My Husband’s Post Knee Replacement Infection Saga

By JillS

1 min read

Eight months after a seemingly smooth knee replacement surgery, my husband developed a staph aureus infection in the knee and needed to have it opened up, cleaned out, and 6 weeks of IV antibiotics followed by oral antibiotics.

We are currently 12 weeks out.

What RA medications to use after knee replacement?

The knee again seems to be good but he had to of course stop Enbrel when this happened and has been on methotrexate tablets, now injectable along with hydroxychloroquine, for six weeks and is just in agony yet.

The RA doctor said no biologic drugs like Enbrel until he’s off antibiotics, which the infectious disease doctor has mentioned a year but we are getting clarified.

The RA doctor said the methotrexate can take up to 12 weeks to kick in. When he initially was diagnosed almost 20 years ago it did help quite a bit but not like Enbrel did which virtually made him pain-free.

Managing RA without medication?

Has anyone had to stay off the meds that really helped for this long?

All I can find is 12 weeks recommended for antibiotics after this occurs but I know his RA and being immunocompromised might be the reason they are saying a year.

We are doing anything else we can think of for pain relief but nothing helps.

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Jo Johnson Moderator & Contributor
 @JillS Oh my goodness! I am so sorry your husband is going through this! I have a loved one who developed a septic knee 1 year post replacement. He does not have RA and was put on 6 weeks IV followed by 6 months of oral antibiotics. They will tap his knee then and determine the next course. A septic joint is a very serious thing! Hopefully the MTX will kick in. Keeping biologics off the table makes treatment difficult. While I can’t make specific recommendations, I think if I were in this situation, I’d seek out a referral to a major Rheumatology Center (Google best Rheumatology program) for help and start to explore Complementary Medicine. Things like PT, acupuncture, massage, CBT, biofeedback and OTC topicals to try to take the edge off. Large medical centers may have Pain Relief Clinical Programs to help. A loving spouse such as you is a blessing. With Hope and Best Wishes, Jo
JillS Member
<inline-mention username="Jo Johnson" user-id="3158858"/> Thank you for your reply! Do you know how your loved one got it? My husbands was doing so well. I will check into a pain center. I work in a hospital so I am limited to their system. He did think he felt a little better today and he did PT so that was good. 🤞🙏
Jo Johnson Moderator & Contributor
He has Diabetes which increases his risk. and had a crack in his skin that may have been the entry point. But we’ll never know.
Richard Faust Community Admin
Hi <inline-mention username="JillS" user-id="4585073"/>. So sorry your husband had this post-replacement infection. My wife, Kelly Mack (a contributor here), had an infection in an artificial knee that was 20 years old. Her case is different in that the artificial knee was removed and the infection treated with iv antibiotics and an antibiotic spacer in the knee joint for a couple of months before a new artificial knee was implanted (yes, a couple of months with no knee). One of the reasons for handling it this way was simply the age of the original replacement. As a result of the infection being treated before the new knee she was able to resume her treatments fairly quickly, although she had been off it the entire time of treatment. I did quite a bit of searching for research on resuming biologics after an artificial joint infection following surgery and only found one paper: <a href='https://tasmanmedicaljournal.com/2020/12/re-introduction-of-biological-dmards-for-rheumatoid-arthritis-during-active-antibiotic-therapy-for-prosthetic-joint-infections/' target='_blank' rel='noopener noreferrer ugc'>https://tasmanmedicaljournal.com/2020/12/re-introduction-of-biological-dmards-for-rheumatoid-arthritis-during-active-antibiotic-therapy-for-prosthetic-joint-infections/</a> (note: there absolutely could be more published research in databases I simply don't have access to). It looks at three specific cases, all of which had a reintroduction of biologics while the patient was still on antibiotics. Two patients remained infection free and one had a recurrence. Part of the conclusion is "Treatment considerations should include organism virulence, risk factors for infection, RA disease activity off bDMARDs and patient preference." Questions that come to my mind (and did with my wife) are why is a biologic prohibited if methotrexate is not and the reverse, why is methotrexate o.k. if a biologic is not (since methotrexate is a blanket immunosuppressant). Asking about the specific virulence of the infection may also be helpful, as well as any risk factors specific to your husband. Also, don't be afraid to ask for second opinions of either the rheumatologist or infectious disease doctor. I know this is a trying time and it is important to gather as much information as possible and make the best decisions for him. Please know that people here understand and feel free, if you like, to keep us posted. Best, Richard (RheumatoidArthritis.net Team)
1. JillS Member
 <inline-mention username="Richard Faust" user-id="3227544"/> thank you! I actually had sent him an email today to ask if infectious disease is ok with him starting a biologic while on the oral antibiotic would we be able to. I don’t understand either and I guess I was so shocked I didn’t push that answer at the appointment. I think everyone is being cautious and I get that but it seems like we have to weigh his misery right now too. Originally I think the thinking is methotrexate is just less risky. It was staph aureus and it did get into his bloodstream but he had a fast positive response with antibiotics. I will keep you posted!
L rick Phillips Moderator & Contributor
 For some doctors this is normal. After an extensive surgery I was directed to stay off of my biologic and MTX. It was tough. But I made it. What makes it better is moving as much as possible, and NSAID's. Did it work? No not really, but I kept going. I hope your husband can weather the storm. I wish him and you the very best. 
1. JillS Member
 <inline-mention username="L rick Phillips" user-id="3194573"/> how long did you have to go? He made it 3 months now and the last two have been brutal.
L rick Phillips Moderator & Contributor
The last time I did it was 7 months. And the first time was 5. Yes it is brutal and you feel like you are losing ground. But it’s a trade off beteeen the surgeon and rheumatologist. I was in north of their offices monthly saving look this is leading to no good outcome. It seemed to me that the surgeon was in control and to that end the infection was I control. I did not have a repeat surgery so I was thankful for that. New joints are so vulnerable to infection in the first 90 days post placement that I came to understand the need. However my rheumatologist felt it was an overrated risk. Rick 
1. JillS Member
 <inline-mention username="L rick Phillips" user-id="3194573"/> ours is the opposite. Infectious disease Dr is ok with a biologic while on oral antibiotics. The RA dr simply will not do anything but methotrexate which another RA dr started because he’s worried about the biologics suppressing his immune system more. We are currently at 3 months. Oral antibiotics possibly a year.
Lynn Marie Witt, MSOT Moderator & Contributor
<inline-mention username="JillS" user-id="4585073"/> I am sorry your husband is going through this. Have you thought about a second opinion with a different rheumatologist? Please keep us posted Wishing for answers, relief, restoration, and healing. I know this has to be an incredibly hard time for your husband, you, and your family. We care here at <a href='https://rheumatoidarthritis.net' target='_blank'>rheumatoidarthritis.net</a>. Please continue to reach out anytime. just Keep Swimming...Lynn Marie, "RheumatoidArthritis.net Team Member"
Daniel Malito Moderator & Contributor
They wanted me to stop my RA meds while I was going through chemo for cancer and I flat out said no. They started with the whole "well it's uncharted territory," "it's basically two biologics at once," etc. etc. I still said no. Finally they made me sign what amounted to a waiver that I understood that they had no idea what would happen. I said fine, where's the pen, and it turned out I went through chemo and kept my RA in check. Surprise, surprise. The moral of the story is sometimes you have to fight for what you need. Only you know your body best! Keep on keepin' on, DPM
JillS Member
Thank you. I told the RA dr today I’m an email I think we have to take the risk. He’s incapacitated. We will give the methotrexate a couple more weeks and if nothing we may have to find a new dr. He can’t live like this.
JillS Member
So to follow up-we are currently now 5 months after the infection occurred and 13 weeks on oral antibiotics, MTX and plaquenil. My husband’s labs were off the charts and his symptoms were horrendous. The RA dr. finally gave him a long taper of prednisone and he’s functioning on 7.5mg Second RA dr’s opinion concurred. Third opinion out of our network in a larger city said he needs a biologic and Orencia is probably the least likely to cause infection but there isn’t much data…so now we hope our local RA dr. will agree,,,,or we fight insurance. He is disabled without it. Anyone have any knowledge on the varying infection risks of the different biologics? 
1. Erin Rush Community Admin
 <inline-mention username="JillS" user-id="4585073"/>, whew! You guys have had such a long road to recovery! I am glad your husband is starting to see some improvements. I don't have any personal insight into the biologics question, so I do hope other community members see your update and chime in here. And, although I know it is infuriating and at times, soul crushing, please keep fighting the good fight with the insurance company! Your husband deserves the best treatment he can get and some bureaucratic red tape shouldn't stop him from having access to what he needs. Hang in there! I hope this is the light at the end of the tunnel for both you and your husband. Best, Erin, <a href='https://rheumatoidarthritis.net' target='_blank'>RheumatoidArthritis.net</a> Team Member. 
2. Richard Faust Community Admin
 Hi <inline-mention username="JillS" user-id="4585073"/>. So sorry your husband has been struggling all this time. I wish I could say there has been comprehensive comparisons of the different infection profiles of the various RA treatments, but didn't find any. I did find this one paper that looks at infection risk and does rate the biologics and other treatments on a scale: <a href='https://rmdopen.bmj.com/content/7/1/e001235' target='_blank' rel='noopener noreferrer ugc'>https://rmdopen.bmj.com/content/7/1/e001235</a>. Hope this can be of some use to you and your husband. Wishing both of you the best. Richard (RheumatoidArthritis.net Team)
JillS Member
Thank you. This is very helpful and what we assumed.