Management of Resistant, Atypical and Culture-negative Periprosthetic Joint Infections after Hip and Knee Arthroplasty

Abstract

Background:Periprosthetic joint infection (PJI) is a devastating complication following lower extremity total joint arthroplasty (TJA). It is a leading cause of morbidity and revision following TJA. As such, PJI is a significant driver of healthcare costs. The prevalence of PJI related to resistant and atypical organisms is increasing, and approximately 10-30% of PJIs are culture-negative. The purpose of this review is to summarize the current epidemiology, diagnostics, and management of PJI associated with resistant and atypical pathogens and of culture-negative PJIs.Methods:The published literature related to the epidemiology, diagnosis, and management of atypical, drug-resistant, and culture-negative PJI is reviewed.Results:The clinical diagnosis of PJI is often challenging, particularly when pathogens are fastidious or when antibiotics have been administered empirically. Molecular diagnostic studies, such as synovial α-defensin, may provide rapid, accurate identification of PJI, even in the setting of concurrent antibiotics administration or systemic inflammatory disease. Once PJI is diagnosed, two-stage exchange arthroplasty remains the gold standard for treating PJI with resistant microorganisms, since there is a high rate of treatment failure with irrigation and debridement and with one-stage exchange arthroplasty.Conclusion:Additional research is needed to define the optimal treatment of PJIs associated with rare pathogens, such as fungi and mycobacteria. There is a need for inexpensive, reliable tests that rapidly detect specific microbial species and antimicrobial susceptibilities. Additional research is also required to define the specific organisms, clinical scenarios, surgical techniques, and antimicrobial regimens that allow for reproducible treatment success with prosthetic retention strategies.

Periprosthetic joint infections after total hip replacement: an algorithmic approach

“…Principles for treating such difficult cases remain the same but with special considerations for each case. For example, in culture negative and resistant organisms, diagnosis can be challenging, but once established using all the diagnostic tools available and applying the International Consensus Meeting (ICM) on management of PJIs diagnostic criteria [12], treatment strategies should follow a two-stage reimplantation procedure as debridement and exchange of mobile parts and single-stage revisions are associated with higher failure rates [18,[46][47][48][49]. Patients who fail treatment may require salvage procedures such as long-term antibiotics, resection arthroplasty, fusion and amputation [50].…”

Evaluation of the standard procedure for the treatment of periprosthetic joint infections (PJI) in Germany - results of a survey within the EndoCert initiative

“…The two-stage exchange is implemented in 100% of the EPZ in Germany. This procedure can be applied to a wider range of patients and leads more reliably to successful treatment of the infection, especially in cases with difficult-to-treat bacteria [ 20 , 40 ]. Shorter OR time, the possibility of fractional expansion, management of the infection situation, the systematic administration of appropriate antibiotics both intravenously and locally with antibiotic-reinforced spacers, and an interval to reduce the risk of infection persistence prior to reinstallation result in an increased use in the EPZ.…”

Evaluation of The Standard Procedure for the Treatment of Periprosthetic Joint Infections (PJI) in Germany - Results of a Survey within the EndoCert Initiative

“…The two-stage exchange is implemented in 100% of the EPZ in Germany. This procedure can be applied to a wider range of patients and leads more reliably to successful treatment of the infection, especially in cases with di cult-to-treat bacteria (39,40). Shorter OR time, the possibility of fractional expansion, management of the infection situation, the systematic administration of appropriate antibiotics both intravenously and locally with antibiotic-reinforced spacers, and an interval to reduce the risk of infection persistence prior to reinstallation result in an increased use in the EPZ.…”