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Prosthetic joint infection

Background

Overview

Definition
PJI is a clinical syndrome referring to an infection involving a joint prosthesis and adjacent tissue.
1
Pathophysiology
The most common infecting pathogens are bacteria, with coagulase-negative staphylococci and S. aureus accounting for the majority of infections. Pathogens that are less frequent include gram-negative bacilli, polymicrobial infection, and anaerobic infection.
2
Epidemiology
The incidence of PJI in the US is estimated at 150 cases per 100,000 person-years.
3
Disease course
PJI causes clinical manifestations of joint pain, erythema, fever, wound drainage, sinus tract formation, and may be complicated by bacteremia.
3
Prognosis and risk of recurrence
The 1-year mortality in patients with infection of a total hip arthroplasty is estimated at 8% (95% CI, 6-11%). The 1-year mortality rate in patients with infection of a total knee arthroplasty is estimated at 4.33% (95% CI, 3.14-5.51%).
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of prosthetic joint infection are prepared by our editorial team based on guidelines from the American Academy of Orthopaedic Surgeons (AAOS 2020), the European Association of Nuclear Medicine (EANM/ESR/ESCMID/EBJIS 2019), the American Dental Association (ADA 2015), and the Infectious Diseases Society of America (IDSA 2013,2011). ...
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Screening and diagnosis

Indications for testing: as per IDSA 2013 guidelines, suspect PJI in patients with any of the following:
sinus tract or persistent wound drainage over a joint prosthesis
acute onset of a painful prosthesis
any chronic painful prosthesis at any time after prosthesis implantation.
B
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  • Timing of testing

  • Diagnostic criteria (definitive PJI)

  • Diagnostic criteria (highly probable PJI)

Classification and risk stratification

Risk factors: as per AAOS 2020 guidelines, recognize that obesity is associated with an increased risk of PJIs.
B
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Diagnostic investigations

Laboratory tests
As per AAOS 2020 guidelines:
Obtain ESR, CRP and IL-6 to aid in the preoperative diagnosis of PJI.
A
Do not obtain peripheral blood leukocyte count and serum TNF-α to aid in the diagnosis of PJI.
D

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  • Diagnostic imaging

Diagnostic procedures

Synovial fluid analysis: as per AAOS 2020 guidelines, obtain the following synovial fluid tests to aid in the diagnosis of PJI:
leukocyte count and neutrophil percentage
aerobic and anaerobic bacterial cultures
leukocyte esterase
α-defensin
CRP
NAAT (such as PCR) for bacteria.
B
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  • Histopathology

Medical management

Antibiotic therapy following debridement, staphylococcal PJI
As per IDSA 2013 guidelines:
Complete 2-6 weeks of pathogen-specific intravenous antimicrobial therapy in combination with rifampin (300-450 mg PO BID) for patients with staphylococcal prosthetic-joint infection undergoing debridement, followed by:
rifampin plus a companion oral drug for a total of 3 months for a total hip arthroplasty infection
rifampin plus a companion oral drug for a total of 6 months for a total knee arthroplasty infection
A
Consider managing patients with total elbow, total shoulder, and total ankle arthroplasty infections using the same protocols as for patients with total hip arthroplasty infections.
C

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  • Antibiotic therapy following debridement (PJI due to other organisms)

  • Antibiotic therapy following exchange arthroplasty (PJI due to other organisms)

  • Antibiotic therapy following exchange arthroplasty (staphylococcal PJI)

  • Antibiotic therapy following resection arthroplasty

  • Antibiotic therapy following amputation

  • Antibiotic therapy for MRSA PJI

Surgical interventions

Exchange strategy
As per IDSA 2013 guidelines:
Use a two-stage exchange strategy in patients who are not candidates for a one-stage exchange, are medically able to undergo multiple surgeries, and are good candidates for reimplantation arthroplasty, based on the existing soft tissue and bone defects.
B
Consider a one-stage or direct exchange strategy in patients with a total hip arthroplasty infection who have a good soft tissue envelope, provided that the identity of the pathogens is known preoperatively and they are susceptible to oral antimicrobials with excellent oral bioavailability.
C

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  • Debridement and retention

  • Resection arthroplasty

  • Amputation

Preventative measures

Preoperative decolonization
As per AAOS 2020 guidelines:
Consider administering universal preoperative chlorhexidine cloth decolonization to reduce PJIs after total hip arthroplasty and total knee arthroplasty.
C
Consider administering preoperative nasal mupirocin decolonization as a low-risk, reasonable option before hip and knee arthroplasty in MRSA carriers.
E

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  • Antibiotic-loaded cement

  • Povidone-iodine lavage

  • Prophylactic antibiotics before dental procedures

  • Prophylactic antibiotics before revision surgery

Follow-up and surveillance

Monitoring of outpatient antibiotics: as per IDSA 2013 guidelines, monitor patients undergoing outpatient intravenous antimicrobial therapy as per published evidence-based guidelines.
B