Characteristics and outcomes of culture-negative prosthetic joint infections from the Prosthetic Joint Infection in Australia and New Zealand Observational (PIANO) cohort study

Abstract

Abstract. Introduction: Culture-negative (CN) prosthetic joint infections (PJIs) account for approximately 10 % of all PJIs and present significant challenges for clinicians. We aimed to explore the significance of CN PJIs within a large prospective cohort study, comparing their characteristics and outcomes with culture-positive (CP) cases. Methods: The Prosthetic joint Infection in Australia and New Zealand Observational (PIANO) study is a prospective, multicentre observational cohort study that was conducted at 27 hospitals between 2014 and 2017. We compared baseline characteristics and outcomes of all patients with CN PJI from the PIANO cohort with those of CP cases. We report on PJI diagnostic criteria in the CN cohort and apply internationally recognized PJI diagnostic guidelines to determine optimal CN PJI detection methods. Results: Of the 650 patients with 24-month outcome data available, 55 (8.5 %) were CN and 595 were CP. Compared with the CP cohort, CN patients were more likely to be female (32 (58.2 %) vs. 245 (41.2 %); p = 0.016), involve the shoulder joint (5 (9.1 %) vs. 16 (2.7 %); p = 0.026), and have a lower mean C-reactive protein (142 mg L−1 vs. 187 mg L−1; p = 0.016). Overall, outcomes were superior in CN patients, with culture negativity an independent predictor of treatment success at 24 months (adjusted odds ratio, aOR, of 3.78 and 95 %CI of 1.65–8.67). Suboptimal diagnostic sampling was common in both cohorts, with CN PJI case detection enhanced using the Infectious Diseases Society of America PJI diagnostic guidelines. Conclusions: Current PJI diagnostic guidelines vary substantially in their ability to detect CN PJI, with comprehensive diagnostic sampling necessary to achieve diagnostic certainty. Definitive surgical management strategies should be determined by careful assessment of infection type, rather than by culture status alone.

Prosthetic joint infection diagnosis in an age of changing clinical patterns of infection and new technologies

“…Of the criteria, those of the European Bone and Joint Infection Society 11 and the International Consensus Meeting 12 are the most up to date, widely used, and accurate. 13 These criteria are primarily intended for research and should be used to supplement rather than replace clinical judgement. In both diagnosis and management of PJI, it is important to have input from a multidisciplinary team, including orthopaedic surgeons, infectious diseases physicians, and clinical microbiologists.…”

“…Traditionally, these require a clinically suspected infection plus a combination of clinical, imaging and laboratory findings. Of the criteria, those of the European Bone and Joint Infection Society 11 and the International Consensus Meeting 12 are the most up to date, widely used, and accurate 13 . These criteria are primarily intended for research and should be used to supplement rather than replace clinical judgement.…”

“…Culture‐negative PJI occurs when diagnostic criteria are met but no organism is cultured (Box 1). This occurs in 5–10% of all PJIs 13 and may be explained by organisms not growing due to recent antibiotic use or fastidious growth requirements. It is therefore important to delay empirical antibiotic therapy until after diagnostic sampling unless the patient has sepsis.…”

Microbial Persistence, Replacement and Local Antimicrobial Therapy in Recurrent Bone and Joint Infection

“…Among 292 patients undergoing revision for chronic knee PJI, of whom 30 had septic failure, no organisms were significantly associated with septic failure [ 9 ]. Conversely a case series of treated extremity osteomyelitis reported that Pseudomonas infection was associated with higher rates of recurrence [ 10 ], and culture negative PJI was associated with better outcomes at two years in a large cohort study [ 11 ]. How microbiology from index surgery relates to subsequent surgeries has not been presented for large cohorts.…”

Staphylococcus aureusPersistence in Osteocytes: Weathering the Storm of Antibiotics and Autophagy/Xenophagy

“…It is worth noting that all currently utilised interventions critically rely on antibiotics for the clearance of intracellular infection, while biofilms upon the abiotic implant surface are removed during staged revision surgery. Regardless of therapeutic strategy, infection relapse remains as high as 8.8-31% within two years after treatment (11–13). The more conservative surgical approach of debridement, antibiotics and implant retention (DAIR) with or without long-term (>1 year) suppressive antibiotic treatment, demonstrated similar to worse outcomes, with reported rates of failure to clear infection of 25% and 35.3% of patients (14, 15).…”