An infected prosthetic hip. Is there a role for prophylactic antibiotics?
Authors: J. C. Mason, C. T. Dollery, A. So, J. Cohen, S. R. Bloom, C. Bulpitt, R. Russell-Jones, C. M. Oakley
Journal: BMJ (1992)

StaffRoundsAn infected prosthetic hip Is there a role for prophylactic antibiotics?Infection of a prosthetic joint is associated with serious prosthesis on the left, but on the right there were areas morbidity, can result in prolonged admission to hos-of lucency around the hip shaft with associated new IA\ t_ pital, and is potentially life threatening.Our case bone formation, consistent with infection (figure).illustrates these problems, and the arguments for and Treatment was started with intravenous benzylpeniagainst the use of prophylactic antibiotics in preven-ciin 2 MU six hourly and subcutaneous heparin.She tion of these infections are discussed.had daily physiotherapy to her hips.The pain in her hip resolved within 48 hours.Her C reactive protein concentration fell to 13 mg/l on day 12 after admission Case history and her erythrocyte sedimentation rate to 41 mm in the A 67 year old woman had congenital dislocation of first hour.Her platelet count also fell to within the the hip diagnosed at the age of 1 year.In 1976 she had a normal range and the white cell count remained right total hip replacement and in 1980 a left total hip normal.After two weeks' intravenous benzylpenicillin replacement, both for osteoarthritis.In 1985 a revision treatmentwas changed to oral phenoxymethylpenicillin of the left hip prosthesis for aseptic loosening was and the acute phase reactants remained stable.She was performed with a good result.She remained well until discharged to be readmitted two weeks later for July 1990 when she was seen by her orthopaedic removal of the infected prosthesis, followed by six surgeon after complaining of increasing discomfort in weeks of traction.It was planned that she would have the right hip.Radiography of the hip showed appreci-bone grafting of the acetabulum and proximal femoral able wear of the socket, but there was no evidence of head six months later followed by implantation of infection and her erythrocyte sedimentation rate was another prosthesis.normal at 7 mm in the first hour.In August 1990 she had an infected wisdom tooth removed and in Novem- ber she had a molar tooth stump extracted.She became Comment unwell in December with malaise, lethargy, sore In 1988 Maderazo et al suggested that the annual throat, and fever.Her general practitioner prescribed incidence of late infection of joint prostheses was three separate courses of antibiotics over the next few 0-6%.'These infections are potentially life threatening, weeks but she remained unwell with intermittent have a high associated morbidity, and require pro- fevers and night sweats.In March 1991 she developed longed admission to hospital.The route of infection is severe pain in her right hip.A radiograph of the right by haematogenous spread.An animal model has been hip appeared consistent with infection of the hip described, in which Staphylococcus aureus was injected prosthesis.This was supported by a raised erythrocyte into rabbits with prosthetic knee joints and one third sedimentation rate of 70 mm in the first hour and a fall subsequently developed joint infections.2A review of in haemoglobin concentration to 95 g/l.An open 43 previously described cases identified the source of biopsy of the right femur was performed.Bacterial infection as skin in 46%, dental in 15%, urinary tract in cultures of both the femoral window swab and the 13%, respiratory tract in 10%, and gastrointestinal femoral biopsy specimen grew Streptococcus mitis, an tract in 2%; in 14% the source ofinfection was unclear.' organism in the viridans streptococcus group.She was Staphylococci are the commonest infecting organisms, admitted to the Hammersmith Hospital for treatment.accounting for about 60% of the infections, withOn admission she complained of severe pain in her streptococci causing 20%.Numerous other organisms right hip but was otherwise well.She had been treated have been implicated, including Gram negative bacilli for tuberculous peritonitis at age 7 but had no other and anaerobes (table).There are only three previously Department of Medicine, relevant medical history.On examination she was reported cases of infection of prosthetic joints with Hammersmith Hospital, afebrile, climcally anaemic, and had no lymphadeno-viridans streptococci.