Guideline sources The following summarized guidelines for the evaluation and management of prosthetic joint infection (PJI) 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). 1 2 3 4 5 6 7 7 8 9 10 Definition PJI is a clinical syndrome referring to an infection involving a joint prosthesis and adjacent tissue. 6 Epidemiology 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. 8 Pathophysiology https://web.pathway.md/diseases/recdywJHEAuDgN7GR 1/8 6/29/23, 11:32 PM Prosthetic joint infection Pathway The incidence of PJI in the United States is estimated at 150 cases per 100,000 person-years. 7 Disease course PJI causes clinical manifestations of joint pain, erythema, fever, wound drainage, sinus tract formation, and may be complicated by bacteremia. 7 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%). 9 10 Guidelines 1. Screening and diagnosis Indications for testing: 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 Timing of testing: in medically stable patients with PJI, withholding antimicrobial therapy for at least 2 weeks prior to collection of synovial fluid for culture increases the likelihood of recovering an organism. B Diagnostic criteria, definitive PJI: As per ESCMID/ESR/EBJIS/EANM 2019 guidelines, diagnose definitive PJI in patients with a sinus tract and purulent discharge. B As per IDSA 2013 guidelines: Diagnose definitive PJI in patients with a sinus tract communicating with a prosthesis. B Diagnose definitive PJI in patients with purulence surrounding a prosthesis without another known etiology. B Diagnostic criteria, highly probable PJI: As per ESCMID/ESR/EBJIS/EANM 2019 guidelines, suspect PJI in patients with 1 of the following symptoms and signs: otherwise unexplained pain and/or fever, redness, swelling, scar inflammation, and movement limitations. Recognize that these symptoms are (especially in the chronic phase) not specific and require other investigations. B As per IDSA 2013 guidelines, diagnose definitive PJI in patients in whom two or more intraoperative cultures, or combination of preoperative aspiration and intraoperative cultures, yield the same organism. B Show 3 more 2. Classification and risk stratification https://web.pathway.md/diseases/recdywJHEAuDgN7GR 2/8 6/29/23, 11:32 PM Prosthetic joint infection Pathway Risk factors: recognize that obesity is associated with an increased risk of PJIs. B Show 4 more 3. 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-alpha to aid in the diagnosis of PJI. D As per ESCMID 2019 guidelines: Obtain CRP and ESR in patients with suspected PJI, recognizing that a normal value does not rule out PJI. B Obtain blood cultures in patients with fever suspected of having PJI to identify the causative bacteria. B Postpone or discontinue antibiotic therapy before pre- and intraoperative sampling. B As per IDSA 2013 guidelines: Obtain CRP or ESR in all patients with a suspected PJI in whom the diagnosis is not clinically evident. The combination of an abnormal sedimentation rate and CRP seems to provide the best combination of sensitivity and specificity. B Obtain blood cultures for aerobic and anaerobic organisms in patients meeting any of the following criteria: acute onset of symptoms presence of fever presence of an underlying condition or pathogen (such as S. aureus) that would increase the chances of a bloodstream infection. B Diagnostic imaging: As per AAOS 2020 guidelines, consider obtaining the following imaging investigations to aid in the diagnosis of PJI: 18F-FDG positron emission tomography/CT 18F-NaF positron emission tomography/CT CT. C Show 2 more As per ESCMID 2019 guidelines, obtain conventional radiography as the first imaging modality for diagnosis and follow-up in patients with suspected PJI. B Show 13 more As per IDSA 2013 guidelines: Obtain a plain radiograph in all patients with suspected PJI. B Avoid the routine use of bone scans, leukocyte scans, MRI, CT, or positron emission tomography scans to diagnose PJI. D https://web.pathway.md/diseases/recdywJHEAuDgN7GR 3/8 6/29/23, 11:32 PM Prosthetic joint infection Pathway 4. 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 alpha-defensin CRP NAAT (such as PCR) for bacteria. B Show 5 more As per ESCMID 2019 guidelines, consider using image guidance for joint aspiration. C Show 3 more As per IDSA 2013 guidelines: Perform a diagnostic arthrocentesis in all patients with suspected acute PJI, unless the diagnosis is evident clinically, surgery is already planned, and antimicrobials can be safely withheld prior to surgery. B Obtain the following analyses on synovial fluid: a total cell count, differential leukocyte count, culture for aerobic and anaerobic organisms, and microscopy for crystals if clinically indicated. B Histopathology: As per AAOS 2020 guidelines, perform histopathological analysis to aid in the diagnosis of PJI. A As per ESCMID 2019 guidelines: Consider using image guidance for periprosthetic tissue biopsy. C Consider performing biopsy of periprosthetic tissue for histology and cultures for preoperative diagnosis, if ESR and/or CRP are positive and aspiration is inconclusive or impossible to test (dry tap). C As per IDSA 2013 guidelines, obtain intraoperative histopathological examination of periprosthetic tissue samples at the time of revision prosthetic joint surgery if the presence of infection is in doubt based on the clinical suspicion of the surgeon, and the results will affect management, such as in deciding between revision arthroplasty and a two-stage exchange procedure. B 5. Medical management Antibiotic therapy following debridement (staphylococcal PJI): 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: https://web.pathway.md/diseases/recdywJHEAuDgN7GR 4/8 6/29/23, 11:32 PM Prosthetic joint infection Pathway 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 Antibiotic therapy following debridement (PJI due to other organisms): Complete 4-6 weeks of pathogen-specific intravenous or highly bioavailable oral antimicrobial therapy following debridement. B Consider indefinite chronic oral antimicrobial suppression after the initial treatment regimen, based on in vitro sensitivities, allergies, and intolerances. C Antibiotic therapy following exchange arthroplasty (PJI due to other organisms): Administer 4 to 6 weeks of pathogen-specific intravenous or highly bioavailable oral antimicrobial therapy. B Initiate indefinite chronic oral antimicrobial suppression according to the regimens listed in the full guideline and based on in vitro sensitivities, allergies, and intolerances. B Antibiotic therapy following exchange arthroplasty (staphylococcal PJI): administer 2 to 6 weeks of pathogen-specific intravenous antimicrobial therapy in combination with rifampin PO BID followed by rifampin plus a companion oral drug for a total of 3 months. B Show 4 more Antibiotic therapy following resection arthroplasty: complete 4-6 weeks of pathogen- specific intravenous or highly bioavailable oral antimicrobial therapy following resection arthroplasty. B Antibiotic therapy following amputation: Continue pathogen-specific antimicrobial therapy until 24-48 hours after amputation, assuming all infected bone and soft tissue has been surgically removed and there is no concomitant sepsis syndrome or bacteremia. B Complete 4-6 weeks of pathogen-specific intravenous or highly bioavailable oral antimicrobial therapy in patients with residual infected bone and soft tissue (e.g. hip disarticulation for THA infection, long-stem TKA prosthesis where the prosthesis extended above the level of amputation). B Antibiotic therapy for MRSA PJI: initiate parenteral therapy with IV vancomycin or IV daptomycin 6 mg/kg/dose once daily plus rifampin 600 mg daily or 300-450 mg PO BID for 2 weeks followed by rifampin plus a fluoroquinolone, TMP-SMX, a tetracycline or clindamycin for 3 or 6 months for hips and knees, respectively, in patients with early-onset (< 2 months after surgery) or acute hematogenous PJIs involving a stable implant with short duration (< 3 weeks) of symptoms and debridement (but device retention). B Show 4 more 6. Surgical interventions Exchange strategy: https://web.pathway.md/diseases/recdywJHEAuDgN7GR 5/8 6/29/23, 11:32 PM Prosthetic joint infection Pathway 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 Debridement and retention: consider a debridement and retention of prosthesis strategy in patients with PJI who have a well-fixed prosthesis without a sinus tract who are within approximately 30 days of prosthesis implantation or < 3 weeks of onset of infectious symptoms. C Show 2 more Resection arthroplasty: Consider permanent resection arthroplasty in the following situations: patients who are non-ambulatory patients with limited bone stock patients with poor soft tissue coverage patients with infections due to highly resistant organisms for which there is limited medical therapy patients with a medical condition prohibiting multiple major surgeries patients with a previous unsuccessful two-stage exchange procedure. C Amputation: consider performing amputation only as a last resort in patients with PJI refractory to other measures. Refer to a center with specialist experience in the management of PJI before carrying out amputation, except in emergent cases. C 7. Preventative measures Preoperative decolonization: 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 Antibiotic-loaded cement: Consider using antibiotics in the cement to reduce the risk of PJIs in patients undergoing cemented total hip arthroplasty. C Avoid using antibiotics routinely in the cement to reduce the risk of PJIs in patients undergoing cemented total knee arthroplasty. D Povidone-iodine lavage: consider performing dilute betadine lavage to decrease infection risk in patients undergoing hip or knee arthroplasty. E Prophylactic antibiotics before dental procedures: avoid administering prophylactic antibiotics to prevent PJI in patients undergoing dental procedures. D Prophylactic antibiotics before revision surgery: administer preoperative antibiotic prophylaxis before revision surgery in patients at low preoperative suspicion for prosthetic https://web.pathway.md/diseases/recdywJHEAuDgN7GR 6/8 6/29/23, 11:32 PM Prosthetic joint infection Pathway infection and in patients with an established diagnosis of PJI of known pathogen undergoing reoperation. A Show 2 more 8. Follow-up and surveillance Monitoring of outpatient antibiotics: monitor patients undergoing outpatient intravenous antimicrobial therapy as per published evidence-based guidelines. B Clinical findings Symptoms Past medical history Chills Diabetes mellitus Fatigue Integument exam Night sweats Pain Drainage from the incision site Swelling Hematological findings Social history WBC count Current cigarette smoking Lab findings CRP ESR Studies 2020 Rifampin in staphylococcal PJIs In patients with prosthetic joint infection after hip and knee arthroplasties, rifampin combination therapy was not superior to monotherapy with respect to the rate of no signs of infection after 2 years of follow-up. ystein Espeland Karlsen et al. J Orthop Surg Res. 2020 Aug 28. References 1. Creighton C Tubb, Gregory G Polkowksi, Barbara Krause. Diagnosis and Prevention of Periprosthetic Joint Infections. J Am Acad Orthop Surg. 2020 Apr 15;28 8):e340-e348. Open 2. Osmon DR, Berbari EF, Berendt AR et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013 Jan;56 1):e1-e25. Open 3. Catherine Liu, Arnold Bayer, Sara E Cosgrove et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus aureus https://web.pathway.md/diseases/recdywJHEAuDgN7GR 7/8 6/29/23, 11:32 PM Prosthetic joint infection Pathway Infections in Adults and Children. Clin Infect Dis. 2011 Feb 1;52 3):e18 55. Open 4. Sollecito TP, Abt E, Lockhart PB et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2015 Jan;146 1 11 16.e8. Open 5. Alberto Signore, Luca Maria Sconfienza, Olivier Borens et al. Consensus document for the diagnosis of prosthetic joint infections: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement). Eur J Nucl Med Mol Imaging. 2019 Apr;46 4 971 988. Open 6. Aggarwal VK, Rasouli MR, Parvizi J. Periprosthetic joint infection: Current concept. Indian J Orthop. 2013 Jan;47 1 10 7. Open 7. Beam E, Osmon D. Prosthetic Joint Infection Update. Infect Dis Clin North Am. 2018 Dec;32 4 843 859. Open 8. Li C, Renz N, Trampuz A. Management of Periprosthetic Joint Infection. Hip Pelvis. 2018 Sep;30 3 138 146. Open 9. Gundtoft PH, Pedersen AB, Varnum C et al. Increased Mortality After Prosthetic Joint Infection in Primary THA. Clin Orthop Relat Res. 2017 Nov;475 11 2623 2631. Open 10. Lum ZC, Natsuhara KM, Shelton TJ et al. Mortality During Total Knee Periprosthetic Joint Infection. J Arthroplasty. 2018 Dec;33 12 3783 3788. Open 11. ystein Espeland Karlsen, P l Borgen, Bj rn Bragnes et al. Rifampin combination therapy in staphylococcal prosthetic joint infections: a randomized controlled trial. J Orthop Surg Res. 2020 Aug 28;15 1 365. Open https://web.pathway.md/diseases/recdywJHEAuDgN7GR 8/8