1204 infection control & hospital epidemiology october 2015, vol. 36, no. 10 Table 4. Continued
Variable Yes
Undernutrition No Yes
Neurologic diseases No Yes
Rheumatologic diseases No Yes
Organ graft No Yes
PVD No Yes
n 3,917
31,745 933
32,438 240
32,336 342
32,635 43
32,007 671
Univariate analysis Mortality rate (%)
3.47 4.77
20.79 5.14
16.67 5.21
6.14 5.21
18.60 5.06
13.11 P
<.001 NA
<.001 NA
.001
NA .66
NA .01
NA .001
Hazard ratio 0.81
1
1.673 1
1.94 1
– 1
1.99 1
1.02 0.99 0.81 Reference 4.02 Reference 1.27
NOTE. HIV, human immunodeficiency virus; HKAI, hip or knee arthroplasty infection; PVD, peripheral vascular disorders. aN=32,582.
site infections. Again, this was mostly due to patients under- going partial hip replacement after hip fracture. PJI patients were more likely to die in hospital than those
without such infection (HR, 1.30 [95% CI, 1.02–1.67]) (Table 4). Inpatient mortality was associated with older age and cancer, hip replacement, chronic renal failure or ulcer sores, liver diseases or alcohol, having a cardiologic device, under- nutrition, a recent year of replacement, and neurologic diseases, whereas hypertension and obesity were protective (Table 4).
discussion Principal Findings
For the first time, to our knowledge, incidence density of PJI after hip or knee arthroplasty (2.3% person-year) was esti- mated from a large and complete database, allowing public policy to consider a routine use for PJI detection and surveil- lance. This routine use of medico-administrative data has proved its efficacy and complementarity with the existing surveillance system, with fewer healthcare professionals involved and a lower cost than previous studies. Incidence density estimation was higher than previous esti-
mations (1% to 2% in published studies in France,1,5,12 the Netherlands, or theUnited States13,15,22). This difference could be due to the possible postdischarge surveillance and 1 year mini- mum follow-up (versus 1 month in the French surveillance network, Infection du site opératoire—Réseau Alerte Investiga- tion Surveillance des Infections).The partition between total and partial prosthesis was not analyzed in this firstevaluationofthe routine use of this validated hospital discharge surveillance method.20 This could explain the distribution of patient
characteristics (replacement age, comorbid factors), major risk factors (cancers, chronic diseases), and mortality after hip or knee arthroplasty. Replacement of the joint after hip fracture corre- sponded to different patients compared with replacement for coxarthrosis purposes.23,24 The incidence increased significantly between the 2008 and the 2011 years of arthroplasty, possibly linked to new hospital financial incentives that have been instal- led in France to report bone and joint infection coding since 2009 (date of establishment of the French reference centers for the treatment of complicated bone and joint infections).5 In this exploratory study, major risk factors of PJI were liver diseases including alcohol abuse, obesity, undernutrition, and chronic renal failure, as already reported, especially after hip fracture replacement.5,19,22,25 The age at surgery was not associated with a higher risk. Several clinical factors were associated with increased mortality after hip or knee arthroplasty (ulcer sore, under- nutrition, chronic renal failure). Being overweight was protective, as in a recent publication from the National Joint registry for England and Wales,14 whereas several previous articles focused on hiporkneelocationshowedthe opposite.8,22,26,27 The number of hip and knee replacements performed each
year steadily rose in France as in other Northern European countries, according to data provided by National Joint Regis- tries. 6,14,28,29 This increased number of primary hip or knee arthroplasties means more complications (infections, revi- sions),5,25,28,30 especially with the rising burden of an aging population, which is accompanied by increasing risk of devel- oping osteoarthritis. The current question is how to improve the quality of orthopedic care in our aging countries. As argued in a report from the British OrthopaedicAssociation28 and in a recent study led by Ravi et al,31 clinical workers are best placed to drive the development of best pathways of orthopedic care. An English
NA .06
NA .88
1.41
Multivariate analysisa (95% CI)
0.68 1.418 0.97 Reference 1.975 Reference 2.66 Reference P .03 NA .001 NA .001 NA
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131 |
Page 132 |
Page 133 |
Page 134 |
Page 135 |
Page 136 |
Page 137 |
Page 138 |
Page 139 |
Page 140