Management and Prevention of Prosthetic Joint Infection

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Pathogenesis and risk factors

PJIs are generally classified according to the timing after surgery: early-onset infection occurs within 3 months after arthroplasty, delayed-onset infection within 3 to 24 months, and late-onset infection after 24 months3; the distribution of patients presenting within each category is approximately equal. As with other surgical site infections (SSIs), PJIs occur most commonly because of contamination of the surgical wound with locally introduced microorganisms.4 Therefore, anything that

Microbiology

Almost any microorganism can be associated with PJI, but staphylococci (coagulase-negative staphylococci and S aureus) are the principal causative agents, accounting for more than half of all PJIs.3, 9 Other gram-positive and gram-negative bacilli each represent about 20% to 25% of infections, and anaerobes, including Propionibacterium acnes, account for another 10%. Polymicrobial infection is reported in 10% to 20% of PJIs. In a retrospective series of polymicrobial PJIs, the most frequently

Clinical presentation and diagnosis

Clinical manifestations of PJI are determined by several factors, including host characteristics, the route of infection, and associated microorganisms. The presentation can vary, ranging from a chronic indolent course characterized only by progressive joint pain to a fulminant septic arthritis; however, diagnosis is not always clear-cut because there are many noninfectious causes of prosthesis failure.

Patients with early-onset infection are more likely to have classic signs of inflammation and

Treatment

The ultimate goal of PJI treatment is to achieve a functional and pain-free joint; the approach requires a combination of medical and surgical therapies. Although treatment with antimicrobials alone is generally inadequate, patient preferences and the potential morbidity of further surgical intervention must be carefully considered. Although the most predictably effective approach involves removal of all foreign materials, patients who are unable or unwilling to undergo additional surgery can

Prevention

The general principles of SSI prevention apply to decreasing the risk of PJI.46 Procedure-related prevention focuses on reducing microbial inoculum and preventing contamination of the surgical site. Specific strategies include preparation of the surgical site with an appropriate antiseptic agent, hand scrubbing and use of appropriate attire by surgical staff, sterilization and disinfection of equipment, minimizing traffic in the operating room, and use of appropriate ventilation systems.49

Summary

PJI can result in significant morbidity, especially in older adults with underlying functional impairment. Diagnosis of PJI is challenging and often cannot be firmly established until the prosthesis is removed. Management of PJI often requires removal of the prosthesis combined with an extended duration of antimicrobial treatment. Prevention of PJI requires a multifaceted approach, including perioperative antimicrobial prophylaxis. Related prevention measures that remain controversial include

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      Citation Excerpt :

      Identification of the infecting organism responsible for PJI and appropriately tailored antibiotic therapy against a specific organism are essential for successful treatment of PJI. Although microbiologic culture is the standard technique for identification of the infecting organism, negative culture results have been reported with a frequency that ranges from 7% to 23% [20,25–29]. In addition, staphylococcal species are the most common causative organisms for PJI in Western countries [30–32].

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    The authors have nothing to disclose. There was no outside support for this work.

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