Do Culture-Negative Periprosthetic Joint Infections Have a Worse Outcome Than Culture-Positive Periprosthetic Joint Infections? A Systematic Review and Meta-Analysis

Abstract

Background Culture-negative periprosthetic joint infections (CN PJI) have not been well studied, and due to the lack of consensus on PJI, especially with culture-negative infections, there are considerable uncertainties. Due to the challenging clinical issue of CN PJI the aim of this systematic review is to describe incidence, diagnosis, and treatment outcomes based on the current literature on CN PJI. Hypothesis The review is designed to assess the formal hypothesis that CN PJI of the hip and knee have a poorer outcome when compared with culture-positive ones. Study DesignIt is systematic review with level of evidence 3. MethodsEMBASE, MEDLINE, and the Cochrane Library were searched electronically in January 2018. All studies regarding CN PJI of the hip or knee published in English or German with a minimum of 10 patients were included. Afterwards, the authors performed a descriptive analysis of diagnosis and treatment outcome. ResultEight studies were identified that met the inclusion criteria. The incidence of CN PJI in the hip or knee ranged from 7% to 42 %. The included studies were pooled to give an overall incidence rate estimate of 11 % [95% confidence interval (CI): 10-12] based on a random-effects model. The most common surgical intervention was the two-stage revision of prosthesis with 283 patients. Postoperatively, the majority of patients received vancomycin as the antibiotic treatment, alone or in combination with other antibiotics. The rate of succesfully treated infections varied from 85% to 95 % in all included studies. The two-stage exchange arthroplasty had the best outcome, based on the infection-free survival rate of 95%, five years after treatment. Conclusions We conclude that CN PJI have the same or even better results than culture-positive infections. Nonetheless, a standardized diagnostic protocol and evidence-based treatment strategies for CN PJI should be implemented for further studies.

Poor performance of open incisional biopsy for the microbiological diagnosis of periprosthetic knee joint infection

“…An undetected low grade infection prior to a partial or complete exchange of the prosthesis may result in repeated revisions, prolonged hospitalization and increased morbidity and mortality 23 , 24 . While Microbiological cultures are a useful tool in the detection of a PJI and offer the opportunity to establish a tailored antibiotic treatment, reported incidences of culture negative PJI from 7 to 42% show the urgent need for further improvement of isolation and identification of the respective organism 25 .…”

Rare Occurrence of Acute Hematogenous Periprosthetic Joint Infection Due to Fusobacterium Nucleatum in the Background of a Dental Procedure: A Case Report

“…The early diagnosis of PJI and identification of pathogenic microorganisms are still the key to successful treatment; however, due to the limitations of culture technology, the culture time, the previous use of antibiotics, and other factors, the positive rate of bacterial culture is not satisfactory, the pathogenic microorganisms was unclear at the time of the second‐stage surgery in some patients, resulting in treatment failure 10 . In fact, etiological evidence cannot be found in approximately 7.0%–42.1% of patients with PJI during the entire treatment process 11 . In recent years, microbial molecular diagnostic techniques such as polymerase chain reaction (PCR), fluorescent in situ hybridization (FISH), and metagenomic next‐generation sequencing (mNGS) have been increasingly used in the diagnosis of PJI 12–13 .…”

Clinical and Histological Features of Prosthetic Joint Infections May Differ In Patients With Inflammatory Arthritis and Osteoarthritis

“…Culture negative (CN) patients were de ned as any patient with negative culture growth either intra-op and/or negative pre-operative aspirate culture growth. 9,10 For those who had culture mismatch (aspiration and intraoperative nding did not agree), infection disease specialist con rmed infection status. Culture positive (CP) patients had at least one intraoperative or preoperative aspirate culture growing any microorganism.…”

“…7 The increased risk of PJI in IA patients may be related pharmacologic immunosuppression, immune dysregulation, and/or high disease activity. [8][9][10] However, the diagnosis of PJI in patients with IA is challenging because aseptic RA or SLE ares may mimic PJI both clinically (joint pain, swelling, fever) and diagnostically (elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and synovial leukocytosis). 11 In addition, the currently available diagnostic criteria for diagnosing PJI does not provide guidance on how to differentiate PJI from RA ares and few studies have comprehensively characterized PJI in patients with RA and SLE.…”