Development of evidence-based guidelines for the treatment and management of periprosthetic hip infection: The INFORM Guidelines

Andrew J Moore*, Vikki Wylde, Michael R Whitehouse, Andrew D Beswick, Nicola Walsh, Catherine M Jameson, Ashley W Blom

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review

1 Citation (Scopus)

Abstract

ABSTRACT

Background
Periprosthetic hip-joint infection is a multifaceted and highly detrimental outcome for patients and clinicians. The incidence of prosthetic joint infection reported within 2 years of primary hip replacement ranges from 0.8% - 2.1%. Costs of treatment are over 5 times greater in people with prosthetic hip joint infection than in those with no infection. Currently there are no national evidence-based guidelines for treatment and management of this condition to guide clinical practice or to inform clinical study design. The aim of this study is to develop guidelines based on evidence from the six-year INFORM (INFection and ORthopaedic Management) research programme.

Methods
We used a consensus process consisting of an evidence review to generate items for the guidelines and online consensus questionnaire and virtual face-to-face consensus meeting to draft the guidelines.

Results
The consensus panel comprised 21 clinical experts in orthopaedics, primary care, rehabilitation, and healthcare commissioning. The final output from the consensus process was a 14-item guideline. The guidelines make recommendations regarding increased vigilance and monitoring of those at increased risk of infection; diagnosis including strategies to ensure the early recognition of prosthetic infection and referral to orthopaedic teams; treatment, including early use of DAIR and revision strategies; and postoperative management including appropriate physical and psychological support and antibiotic strategies.

Conclusions
We believe the implementation of the INFORM guidelines will inform treatment protocols and clinical pathways to improve the treatment and management of periprosthetic hip infection.
Original languageEnglish
Pages (from-to)226-233
Number of pages8
JournalBone & joint open
Volume4
Issue number4
DOIs
Publication statusPublished - 1 Apr 2023

Bibliographical note

Funding Information:
At the time of writing, there are no standard UK guidelines for the treatment of hip PJI. Local pathways are often based on small local case series and observational studies.25 As part of a follow-on Programme Development Grant, funded by the National Institute of Health Research, the aim of this study was to mobilize evidence from the INFORM programme by using it to develop best practice guidelines which can be implemented nationally. Study design. We worked with expert stakeholders involved in the treatment of PJI, from across the UK, to develop best practice guidelines for hip PJI based on evidence from the INFORM programme. Evidence-based recommendations derived from the programme were evaluated by a panel of 21 expert clinical stakeholders via an online consensus questionnaire in phase 1, and subsequent consensus meeting in phase 2, similar to a Modified Nominal Group Technique.26 The study received Health Research Authority approval (ref: 22/HRA/0399) and University of Bristol, Faculty of Health Sciences Ethics approval (ref: 10069). Initial draft guideline. The initial draft guideline was developed by study team members with expertise in orthopaedic surgery, evidence synthesis, health services research, social science, physiotherapy, and knowledge mobilization. Evidence from the INFORM programme relevant to the preoperative, perioperative and postoperative patient pathway were aggregated into a table by an evidence synthesis expert, which provided the basis for the initial draft guideline. On 28 January 2022, the draft guideline was sent to the project steering committee, which comprised three consultant orthopaedic surgeons, a professor of musculoskeletal therapies, and a senior research fellow in patient experiences in trauma and musculoskeletal sciences. Further refinements were made until a draft guideline consisting of 12 statements was agreed. The draft was then reviewed by the INFORM patient and public involvement (PPI) group, which includes five people with experience of PJI. Sample size and recruitment. Participants were identified through participation in a previous study,17 and through informal and professional networks. After providing informed consent, participants completed the online questionnaire via Online Surveys (UK). Sample size was guided by the need to elicit the views of expert stakeholders in the design of guidelines, rather than statistical power.27 Consensus questionnaire. The consensus questionnaire was designed to elicit opinions about the appropriateness of each guideline draft statement (Supplementary material i). Participants were asked to rate each statement from 1 to 9 ('not appropriate' to 'very appropriate'). Participants were also provided with a free-text space to explain their rating and to make suggestions for alterations or additions. All participants were assigned ID numbers, and personal data (names, contact details) were stored separately from the data. All written reports about the questionnaire data were anonymized, removing any data that may potentially be used to identify individuals. The questionnaire was piloted with a member of the research team to check functionality. The questionnaire opened on 9 March 2022 and closed on 6 April 2022. Stakeholder meeting. An expert stakeholder meeting was held virtually using an online video collaboration platform. The meeting was facilitated by the chief investigator (AJM) and co-chief investigator (AWB) with research team members attending. Proposed changes to the draft statements (informed by analysis of the free-text survey responses) were discussed in the meeting and then re-rated by participants. As in other co-design studies, voting was facilitated by the use of the Mentimeter interactive polling survey app, which allows stakeholder participants to use smartphones to vote anonymously.28 Following the meeting, those that could not attend were invited to vote by email on any amended or new statements. Analysis. We used the RAND/UCLA appropriateness method to determine consensus scores in the questionnaire and stakeholder meeting.29 A guideline statement with a median score of 1 to 3 was considered as unimportant (good to excellent consensus over lack of importance), statements with a median score of 4 to 6 as uncertain (some consensus over importance), and those with a score of 7 to 9 as important (good to excellent consensus over importance). Those guideline statements given an importance rating of 7 to 9 by ≥ 70% of participants were retained. Free-text comments were entered into a Excel spreadsheet (Microsoft, USA) and categorized according to their key content. We did not perform a full thematic or similar analysis on this qualitative data, instead, categorization in the form of tables enabled us to collate and display the information which was reviewed at a team meeting to decide whether amendments should be proposed for each statement. For statements where consensus was reached, no amendments or minor amendments were proposed, informed by the free-text comments. For statements where consensus was not reached, major amendments were proposed.

Funding Information:
The research team would like to thank the individuals who provided their time and expertise to the study. We would also like to acknowledge the support of the Nation- al Institute for Health Research Clinical Research Network (NIHR CRN). This study was also supported by the NIHR Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol, UK.

Publisher Copyright:
© 2023 Author(s) et al. Open Access.

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