What is the course of action in an arthroplasty which is infected clinically but is culture negative? I find this a difficult situation in many orthopaedic infections not only arthroplasty where the clinical features from a weeping wound to local signs cry infection and even the deeper swabs grow nothing. How does one tailor the antibiotics in such situations?
Dear Murali
It is a difficult decision
In patients with a infected joint, either discovered at routine revision, diagnosed by the presence of a sinus or microbiological tests or clinically , my preferred option is to remove the joint implants and do a thorough debridement without immediate re-implantation. In some centres, one-stage revision is performed even in the presence of infection. Again, multiple samples should be taken.
Dear Nelson
How do you decide your antibiotic policy if it is negative swab
Dear Murali
It is necessary a multidisciplinary team composed of orthopaedic surgeon, microbiologists, infectious disease physicians,
Staphylococci are the most frequently isolated organism at all timepoints: early, delayed and late. The antibiotic choice is empirical and will be based on the characteristics of each patient (history of prior infection, previous antibiotic use)
Dear,
If you have a suspicious PJI, but you were not able to diagnose it preoperatively the only way to treat it is a two stage approach. During surgery it is important to take fluid samples for citology, gram staining and microbiology as well as 6 tissue biopsies and sonication of the implant (if available). It is important to use a PCR technology to improve the diagnostic gain. Empirical antibiotics are necessary after the surgery: the best combination in a hospital with a low MR organisms is amox-clav acid 1.2g/8h + gentamicin 240 mg /24h. Samples shoud be processed in solid and liquid media and subcultured and cultivated for 3 weeks.
In case the diagnostic evaluation is succesfull and it is not a difficult to treat germ it is possible to reimplant the prostheses after 2-3-weeks otherwise the reimplantation should be delayed for 4-6 weeks. In invironments with high incidence of MR organisms vanco or dapto based antibiotic protocols are to be considered.
Clinically manifested implant infection is a surgical disease and should be treated surgically. There are similar patients with multiple negative cultures that are difficult to treat because the antibiosis is rather empiric and yields poor results. Anyway, debridement is indicated. If it is an osteosynthesis for fracture and the general condition of the patient allows, then the osteosynthetic material should be left in situ untill healing under the conditions of infection is achieved. If it is joint replacement - two staged surgery is adviced - removal + debidement + lavage+drainage+spacer as a first stage procedure, and reimplantation as a second stage procedure.
Thank you DrTrebse and Dr Tanchev for the wonderful responses. If I may continue the topic, what is the best time after the first stage, which is the spacer, to attempt a reimplantation and what should be your criteria to decide a second stage implantation is now safe. I would follow a first stage implantation, 6 weeks of IV antibiotics tailored to sensitivity or till CRP negative , then a 6 weeks to three months antibiotic free interval. Clinically, resolution of pain, inflammation, sinuses and local features should help decide.
Dr. Poduval, I agree entirely with your protocol. I would only add that the exact schedule may change from case to case dependent on the clinical signs and lab tests.
Dear,
If it is an easy to treat organism, that reacts to antibiofilm antibiotcs (rifampicin for staphylococcy and quinolones for gramnegatives) You can re-implant the prosthesis as soon as the skin has healed after 2-3 weeks, otherwise in the case of difficult to treat organisms (MRSA/E, VRE, ESBL variants, small colony variants, fungi etc) 6-12 weeks of antibiotics is necessary but not all iv, normally only up to 2 weeks. For details you can consult my Springer book : Infected total joint arthroplasty. The algorithmic approach.
Regards,
Rihard
Negative culture results weren’t really terrible
One-stage revision arthroplasty demonstrated similar outcomes including reinfection, re-revision, and readmission rates for the treatment of chronic culture-negative PJI after TKA and THA compared to two-stage revision （van den Kieboom J, . One-stage revision is as effective as two-stage revision for chronic culture-negative periprosthetic joint infection after total hip and knee arthroplasty. Bone Joint J. 2021 Mar;103-B(3):515-521. ）
If you have a patient with pain, inflammation, immobility and sinus, this it is an infection, and needs to be opened. If very early you might get away with DAIR (Debridement, Antibiotics and Implant Retention) but anyway you need to debride until the tissue looks healthy and bleeds. Samples of tissue (not swabs as in your query!) should be taken from areas appearing infected and some sent for histology, and some processed and cultured with prolonged culture. IMPORTANTLY, if you remove implant material (and even with DAIR you will probably remove the acetabular liner) then you should sonicate this and culture the sonicate as for tissue. Gram film of sonicate is not very sensitive but if positive can be helpful. Sonicate cultures are sometimes positive when tissue cultures are negative.
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