Infection prevention
To maximise ability to infect and evade host defences and antibiotics, bacteria develop a protective ‘community’ or biofilm. Biofilms have been defined as fixed microbial communities encased in extracellular polymeric substances. Their formation is a multi-step process progressing along the following course: reversible attachment, irreversible attachment and then growth of a bacterial colony or community under the protective extracellular polymer layer – the biofilm.8,9 It is clear, therefore, that there is a ‘race for the surface’. A coating on the surface that prevents adherence can extend that time in which the vulnerability of bacteria is maximal. This coating and adherence reduction results in a maintenance of vulnerability and prevention of single or groups of organisms converting into a protected thriving bacterial community.10
It is
here, at that opportunity to prevent the loss of bacterial vulnerability and biofilm formation, that Hydrogel plays its role. As with any technology or technique, there is balance of cost and risk to the patient and their treating healthcare system with the introduction of antimicrobial adjuncts. No intervention to prevent infection comes without cost but, equally, the cost of infection when established as explored above is devastating for the patient and extremely costly for the healthcare provider.11 Potentially, clinicians could ‘balance’ the personal patient and societal costs through incorporation of all adjuncts in a spirit of marginal expenditure to offset the monstrous costs of prosthetic joint or fracture related infection. The evidence of a ‘blanket’ adoption in the spirit of prevention is, however, not present. Clinicians need instead to be mindful of the numerator and denominator in both PJI and FRI incidence. Treating every case with every preventative technique is not necessary, and thereby coating every implant with Hydrogel is equally not required. The treating surgeon should instead
reserve the use of Hydrogel for cases where the likelihood of joint or fracture infection is higher than baseline. This therefore negates its use and all other similar adjuncts in the surgeon’s armamentarium for most standard cases in healthy adults. This appropriately limits the benefits to those patients where use is most likely to have impact – that minority of patients who go on to develop an infection. It has shown to be cost-effective if used within these parameters in arthroplasty.12 ‘Named case or host factor basis’ is the
philosophy on which infection prevention is best developed as a premise. It is not difficult to identify such patients. Patients undergoing
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revision arthroplasty, surgery for failed fracture fixation, or implantation of oncology megaprostheses should be considered. Patients in whom multiple surgeries have been performed clearly have a greater risk than baseline. Patients with open fracture, compromised soft tissues or immunocompromise equally figure. Smokers, patients with diabetes and those in whom venous outflow is compromised all bring an increased relative risk profile and significantly exceed baseline expectation of fracture healing or implant longevity. While DAC is specifically intended as a
prophylactic medical device, there is a group of patients in whom we use the product that already sit at the peak of infective risk. Those in whom an infection is already present – as proven on prior deep tissue sampling. A small but incredibly
difficult subset of orthopaedic patients, in whom an implant is needed to maintain quality of life and prevent life altering pain or diminished function. These patients do not have the option of prolonged staged surgeries or a future without implant presence. In these patients, we use a hydrogel to protect the implant. By judicious case selection, surgical teams
can avoid utilising hydrogel in cases that are expected to proceed to complete resolution without infection. Instead, by choosing to use it on cases where the risk profile (for whatever contributing reason) is greater, the risk / reward ratio becomes much more beneficial. It is this assessment of risk that is central to the effective and successful use of these products in the authors’ experience. This judicious case selection can be observed in three cases operated on at our institution in the last week:
TIME IS OF THE ESSENCE WHEN FIGHTING ANTIMICROBIAL RESISTANCE
bioMérieux provides the most complete solution to support Antimicrobial Stewardship (AMS) initiatives with 80% of our product portfolio dedicated to the fight against AMR.
Our actionable diagnostics paired with complementary advanced analytics, collaborative services and educational modules, enable clinicians to provide earlier, optimised and data-driven therapy for better patient management and a responsible use of antimicrobials.
bioMérieux is the trusted partner that today’s healthcare systems need to confidently deliver evidence-based clinical decisions along the entire patient pathway.
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