 00:06:53,405 --> 00:06:53,974 Sara Dong: Perfect. 86 00:06:54,025 --> 00:06:56,924 And we can step away from that case for a second. 87 00:06:56,934 --> 00:07:13,995 And I would love as an ID doctor to hear how you sort of think about what is the spectrum of interventions that are available, because I think that sometimes just understanding exactly what's happening in the OR for patients that you do end up taking to the OR is helpful. 88 00:07:14,094 --> 00:07:15,954 Do you mind telling us a little bit about that? 89 00:07:16,230 --> 00:07:25,770 Antonia Chen: It's always a special in between and this is a constant source of debate between orthopedic surgeons, ID docs, and generally people because there's no hard and straight answer. 90 00:07:26,159 --> 00:07:39,275 Typically when a patient has an acute infection, so typically defined as let's say within four weeks of the index surgery or four weeks of symptoms, we could do something called DAIR, which is debridement, antibiotics, and implant retention. 91 00:07:39,655 --> 00:07:43,755 And when I was in training, it used to be irrigation, debridement, and polyethylene exchange. 92 00:07:43,805 --> 00:07:45,005 In theory, it's the same thing. 93 00:07:45,015 --> 00:07:47,075 You're taking out what we call the modular components. 94 00:07:47,384 --> 00:08:01,577 So typically for a hip replacement, typically for a knee replacement, what we're doing is we're putting in a plastic component in there, and we can take it out, and by taking out this plastic component, we have more access to either the joint or to other surfaces. 95 00:08:01,577 --> 00:08:07,510 So this group knows better than I do that bacterial organisms have a higher affinity towards metal, right? 96 00:08:07,510 --> 00:08:09,160 Or towards foreign objects. 97 00:08:09,310 --> 00:08:14,350 So the more foreign objects you can remove, the better it is, but you wanna be as least invasive as possible. 98 00:08:14,350 --> 00:08:20,140 So if an acute setting, if you can get away with it, a DAIR is nice because you take out the modular parts and you clean back. 99 00:08:20,170 --> 00:08:24,970 If you're doing the knee replacement, the idea of taking the modular part allows you get to the back of the knee or the posterior capsule. 100 00:08:25,360 --> 00:08:30,160 And for the hip replacement, if you take the plastic part out, you can get to the acetabulum or to the metal component there. 101 00:08:30,490 --> 00:08:33,850 But you can't get down the canal because it's already filled with a metal piece. 102 00:08:34,449 --> 00:08:35,610 So that's the first option. 103 00:08:36,240 --> 00:08:41,189 The next thing that has changed actually over time is this thing called a, people call it a destination spacer, a 1. 104 00:08:41,319 --> 00:08:42,970 5 stage spacer. 105 00:08:43,230 --> 00:08:45,660 It's kind of when you take everything out of the joint. 106 00:08:45,740 --> 00:08:48,000 So you're removing all the potential bio burden, right? 107 00:08:48,000 --> 00:08:53,630 You're taking the metal, you're taking the plastic, you're taking everything out of the joint, whether it be a hip or a knee or a shoulder or wherever you're taking it. 108 00:08:54,089 --> 00:08:55,959 And you're putting in something in the interim. 109 00:08:56,394 --> 00:09:02,334 When I was in training, the interim part was a spacer, and that spacer could take multiple different forms. 110 00:09:02,724 --> 00:09:06,854 The first spacer type would be what we call a static spacer, meaning it didn't move. 111 00:09:07,204 --> 00:09:08,894 So if you're on a knee, you'd be stuck straight. 112 00:09:08,925 --> 00:09:11,494 If you're on a hip, you'd be stuck in one spot as well too. 113 00:09:11,834 --> 00:09:14,464 And as you can imagine from a functional perspective, it's not great. 114 00:09:14,744 --> 00:09:19,714 But it eludes antibiotics, it delivers antibiotics, and you do go back in and you replace it with a new joint. 115 00:09:20,314 --> 00:09:24,265 That said, more and more patients don't want to go back under surgery, which I understand. 116 00:09:24,495 --> 00:09:34,315 If your infection is, for lack of a better term, suppressed or at least treated, and you don't need to go back from a surgical perspective, why not put in an implant and actually serve as a regular implant? 117 00:09:34,555 --> 00:09:35,724 And that's where this 1. 118 00:09:35,725 --> 00:09:37,124 5 stage spacer comes in. 119 00:09:37,405 --> 00:09:46,810 So for a knee replacement, for example, my algorithm is to put a metal femur and put in all poly tibia, and then I put dowels up and down the femur and the tibia. 120 00:09:46,810 --> 00:09:52,490 So it allows for antibiotic cement delivery in the canals and on the prosthesis itself, but it's a brand new implant. 121 00:09:52,760 --> 00:09:54,480 You can walk on it, you can do everything you want to. 122 00:09:54,490 --> 00:09:57,490 It's put in with antibiotic cement, which has less strength. 123 00:09:57,780 --> 00:10:00,980 So if you have to go back in to take it out, it's easier to take out. 124 00:10:01,179 --> 00:10:11,390 So it's not as robust or not as good as a real revision implant, but for especially a low demand patient or patients who say, I want to put off surgery for as long as possible, it's not a bad option. 125 00:10:11,830 --> 00:10:15,810 And then for the hip, what you do is you can put, you can cement an all poly liner in there. 126 00:10:16,035 --> 00:10:18,635 and put a stem that's coated in antibiotic cement. 127 00:10:18,864 --> 00:10:24,665 And again, it's not as good as the real thing, but it gives you an articulating surface that you can walk on and function with. 128 00:10:24,665 --> 00:10:26,854 And some people, I have them live them for life. 129 00:10:27,145 --> 00:10:31,074 They really don't want to go back for surgery as long as their infection doesn't come back and things like that. 130 00:10:31,704 --> 00:10:35,274 And then from a surgical perspective that you do have to come back, that's one thing you can do. 131 00:10:35,295 --> 00:10:37,404 And then the one stage is something else you can think of. 132 00:10:37,404 --> 00:10:38,324 So the reason it's called 1. 133 00:10:38,364 --> 00:10:43,634 5 stages, the two stage procedures, you take everything out, you put it in a spacer, and you have to go back in with a new implant. 134 00:10:43,950 --> 00:10:52,864 The one stage is, at the same time you take everything out, you remove everything, clean everything up, you put a whole new setup and you put all the brand new prosthesis at that time. 135 00:10:53,475 --> 00:10:57,155 So from a patient perspective, that's wonderful because it's only one surgery. 136 00:10:57,405 --> 00:11:00,265 From a morbidity perspective, it's a long procedure, right? 137 00:11:00,265 --> 00:11:02,065 It's twice as long as the other cases. 138 00:11:02,065 --> 00:11:05,205 For some, some patients can't sustain that, so you can't offer that to them. 139 00:11:05,595 --> 00:11:09,054 And it typically is with certain sites that do them more commonly than others. 140 00:11:09,220 --> 00:11:12,080 It's something that can be done, but a lot of surgeons don't necessarily offer that. 141 00:11:12,150 --> 00:11:18,340 So that's the gamut of different treatment options, and obviously it can go into a lot of depth of all of them at any point in time. 142 00:11:18,350 --> 00:11:19,180 Sara Dong: Thanks so much. 143 00:11:19,700 --> 00:11:25,600 So, you know, we're making up this scenario a little bit, but let's just say, you know, this patient was taken to the operating room. 144 00:11:25,859 --> 00:11:36,600 We have some operative culture results, and Sandy, you get called and are told that one of five of the cultures from the OR obtained are positive for Cutibacterium acnes. 145 00:11:37,040 --> 00:11:41,099 So, you know, ID is called in to see how do we address this C. 146 00:11:41,099 --> 00:11:43,459 acnes in just a single positive culture? 147 00:11:43,520 --> 00:11:44,979 Is this PJI? 148 00:11:45,239 --> 00:11:47,349 Sandy Nelson: So, I think that there's really two questions there. 149 00:11:47,489 --> 00:11:50,420 And one of the questions is, is this a prosthetic joint infection? 150 00:11:50,820 --> 00:12:00,150 And we now have a better potential chance of answering that question because the data that we get from the surgical procedure is much more complete than what can be obtained preoperatively. 151 00:12:00,590 --> 00:12:03,939 And then the second question is, is this infection secondary to it? 152 00:12:03,940 --> 00:12:21,980 And to the first question, I think that Antonia addressed this, the one addition that I would say is that while there are these thresholds that are used in the diagnostic criteria, and there is a threshold of around 3, 000 for synovial fluid white cells, that's really not a hard and fast number. 153 00:12:22,179 --> 00:12:25,890 Many individuals will have infections with lower cell counts than 3, 000. 154 00:12:26,230 --> 00:12:33,400 That's particularly true in knees, in which some other studies suggest that the, that the optimal cell count threshold is actually lower. 155 00:12:33,870 --> 00:12:38,260 While you'd say that they don't actually meet criteria, it's also not the same as saying that they don't. 156 00:12:38,710 --> 00:12:47,580 And so in this individual, we have normal inflammatory markers, but borderline cell counts, a pretty concerning percent neutrophil, and now we have one positive culture. 157 00:12:48,010 --> 00:12:55,540 And this isn't going to be a confirmed diagnosis, because a single positive culture with several minor criteria, it does not confirm. 158 00:12:55,880 --> 00:13:00,080 But you've really met the criteria for possible or probable prosthetic joint infection. 159 00:13:00,080 --> 00:13:04,895 And then when we think about how to treat it, we also think about what are the stakes and what has been done. 160 00:13:04,935 --> 00:13:06,845 And so this is an individual that's had a surgery. 161 00:13:06,915 --> 00:13:08,835 We didn't discuss which particular surgery. 162 00:13:09,545 --> 00:13:14,384 And in that case, I'm likely going to say, you know, we've gone to great lengths already for this patient. 163 00:13:14,395 --> 00:13:18,074 And I think the safest option is probably to presume that there is a prosthetic joint infection. 164 00:13:18,714 --> 00:13:20,435 Cutibacterium is particularly tough. 165 00:13:20,675 --> 00:13:25,074 It's particularly tough in the shoulders, but we do see it sometimes in hips and knees. 166 00:13:25,635 --> 00:13:30,405 With one out of five positive cultures, as a general rule, we're going to discount that as a contaminant. 167 00:13:30,755 --> 00:13:37,985 I think that's a little bit of a harder judgment to make in the shoulder setting, in which it really can go either way with true infection or contamination. 168 00:13:37,985 --> 00:13:53,885 But in the knee or hip with one out of five studies, I'm not going to put all of my eggs in the Cutibacterium basket, and I'm gonna treat more broadly as if this is a culture negative infection, and this is the time that you might think about doing some of those advanced diagnostics for, you know, molecular identification of pathogens. 169 00:13:54,120 --> 00:14:12,409 Sara Dong: Of course, as you both were mentioning, the antibiotic strategies and the surgical approaches are entwined, and we really have to understand if there's residual undebrided infection left, is there retention of hardware, and that helps us select and construct an antibiotic plan. 170 00:14:12,430 --> 00:14:26,330 And maybe trying to think more broadly, Aaron, I was hoping you could talk a little bit about how you approach antibiotic selection and how you think about duration of therapy, and that could be thinking about these example cases, but really just more generally in your practice. 171 00:14:26,610 --> 00:14:28,540 Aaron Tande: No, I think that that's the right place to start. 172 00:14:28,560 --> 00:14:32,120 And that's one of the values of working closely with our colleagues in orthopedic surgery. 173 00:14:32,120 --> 00:14:35,409 You really have to go back to and say, you know, I'm not in the OR. 174 00:14:35,419 --> 00:14:36,320 You don't want me in the OR. 175 00:14:36,350 --> 00:14:37,260 I don't know what I'm doing in there. 176 00:14:37,499 --> 00:14:40,390 But I want to know what Antonia saw in the OR. 177 00:14:40,390 --> 00:14:45,025 I want to know, what was debrided, how confident she is in the adequacy of debridement. 178 00:14:45,025 --> 00:14:46,775 And that doesn't get to a surgical skill. 179 00:14:46,775 --> 00:14:49,415 It gets to what's available to the surgeon at the time of debridement. 180 00:14:50,065 --> 00:14:57,125 So you want to have an idea of what was debrided, what's left after the debridement, what was done with the implants, and we mean all the implants. 181 00:14:57,415 --> 00:14:59,475 Was the metalwork revised? 182 00:14:59,495 --> 00:15:10,315 Is there a cerclage wire there to fix a extended trochanteric osteotomy or some other defect that had to be left behind, because that is going to play into the treatment decisions. 183 00:15:10,939 --> 00:15:29,104 In general, we sort of approach this thinking about was everything resected and we have fresh either just cement or implants there, and was it done in a completely clean way, and if that's the case, then you're going to be looking at trying to go for a cure where you're going to be treating and stopping. 184 00:15:29,185 --> 00:15:35,564 And the duration of, of treatment, we're getting more and more data, uh, over time about what is that optimal duration of treatment. 185 00:15:35,574 --> 00:15:42,085 We had this really nice DATIPO study that I'm sure your listeners have probably read, um, looking at 12 versus 6 weeks. 186 00:15:42,134 --> 00:15:44,165 You have to be careful when you're interpreting that. 187 00:15:44,210 --> 00:15:54,630 But what I took away from that is that there's no difference for, uh, carefully done one stage exchange between 12 and 6 weeks, although a lot of times we will use 12 weeks for one stage exchange. 188 00:15:55,150 --> 00:16:04,459 For two stage exchange, there seemed to be a difference, but I think when we interpret that study, you have to look at who got the two stage exchange in that European center, and it was probably those higher risk patients. 189 00:16:04,880 --> 00:16:14,949 In our practice, and I think the totality of data says that, after a complete resection without re implantation at that time, six weeks is probably sufficient for the vast majority of patients. 190 00:16:15,360 --> 00:16:16,689 We typically stop there. 191 00:16:17,340 --> 00:16:34,160 For those patients, either with what I would call an unintentional one stage exchange, and what I mean by that, and again, it's really important to talk to your surgeon, was it that they did a direct revision to new components there, but they didn't re drape or re set up, as Antonia said, they didn't use new instruments, and it was sort of like, oh. 192 00:16:34,325 --> 00:16:36,385 We're surprised with multiple positive cultures. 193 00:16:36,795 --> 00:16:39,875 Then I think you're looking more along the 12 week line of therapy. 194 00:16:40,315 --> 00:16:44,594 And then debridement and implant retention, that is something that we are still learning more and more about. 195 00:16:44,865 --> 00:16:51,884 My approach and the way I think about that, again, incorporating the DATIPO study and other data is, I typically say 12 weeks is where we start. 196 00:16:52,495 --> 00:16:55,545 And then from there, you really have to individualize it after that. 197 00:16:55,545 --> 00:17:00,315 And you have to take into account all the different factors that weigh into the art of medicine. 198 00:17:00,485 --> 00:17:07,925 Sandy Nelson: Erin really stated the way that many of us or most of us practice and the majority of the literature really is pretty limited when we think about it. 199 00:17:07,955 --> 00:17:24,935 We are learning a lot more and we're beginning to dial it down, but there are some features that certainly would support longer treatment and the knee as opposed to the hip is one of those scenarios because knee prosthetic joint infections actually don't do as well and there is some data to support longer treatment for knees. 200 00:17:25,285 --> 00:17:28,425 There is also more data about Staph aureus than other pathogens. 201 00:17:28,665 --> 00:17:33,915 You know, Staph aureus, especially the severe infections, would make us want to think about a longer treatment course. 202 00:17:34,495 --> 00:17:38,434 But otherwise, we don't have a test of cure, and these are really, really difficult decisions. 203 00:17:38,915 --> 00:17:48,795 Sara Dong: Two other management questions that come up a lot that I wanted to make sure we didn't skip, even though I think it sort of takes us in a step away from the example case. 204 00:17:48,825 --> 00:17:55,730 But say we had someone who had acute Staph PJI, and the question about rifampin comes up. 205 00:17:55,810 --> 00:18:01,570 I would love to hear insight on how you think about rifampin and incorporating it into your regimens. 206 00:18:01,880 --> 00:18:15,125 Sandy Nelson: If you talk about Cutibacterium as sort of the bane of my existence, rifampin is in some ways the antibiotic, the most challenging drug that we use in musculoskeletal infectious disease, simply because there is a lot of controversy around its role. 207 00:18:15,125 --> 00:18:22,355 And if it were easy to use, and if it didn't have toxicities and side effects and drug interactions, it would probably be a little bit less of an issue. 208 00:18:22,894 --> 00:18:26,285 This is one, again, where we have to look at the totality of the evidence. 209 00:18:27,065 --> 00:18:35,155 There are really two small randomized control trials that have looked at the role of rifampin in orthopedic device infections, one specific to PJI. 210 00:18:35,155 --> 00:18:41,235 And both of the studies have really pretty significant limitations that make it hard to draw significant conclusions. 211 00:18:41,265 --> 00:18:48,475 But when you look at the totality of data, which includes retrospective human data and animal data and some vitro data. 212 00:18:48,800 --> 00:18:56,450 There really is increasing support for the use of rifampin and the data is the greatest when the infection is due to Staph with retained hardware. 213 00:18:56,680 --> 00:19:04,399 And then as you move away from staph towards different gram positive organisms or towards removal or exchange of hardware, the data is a little bit less clear. 214 00:19:04,860 --> 00:19:11,750 And so, because rifampin is not easy to use, I think we work the hardest to use it when the indications are clearest. 215 00:19:11,770 --> 00:19:17,610 And so, the patient with a Staph infection with retained hardware, that's someone who we're going to really try to use rifampin. 216 00:19:17,910 --> 00:19:27,689 But when we talk about other organisms, Cutibacterium, Strep, Enterococcus, all of which have some support, low quality support, I would say, for the addition of rifampin. 217 00:19:27,699 --> 00:19:34,509 We may not push as hard in those individuals or if hardware has been removed, particularly if there are some drug interactions. 218 00:19:35,019 --> 00:19:39,429 In this case, the one that you highlighted, I would call this culture negative infection. 219 00:19:39,759 --> 00:19:56,219 I personally don't add rifampin in culture negative infection because it really does add to toxicity and you usually have to use a little bit more breadth of a regimen and in a lower burden infection, which presumably culture negative infections are, I don't think we actually have the data to support it, but that would be my own practice. 220 00:19:56,669 --> 00:19:58,749 Aaron Tande: Yeah, I would, I would agree with you, Sandy. 221 00:19:58,749 --> 00:20:03,870 I wouldn't use it in culture negative infection and I really do, you know, you have to be very thoughtful about it. 222 00:20:03,870 --> 00:20:17,530 And this is where medicine becomes a team sport and we involve other team members, our pharmacy colleagues with their expertise in drug drug interaction Internal medicine specialists or family medicine specialists that are primarily caring for this patient and looking at those drug interactions. 223 00:20:17,530 --> 00:20:25,839 So, um, yeah, I, I probably wouldn't use it in this case, but I do really try and make an effort to use it for Staphylococcal PJI with implant retention. 224 00:20:26,069 --> 00:20:26,489 Sara Dong: Great. 225 00:20:26,939 --> 00:20:34,265 And the other question, uh, is how do you decide who does or does not need long term antibiotic suppression? 226 00:20:34,565 --> 00:20:41,434 You have a really nice Table 3 in your article that shares some of the considerations for suppressive therapy. 227 00:20:41,434 --> 00:20:43,105 I was wondering if you could walk us through that. 228 00:20:43,615 --> 00:20:45,625 Aaron Tande: Yeah, I'll take a jump at that. 229 00:20:45,625 --> 00:20:49,514 And I think, again, it gets back to what do I love about OrthoID, and I do love it. 230 00:20:49,795 --> 00:21:00,815 I love working with my colleagues in surgery and the decision about suppression really has to go back to that partnership and understanding, how does the surgical management depend on success or failure? 231 00:21:01,785 --> 00:21:09,895 And it starts with a good discussion with the surgeon about what are the options and what are the risk factors that they see for failure for this individual patient? 232 00:21:10,345 --> 00:21:12,695 And then if failure occurs, what are the consequences? 233 00:21:12,695 --> 00:21:17,735 Because I think those are the two key things that help us decide whether or not to give suppression. 234 00:21:18,105 --> 00:21:24,595 So as far as risk factors for failure, I usually just start by looking at the infection when it occurred, and were they inappropriate? 235 00:21:24,625 --> 00:21:36,504 Again, if we're talking about debridement implant retention, which is the most common indication for suppression, were they a good DAIR candidate, or debridement implant retention candidate in the first place, or was this a salvage DAIR? 236 00:21:37,004 --> 00:21:46,215 If it was a chronic infection and the outcome of performing more radical surgical approach such as reconstruction would be too morbid and that's why DAIR was chosen. 237 00:21:46,774 --> 00:21:56,385 Those patients typically do benefit, in my opinion, from suppression because we're really trying to do everything we can to keep this patient functional and avoid a very morbid procedure. 238 00:21:56,914 --> 00:21:57,915 So that's where I start. 239 00:21:58,040 --> 00:22:08,800 And then if the patient did have an appropriately timed performed DAIR, then I look at what is my estimate, both currently and as well as at the time of infection, of their risk of failure. 240 00:22:08,930 --> 00:22:12,019 So, did they only require one debridement? 241 00:22:12,329 --> 00:22:14,770 Did they have that debridement performed in a timely manner? 242 00:22:14,770 --> 00:22:17,600 Was polyethylene exchanged or the modular components exchanged? 243 00:22:17,960 --> 00:22:21,360 If there was Staph aureus or Staphylococcal PGI, did they get rifampin? 244 00:22:21,370 --> 00:22:27,700 Was it a late acute infection which seems to have a higher rate of failure versus early postoperative, which has a lower rate of failure? 245 00:22:28,060 --> 00:22:29,340 Was it a knee versus a hip? 246 00:22:29,340 --> 00:22:31,350 Like Sandy mentioned, knees have higher rate of failure. 247 00:22:31,719 --> 00:22:43,690 I look at all these things and I talk to the surgeon and we sort of come up with a plan about whether to offer suppression and the key thing too is I think that we have to reassess as data points accrue. 248 00:22:43,810 --> 00:22:50,920 So, if a patient is offered suppression, they're put on suppression and then they're tolerating it very poorly, look at the risk benefit approach. 249 00:22:51,365 --> 00:22:54,905 And maybe then those risks are now starting to outweigh the benefits. 250 00:22:54,935 --> 00:23:01,415 And, but again, this is an ongoing discussion with our colleagues in surgery, as well as with the patient and their decision makers. 251 00:23:01,924 --> 00:23:05,545 Sandy Nelson: You know, especially historically, we use suppression more than we are now. 252 00:23:05,565 --> 00:23:08,135 We're seeing a little bit more of the harms of long term suppression. 253 00:23:08,514 --> 00:23:14,575 And in addition, we are beginning to have some more fine tuned data that not everybody needs suppression. 254 00:23:15,075 --> 00:23:18,905 And then you're stuck with patients who've been on suppression for some period of time. 255 00:23:18,915 --> 00:23:27,235 And putting somebody on suppression is, in some ways, is an easier decision than making the decision to stop suppression down the road. 256 00:23:27,525 --> 00:23:30,735 And those are very challenging, but can be done. 257 00:23:30,835 --> 00:23:38,175 And over time, as I've stopped more and more of my chronic suppression patients, the vast majority of them have, reassuringly, done well. 258 00:23:38,215 --> 00:23:44,170 But these are really, I think, scary, for the patients, uh, for us and, and probably for the surgeon as well. 259 00:23:44,720 --> 00:23:50,899 Aaron Tande: Yeah, you know, you want to sort of start those discussions early and then pick a time that works for everybody involved. 260 00:23:50,919 --> 00:24:00,879 If you are going to stop suppression, which I totally agree, we, we are probably giving too much suppression, pick a time that works with the patient, with the surgeon, where you're going to carefully stop that suppression in a controlled manner. 261 00:24:01,334 --> 00:24:01,715 Sara Dong: Okay. 262 00:24:01,865 --> 00:24:04,064 We're going to go to a second case. 263 00:24:04,764 --> 00:24:06,715 This time we have a 50 year old male. 264 00:24:06,725 --> 00:24:17,554 He has a history of CKD, obesity, and diabetes, and underwent a right total hip arthroplasty for osteoarthritis about five years ago before coming in. 265 00:24:18,215 --> 00:24:30,830 He comes in now with right hip and thigh pain, and he reports that he initially was doing okay, but really, it's just been over these past couple weeks that he's noticed these symptoms. 266 00:24:31,440 --> 00:24:35,440 Other than the pain, he has not had drainage from an incision. 267 00:24:35,450 --> 00:24:39,930 He's had no fevers or overlying skin changes, no obvious sinus tracks. 268 00:24:40,649 --> 00:24:46,080 We have some initial labs that show that his white blood cell count is 11 with a normal differential. 269 00:24:46,500 --> 00:24:48,570 His platelets were 275. 270 00:24:49,030 --> 00:24:54,060 And his chemistry is normal with the exception of his creatinine of 1.3, which is his baseline. 271 00:24:54,790 --> 00:24:58,360 We have a CRP of 10, which is slightly elevated. 272 00:24:58,370 --> 00:24:59,749 The normal is less than 1. 273 00:25:00,129 --> 00:25:04,899 And then the ESR is 40, and the normal range for that is 0 to 30. 274 00:25:05,549 --> 00:25:13,350 So he has an initial joint aspiration that has 25, 000 white blood cells and 90 percent neutrophils. 275 00:25:13,769 --> 00:25:17,829 So, Antonia, I wanted to get a sense of what you're thinking about for this case. 276 00:25:18,069 --> 00:25:19,209 Antonia Chen: These are the tough ones. 277 00:25:19,239 --> 00:25:23,879 You kind of look at this and I think immediately people will think and scream, Oh, this has to be infected, right? 278 00:25:23,889 --> 00:25:25,639 The white blood cell count is a little bit elevated. 279 00:25:25,979 --> 00:25:27,039 Patients have some symptoms. 280 00:25:27,049 --> 00:25:29,779 ESR and CRP are on the cusp of elevation, right? 281 00:25:29,779 --> 00:25:30,950 I used 10. 282 00:25:31,190 --> 00:25:33,810 I guess the mark of the use here is normal of 1. 283 00:25:33,830 --> 00:25:35,000 But it depends on your units. 284 00:25:35,080 --> 00:25:37,110 You have to pay good attention to your CRP units. 285 00:25:37,560 --> 00:25:39,830 In your ESR 40, our 30s are cut off. 286 00:25:39,870 --> 00:25:51,229 And we just had a good conversation about white blood cell counts, but when you get 25, 000 in a joint that has been there for a long time, five years, then you become a little bit more concerned about infection. 287 00:25:51,700 --> 00:25:58,010 That said, these are the type of patients that you look at and you say, well, you know, we want to make sure that we see the type of hip there is. 288 00:25:58,450 --> 00:26:03,259 And this is where having our ortho with ID colleague collaboration is really useful. 289 00:26:03,660 --> 00:26:07,320 And one of the things that really became a problem was actually metal on metal implants. 290 00:26:07,790 --> 00:26:13,870 And metal on metal implants are not being used as frequently now as they were in the past, but patients are obviously living with a bunch of them. 291 00:26:13,870 --> 00:26:17,160 And there've been a bunch of recalled metal on metal hip implants. 292 00:26:17,910 --> 00:26:26,680 And what this means is for hip implants, you have a metal cup, you have a metal stem, and they're typically made of titanium, and then you put a ball on that, and you have a neck. 293 00:26:26,710 --> 00:26:31,799 So the neck trunnion is made of titanium, and the head is typically made of cobalt chromium. 294 00:26:32,200 --> 00:26:39,620 And by doing so, you have dissimilar metals, and by doing those dissimilar metals, it can actually cause what is called an adverse local tissue reaction. 295 00:26:40,140 --> 00:26:49,780 It can cause metal debris, essentially, and if there's a little bit of metal debris, your body will clear it, but as it accumulates over time, which happens with use of the hip, that becomes problematic. 296 00:26:50,290 --> 00:26:53,000 It is normally measured by cobalt and chromium levels. 297 00:26:53,039 --> 00:26:55,569 Now there's two ways that you can have metal issues. 298 00:26:55,840 --> 00:27:04,180 You can have metal issues from the cup itself to the ball, because it's one metal articulation, or you can have trunnionosis, where is that stem to the ball, right? 299 00:27:04,200 --> 00:27:07,110 So the one that's at typically higher levels are the one that's the cup. 300 00:27:07,280 --> 00:27:10,170 and the ball because it's cobalt chromium rubbing against each other. 301 00:27:10,170 --> 00:27:12,930 So those are typical lab values that I'll check on patients. 302 00:27:13,540 --> 00:27:15,360 A lot of these patients are asymptomatic. 303 00:27:15,660 --> 00:27:18,440 They don't have any symptoms, they don't hurt, but they have this implant. 304 00:27:18,450 --> 00:27:24,329 So typically what I do for these patients is every year I check these lab values and if they start creeping up, that's something concerning. 305 00:27:24,769 --> 00:27:26,280 This patient had an aspirate done. 306 00:27:26,565 --> 00:27:28,395 And you can see it here that the numbers out there. 307 00:27:28,825 --> 00:27:33,845 If your facility has it, our facility doesn't have it, but you can potentially ask for a manual cell count. 308 00:27:34,295 --> 00:27:42,604 When you have to take the fluid out, they can actually count it and that actually really helps determine what the fluid levels are there with regards to inflammatory factors. 309 00:27:42,995 --> 00:27:50,825 And if you want to look at it from an imaging perspective, you can get what we call a MARS MRI or a Metal Artifact Reduction Sequence MRI. 310 00:27:51,035 --> 00:27:54,680 So it suppresses the metal there and you see if there's any sort of soft tissue out there. 311 00:27:55,080 --> 00:27:58,800 The worst case scenarios are patients who've had this for a long time, really high cobalt and chromium. 312 00:27:58,840 --> 00:28:00,240 It can affect cardiac issues. 313 00:28:00,240 --> 00:28:01,500 It can be neurologic issues. 314 00:28:01,749 --> 00:28:03,570 It can have other sequelae as well. 315 00:28:03,800 --> 00:28:04,630 That's problematic. 316 00:28:04,630 --> 00:28:13,750 And we obviously don't want that for our patients, but this is what you can look for in these types of patients, the problem is there's inflammation around the joint and called pseudotumor can be produced there. 317 00:28:14,190 --> 00:28:21,869 So if you're looking at this inflammatory level, don't just jump to infection right away with a 25k white blood cell and a 90 percent polymorphonucleocytes. 318 00:28:22,380 --> 00:28:30,090 Still culture, you know, still do the routine stuff and think of it also, you can have a metal on metal reaction and have infection at the same time. 319 00:28:30,410 --> 00:28:37,640 So be sure to cover all bases with these patients but this is something I think about in these total hip patients as well. 320 00:28:37,660 --> 00:28:38,050 Sara Dong: That's so helpful. 321 00:28:38,050 --> 00:28:56,825 If we say, in this case, we have negative cultures, we're having that question of, is a culture negative PJI here, we mentioned briefly earlier about some of the non culture based tools that we have for PJI, and so I do think there is some variable use of those tests in 322 00:28:56,825 --> 00:29:04,785 different centers as far as alpha defensin or synovial CRP, and I was just wondering if we could pause for a second to talk about those. 323 00:29:04,815 --> 00:29:08,205 Like how, how are those tests used in PJI? 324 00:29:08,485 --> 00:29:10,135 Sort of what is your perspective? 325 00:29:10,395 --> 00:29:11,865 Aaron Tande: Yeah, no, I think that that's a great question. 326 00:29:11,865 --> 00:29:20,484 And this is the exact kind of case, much like the previous case too, where you've got some discrepant test results, you may or may not have infection. 327 00:29:20,575 --> 00:29:23,071 And so that's when you want to start to look at that. 328 00:29:23,071 --> 00:29:28,945 And the, the non culture based diagnostics looking synovial fluid fall into two categories. 329 00:29:28,945 --> 00:29:30,925 The first is, is there infection or not? 330 00:29:31,255 --> 00:29:35,905 And the second is, okay, we think there's infection, but we can't culture anything. 331 00:29:35,905 --> 00:29:38,455 And so how can we sort of make a microbiologic diagnosis? 332 00:29:38,465 --> 00:29:41,175 So the first question of the, is there infection or not? 333 00:29:41,175 --> 00:29:44,125 Yeah, there, there are a number of different options out there. 334 00:29:44,195 --> 00:29:48,115 I think that the one with probably the most data thus far is alpha defensin. 335 00:29:48,184 --> 00:29:51,425 And the data does suggest this is probably a good test. 336 00:29:51,475 --> 00:29:59,745 However, to me, I remain to be convinced that it is superior to the much more widely available and cheaper cell count and differential. 337 00:30:00,185 --> 00:30:11,045 I think it should be reserved for use in cases like this where you may need an additional piece of data because, say, your cell count may be artificially changed based on adverse local tissue reaction. 338 00:30:11,205 --> 00:30:23,100 I think alpha defensin, synovial fluid CRP, if they're available to you, they're good in situations where you're on the border between infection versus not, and that's going to affect your initial surgical management strategy. 339 00:30:24,340 --> 00:30:35,749 To get to the second question of, okay, I think there's infection, but we can't grow anything, you know, there are, again, now a few different options available, and these molecular diagnostics, they're sort of in two flavors. 340 00:30:36,199 --> 00:30:45,900 The first is using a broad based approach, such as a 16S PCR, and that can be followed by either Sanger sequencing or a targeted metagenomic sequencing. 341 00:30:46,550 --> 00:30:52,760 The advantage there is that you can identify novel pathogens that are not common causes of PJI. 342 00:30:52,780 --> 00:30:55,250 You know, there's a lot of case reports about that. 343 00:30:55,260 --> 00:31:04,890 And I think that that, uh, does seem to show some benefit, again, in those unique circumstances where you need to make a culture based, culture negative diagnosis. 344 00:31:05,489 --> 00:31:09,380 The other category are sort of multiplex PCR assays. 345 00:31:09,380 --> 00:31:11,390 And there's one that's commercially available. 346 00:31:11,880 --> 00:31:17,359 The chief advantage there, again, it may be less influenced by antimicrobials previously. 347 00:31:17,760 --> 00:31:27,780 It also typically has a rapid turnaround time, but the huge limitation of that test is it didn't include some key pathogens such as Cutibacterium acnes or Staph epi. 348 00:31:27,800 --> 00:31:30,740 And so there's a couple different options. 349 00:31:31,000 --> 00:31:32,620 Each probably has a role. 350 00:31:32,710 --> 00:31:40,420 Each is a tool in trying to get to that answer of what is the pathogen here that can help you with your management. 351 00:31:40,790 --> 00:31:58,225 Sara Dong: Aaron talked a little bit about duration of therapy earlier and in your article, you talk about how we sometimes think about the treatment courses and stages with IV therapy and oral phase and then whether or not that patient also then gets oral suppression. 352 00:31:58,555 --> 00:32:05,145 I want to make sure that we give a little bit of time to talk about that sort of oral therapy options and that phase. 353 00:32:05,605 --> 00:32:07,145 Sandy, maybe you can tell us a little bit. 354 00:32:07,540 --> 00:32:12,490 Sandy Nelson: So, we have a patient who has a confirmed or suspected PJI and we're planning on treatment. 355 00:32:12,760 --> 00:32:33,060 The standard is usually to start with IV antibiotics in the perioperative window and that's generally for a couple of reasons and, you know, one is simply logistics that the patient may not be able to tolerate oral medications very well early on, but there's also this idea that we can have enhanced drug delivery with higher level dosing that can be achieved through the intravenous route. 356 00:32:33,840 --> 00:32:39,460 There is very strong emerging data in support of oral therapy for many bone and joint infections. 357 00:32:39,900 --> 00:32:42,880 You know, our pharmacists like to say that the bug doesn't really care. 358 00:32:42,940 --> 00:32:48,580 The bacteria don't really care whether the antibiotic was ingested or injected. 359 00:32:48,630 --> 00:32:52,420 It's going to get there, and as long as the drug gets there, it doesn't really matter. 360 00:32:52,810 --> 00:33:01,190 My focus has shifted a little bit away from using intravenous antibiotics to using oral antibiotics that have a very good bioavailability. 361 00:33:01,460 --> 00:33:04,830 And it seems to be that the bioavailability is the relevant factor. 362 00:33:05,270 --> 00:33:13,060 I think there are some important cautions and, you know, number one is most of the studies in support of oral therapy don't start oral therapy on day one. 363 00:33:13,110 --> 00:33:23,144 There is usually a window of time where patients are receiving IV therapy and that ranges in the various studies from, you know, a day or two up to five days or up to nine days depending on the study. 364 00:33:23,145 --> 00:33:26,245 So it's not a right away, do we start oral therapy? 365 00:33:26,545 --> 00:33:37,104 But once they're able to tolerate oral antibiotics, and if there is a good, highly bioavailable oral option for that particular organism, then it is reasonable to discuss and reasonable to consider. 366 00:33:37,865 --> 00:33:44,410 You know, this individual has culture negative infection, or, You know, assuming that we didn't identify an organism through some of these advanced diagnostics. 367 00:33:45,100 --> 00:33:52,610 I think that we have to use a little bit more caution with culture negative infections simply because there is a greater chance that we're going to potentially miss the pathogen. 368 00:33:52,930 --> 00:33:54,689 I think there are some other considerations. 369 00:33:54,690 --> 00:33:56,750 We need a, you know, a functioning GI tract. 370 00:33:57,040 --> 00:34:05,580 We have to really consider those drug drug interactions because if a medication has excellent bioavailability but not if it's taken with some other medications that the patient's on. 371 00:34:05,945 --> 00:34:07,895 then that becomes a barrier as well. 372 00:34:08,165 --> 00:34:15,865 We don't have good data in support of its use in patients who are obese, simply from the standpoint of pharmacokinetics and drug distribution. 373 00:34:16,475 --> 00:34:20,035 I personally avoid oral therapy if an infection is life threatening or limb threatening. 374 00:34:20,065 --> 00:34:30,425 We don't have data to say that you can't use oral therapy in those settings, but I feel less comfortable in those settings that We really want to give these patients the absolute best tool in those situations. 375 00:34:30,425 --> 00:34:35,954 And, and the final point around oral therapy, which I don't think I appreciated until I started using more oral therapy. 376 00:34:36,265 --> 00:34:42,964 With IV therapy, we've, you know, many of our hospitals have developed these infrastructures to support patients after they leave the hospital. 377 00:34:43,464 --> 00:34:53,115 And those, we haven't really developed the same infrastructure to support patients who leave the hospital on oral therapy, but may actually still have significant toxicity, significant intolerances. 378 00:34:53,865 --> 00:35:08,214 And making sure that we have equal paths for bi directional communication with the patients so that we are ensuring that they're tolerating, adhering, and succeeding with that therapy has been one of the barriers that I didn't think about before I started doing it. 379 00:35:08,645 --> 00:35:16,965 Sara Dong: I want to thank you all for emphasizing a lot of important points, but especially this collaborative and multidisciplinary approach to these infections. 380 00:35:17,395 --> 00:35:25,345 Another key theme in a lot of these CID reviews is thinking about ID topics through the lens of health equity. 381 00:35:25,804 --> 00:35:34,235 And Jodi, I know you've been leading some work and thinking about how racial disparities may affect PJI, and I'd love to hear a little bit more about that. 382 00:35:34,480 --> 00:35:35,080 Jodi Pinkney: Thanks, Sara. 383 00:35:35,130 --> 00:35:51,839 Yeah, we actually did a follow up study to this afterwards looking at racial disparities in PJI incidents and found that non Hispanic Black patients were twice as likely to develop prosthetic joint infections compared to their white counterparts. 384 00:35:51,960 --> 00:36:16,580 And so really trying to understand why that is, at the end we realized that comorbidities played a huge role in this disparity, accounting for 26 percent of the difference between And so, thinking as a clinician, what are some of the health related social needs that may be acting as barriers for our patients going forward? 385 00:36:16,940 --> 00:36:21,680 We've mentioned that this is management is extremely complicated and collaborative. 386 00:36:21,700 --> 00:36:26,550 We have a lot of questions about diabetes, and we have been working with surgeons and infectious disease specialists, but also considering their primary care physicians. 387 00:36:26,560 --> 00:36:37,879 You know, a lot of them have obesity that needs to be managed, diabetes, chronic kidney disease, and so are we also opening the channel for communication with their primary care providers? 388 00:36:37,919 --> 00:36:41,040 You know, does their insurance cover their primary care visit? 389 00:36:41,079 --> 00:36:52,525 Does it cover the medications that they need to be adequately treated for these other contributing comorbidities that can really affect their outcomes. 390 00:36:52,635 --> 00:36:59,974 From the health equity lens, we usually need to take a step back and think of the multiple layers or structures. 391 00:36:59,975 --> 00:37:04,435 One great framework to do this is the socio ecological model. 392 00:37:04,605 --> 00:37:20,775 That looks at individual patient factors, which may include like comorbidities and, you know, level of trust, establishing trust, especially because this is such a stressful and overwhelming diagnosis for many patients that are now unable to do their day to day activities. 393 00:37:20,804 --> 00:37:23,394 Walking the dog in the park is hard. 394 00:37:23,415 --> 00:37:24,404 Going upstairs is hard. 395 00:37:24,424 --> 00:37:25,244 Going to work is hard. 396 00:37:25,614 --> 00:37:28,084 So, understanding what factors is. 397 00:37:28,175 --> 00:37:42,275 um, are driving their decisions on an individual level, but also understanding what factors are driving their decisions on, um, the social level, you know, are we being flexible in the care that we can provide? 398 00:37:42,444 --> 00:37:50,540 Maybe they can't come in during the week because they have, um, You know, they're an essential worker, they're working 9 to 5, so do you have flexible office hours? 399 00:37:50,540 --> 00:37:55,819 Do you have language congruent information about what to do if you are having pain? 400 00:37:56,140 --> 00:38:04,550 Is everyone on your healthcare team aware of the different ways that people perceive pain or communicate that they're having pain? 401 00:38:04,935 --> 00:38:13,805 are open to that across all, all racial groups because there has been discrimination in that arm for just over a long time in the U. 402 00:38:13,805 --> 00:38:13,985 S. 403 00:38:13,985 --> 00:38:14,745 healthcare system. 404 00:38:14,745 --> 00:38:23,704 So really, I think thinking about individual factors, social factors, health policy factors, including things like that you don't normally think about. 405 00:38:24,074 --> 00:38:30,055 Hey, does this person patient of mine that I'm really invested in, I really want to see them get better, does they have access to a dentist? 406 00:38:30,505 --> 00:38:39,295 You know, dental care is really important in terms of being a risk factor for transient bacteremia and seeding of your prosthetic joint. 407 00:38:39,295 --> 00:38:43,135 But hey, a lot of our insurance plans don't cover this. 408 00:38:43,334 --> 00:38:46,334 Private insurance is not, you know, easily accessible. 409 00:38:46,334 --> 00:39:08,139 So thinking about maybe I need to connect my patient with my social worker or a free medical clinic or a mobile clinic that's dental led is something we really need to start taking into account as physicians, particularly now given the increased emphasis on social determinants of health screening that has now become mandatory as 410 00:39:08,140 --> 00:39:30,060 of January this year, where hospitals accreditation will depend on the fact that they're screening and mitigating these social risk factors for patients, so I think just zooming out a bit and not just, you know, realizing that our patients have individual concerns, but also that broader policies and social needs are at play. 411 00:39:30,520 --> 00:39:36,800 Sara Dong: At the, at the end of these, I like to leave it open in case there's things that you want to highlight or take home point. 412 00:39:36,800 --> 00:39:40,920 So I'll open it up and see if there's anything else you guys want to make sure that we add. 413 00:39:41,240 --> 00:39:49,799 Sandy Nelson: I'll just like to thank you, Sara, for having us, but also a particular shout out to my co authors on this because, you know, it really was a collaborative team approach. 414 00:39:49,800 --> 00:40:05,534 And I just wanted to highlight that as an ID physician who specializes in musculoskeletal infections I think one of the most rewarding things that we really get to do is work collaboratively with our colleagues, not only our orthopedic surgeons, but our musculoskeletal radiologists and the pharmacists and plastic surgeons and others, and, 415 00:40:05,735 --> 00:40:15,532 and really working together to brainstorm ideas for really difficult or challenging problems has been a surprising source of a tremendous amount of joy in my practice. 416 00:40:15,532 --> 00:40:20,515 And so just wanted to express that and hope that those that listen can share in that joy. 417 00:40:20,675 --> 00:40:24,955 Antonia Chen: I'll let go that from the orthopedic standpoint that it's wonderful that you guys actually listen to us. 418 00:40:25,745 --> 00:40:31,475 I'm heartened by that because a lot of times I think these stereotypes in medicine are probably true when it comes to orthopedics. 419 00:40:32,085 --> 00:40:34,154 We really don't think about things as deeply as you guys. 420 00:40:34,165 --> 00:40:39,584 So we're thankful for you guys and we're thankful that you guys listen to us and we really all do this to make our patients better. 421 00:40:40,924 --> 00:40:47,205 Sara Dong: A huge thank you to our guests, Sandy, Jodi, Aaron, and Antonia for joining Febrile today. 422 00:40:47,785 --> 00:40:57,345 You can find their article at State of the Art Review, Periprosthetic Joint Infection, Current Clinical Challenges from CID, linked in the episode information and on the Consult Notes. 423 00:40:57,865 --> 00:41:00,085 We'll be back next week with another STAR episode. 424 00:41:00,725 --> 00:41:03,045 Don't forget to check out the website, febrilepodcast. 425 00:41:03,045 --> 00:41:08,095 com, where you can find the Consult Notes, our library of infographics, merch store. 426 00:41:08,905 --> 00:41:13,765 Febrile is produced with support from the Infectious Diseases Society of America, IDSA. 427 00:41:14,145 --> 00:41:16,465 Editing and mixing is provided by Bentley Brown. 428 00:41:17,415 --> 00:41:21,555 Please reach out if you have any suggestions for future shows or want to be more involved with Febrile. 429 00:41:21,965 --> 00:41:22,725 Thanks for listening. 430 00:41:23,045 --> 00:41:24,355 Stay safe and I'll see you next time.