人工关节置换术后假体周围感染治疗中抗生素的应用  

Application of antibiotics in the treatment of periprosthetic joint infections after total joint arthroplasty

作　　者：曹力[1] CAO Li(Orthopaedic Center,the First Affiliated Hospital of Xinjiang Medical University,Urumqi 830054,China)

机构地区：[1]新疆医科大学第一附属医院骨科中心,乌鲁木齐830054

出　　处：《中华骨与关节外科杂志》2024年第11期961-967,共7页Chinese Journal of Bone and Joint Surgery

基　　金：新疆维吾尔自治区重大科技专项项目(2022A03011);新疆维吾尔自治区科学技术厅科技创新团队项目(2023TSYCTD0014)。

摘　　要：人工关节置换术后假体周围感染(PJI)是骨科领域最具挑战的并发症之一。PJI的治疗基于外科干预,彻底清创结合合理应用抗生素是关键。抗生素的应用主要分为升阶治疗原则和降阶治疗原则,在两者的选择上存在争议。升阶治疗原则源于内科系统感染,被多数医院所采用;而降阶治疗原则强调在假体生物膜成熟前尽早杀灭残余病原菌,并逐渐被更多医院所认可。静脉滴注是抗生素的经典给药方式,病原菌培养结果为阳性时,应根据药敏试验结果并结合患者的合并症选择敏感抗生素。需警惕粪肠球菌和真菌引起的PJI,这类感染治疗效果较差。当病原菌培养结果为阴性时,应选择覆盖革兰氏阳性菌和革兰氏阴性菌的抗生素,但不建议无明确证据时联合覆盖抗真菌药物。抗生素局部应用广泛,如抗生素复合骨水泥间隔器,尽管存在争议,仍是PJI常见的治疗方式。硫酸钙颗粒和海藻酸钠克服了需移除载体的局限,但疗效仍需更多证据支持。关节腔内注射抗生素能提供足够高的局部药物浓度,避免静脉给药途径带来的肝、肾毒性,临床数据逐渐增多,或将成为PJI治疗的主要方式。口服抗生素以左氧氟沙星和利福平为主,需依据患者具体情况调整。PJI的抗生素最佳应用时间存在争议,大多数医院应用4~6周,但研究表明短期静脉滴注抗生素不会增加感染复发风险。针对假体生物膜的多种治疗策略目前正处于动物实验研究和Ⅱ期临床试验阶段,希望这些方案能早日应用于临床,使更多患者获益。Periprosthetic joint infection(PJI) following total joint arthroplasty(TJA) remains one of the most challenging complications in the field of orthopedics.Effective treatment of PJI requires surgical intervention,with thorough debridement combined with appropriate antibiotic therapy being crucial.The application of antibiotics mainly follows either an escalation or de-escalation treatment strategy,though there is ongoing debate between these approaches.Escalation strategy,derived from the management of systemic infections in internal medicine,is widely adopted by hospitals.In contrast,de-escalation strategy focuses on the early eradication of residual pathogens before biofilm maturation on the prosthesis and is gaining traction in clinical practice.Intravenous administration is the standard route for antibiotics.When pathogens are identified,antibiotic selection should be guided by susceptibility testing and the patient's comorbidities particular caution is required for PJIs caused by Enterococcus faecalis and fungi,as these infections often lead to poor outcomes.In cases of culture-negative PJI,broad-spectrum antibiotics targeting both Gram-positive and Gram-negative bacteria are recommended,though routine coverage for fungal infections is not advised without clear evidence.Local antibiotic delivery is widely employed in PJI management,with antibiotic-loaded cement spacers being a common method,despite some controversies.Calcium sulfate and sodium alginate carriers,which do not require removal,offer an alternative,though further clinical evidence is needed to validate their efficacy.Intra-articular antibiotic infusion,which achieves high local drug concentrations to disrupt biofilm while avoiding the systemic toxicity of intravenous routes,is increasingly supported by clinical data and may emerge as a key future treatment modality.Oral antibiotics,primarily levofloxacin and rifampin,should be adjusted based on the patient's specific condition.The optimal duration of postoperative antibiotic therapy in PJI remains

关 键 词：假体周围感染 人工关节置换术 抗生素 

分 类 号：R684[医药卫生—骨科学]