Diagnosis and Prevention of Periprosthetic Joint Infections

Publication Date: March 11, 2019
Last Updated: March 14, 2022

RECOMMENDATIONS

RISK FACTORS FOR PJI

A. Moderate strength evidence supports that obesity is associated with increased risk of PJI. (M)
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B. Limited strength evidence supports that patients in which one or more of the following criteria are present are at an increased risk of periprosthetic joint infection after hip and knee arthroplasty:
  • Cardiac disease (arrhythmia, CAD, congestive heart failure, other)
  • Immunocompromised status (other than HIV), including transplant, cancer
  • Peripheral vascular disease
  • Inflammatory arthritis
  • Prior joint infection
  • Renal disease
  • Liver disease (hepatitis, cirrhosis, other)
  • Mental health disorders (including depression)
  • Alcohol use
  • Anemia
  • Tobacco use
  • Malnutrition
  • Diabetes
  • Uncontrolled diabetes
(L)
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C. In the absence of reliable evidence, it is the opinion of this work group that in the case thatone or more of the following conditions are present, the practitioner should carefully consider the risk before proceeding with surgery:
  • Active infection (strongly caution against proceeding with surgery given the risks)
  • Anticoagulation status, active thromboprophylaxis (proceed only after careful consideration of the risks)
  • Autoimmune disease (proceed only after careful consideration of the risks)
  • HIV status (proceed only after careful consideration of the control and risks)
  • Institutionalized patients (proceed only after careful consideration of the risks)
  • Prior bariatric surgery (proceed only after careful consideration of the risks)
(C)
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D. In the absence of reliable evidence, it is the opinion of this work group that the following conditions have an unclear effect on risk of PJI:
  • Age (conflicting evidence)
  • Dementia (insufficient evidence due to imprecise confidence intervals)
  • Poor dental status (insufficient evidence for a recommendation)
  • Asymptomatic bacteriuria (conflicting evidence)
(C)
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INJECTIONS PRIOR TO ARTHROPLASTY

Limited evidence suggests intra-articular injection performed prior to total joint arthroplasty may have a time-dependent association for increased risk of PJI. (L)
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BLOOD TESTS FOR PREOPERATIVE DIAGNOSIS

A. Strong evidence supports the use of the following to aid in the preoperative diagnosis of prosthetic joint infection (PJI):
  • Serum erythrocyte sedimentation rate (ESR)
  • Serum C-reactive protein (CRP)
  • Serum interleukin-6
(S)
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B. Moderate strength evidence does not support the clinical utility of the following to aid in the diagnosis of PJI:
  • Peripheral blood leukocyte count
  • Serum tumor necrosis factor-α
(M)
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DIAGNOSIS OF INFECTED JOINT REPLACEMENTS

SYNOVIAL FLUID TESTS
A. Moderate strength evidence supports the use of the following to aid in the diagnosis of prosthetic joint infection (PJI):
  • Synovial fluid leukocyte count and neutrophil percentage
  • Synovial fluid aerobic and anaerobic bacterial cultures
  • Synovial fluid leukocyte esterase
  • Synovial fluid alpha-defensin (α-defensin)
  • Synovial fluid C-reactive protein (CRP)
  • Synovial fluid nucleic acid amplification testing [e.g., polymerase chain reaction (PCR)] for bacteria
(M)
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INTRAOPERATIVE TESTS
B. Strong evidence supports the use of histopathology to aid in the diagnosis of PJI. (S)
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C. Moderate strength evidence supports the use of the following to aid in the diagnosis of prosthetic joint infection (PJI):
  • Multiple aerobic and anaerobic bacterial periprosthetic tissue cultures
  • Implant sonication fluid aerobic and anaerobic bacterial cultures
  • Implant sonication fluid nucleic acid amplification testing (e.g., PCR) for bacteria
(M)
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D. Limited strength evidence supports that periprosthetic tissue nucleic acid amplification testing for bacteria is not useful in the diagnosis of PJI. (L)
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DIAGNOSTIC IMAGING

A. Limited strength evidence supports the use of the following to aid in the diagnosis of PJI:
  • 18F-FDG PET/CT
  • 18F-NaF PET/CT
  • CT
(L)
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B. Limited strength evidence supports the clinical utility of nuclear imaging to aid in thediagnosis of PJI. (L)
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C. In the absence of reliable evidence for gallium-67 imaging it is the opinion of this workgroup that this radiopharmaceutical does not have a role in the workup of PJI. (C)
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GRAM STAIN

Moderate strength evidence supports that the practitioner avoid the use of intraoperative gram stain to rule out periprosthetic joint infection. (M)
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AVOIDING ANTIMICROBIALS TWO WEEKS PRIOR TO OBTAINING INTRAARTICULAR CULTURE TO IDENTIFY A PATHOGEN FOR THE DIAGNOSIS OF PJI

Limited evidence supports withholding antimicrobials for a minimum of two weeks prior to obtaining intra-articular culture to establish the diagnosis of PJI. (L)
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AVOIDING INITIATING ANTIMICROBIALS PRIOR TO OBTAINING INTRAARTICULAR CULTURE IN PATIENTS SUSPECTED OF HAVING PJI

Moderate evidence supports avoiding administration of antimicrobials in patients suspected of having a periprosthetic joint infection until cultures have been obtained and a diagnosis has been established. (M)
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ANTIBIOTICS WITH LOW PREOPERATIVE SUSPICION OF PJI OR ESTABLISHED PJI WITH A KNOWN PATHOGEN

Strong evidence supports that preoperative prophylactic antibiotics be given prior to revision surgery in patients at low preoperative suspicion for periprosthetic infection and those with an established diagnosis of periprosthetic joint infection of known pathogen who are undergoing reoperation (S)
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PERIOPERATIVE ANTIBIOTIC SELECTION

A. Limited strength evidence supports the use of any of the following perioperative antibioticsin reducing risk of PJI, though no studies reviewed were powered to detect a significant difference among those listed:
  • 1st generation cephalosporin (e.g. cefazolin)
  • 2nd generation cephalosporin (e.g. cefuroxime)
  • Glycopeptide (e.g. vancomycin)
(L)
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B. In the absence of reliable evidence comparing other antibiotics and antibiotic combinations, including those listed in the guideline, it is the opinion of this work group that perioperative antibiotics should be selected based on principles of responsible stewardship, balancing the risk of PJI and antibiotic resistance. Selection should reflect the antibiogram of the individual institution, the individual risk factors of the patient, and multidisciplinary support of institutional infection control experts. There is no current reliable evidence to support one antibiotic versus the other (examples provided in the rationale). (C)
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ANTIBIOTIC CEMENT

A. Limited evidence suggests the routine use of antibiotics in the cement does not reduce the riskof periprosthetic joint infections for patients undergoing cemented TKA. (L)
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B. Limited evidence suggests the use of antibiotics in the cement may reduce the risk of periprosthetic joint infections for patients undergoing cemented THA. (L)
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PREOPERATIVE SCREENING AND DECOLONIZATION

A. Limited strength evidence supports the use of universal preoperative chlorhexidinecloth decolonization to reduce PJI after total hip arthroplasty (THA) and total knee arthroplasty (TKA). (L)
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B. In the absence of reliable evidence for screening and nasal decolonization, it is the opinion of this work group that preoperative nasal mupirocin decolonization is a low-risk, reasonable option prior to hip and knee arthroplasty in patients who are MRSA carriers. (C)
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INTRAOPERATIVE TECHNICAL FACTORS

In the absence of reliable evidence for the use of an antiseptic wash during total hip or knee arthroplasty, it is the opinion of this work group that dilute betadine lavage be used as a method to decrease infection risk in hip or knee arthroplasty. (C)
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Recommendation Grading

Overview

Title

Diagnosis and Prevention of Periprosthetic Joint Infections

Authoring Organization

American Academy of Orthopaedic Surgeons

Endorsing Organization

Infectious Diseases Society of America

Publication Month/Year

March 11, 2019

Last Updated Month/Year

January 29, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital, Operating and recovery room, Outpatient

Intended Users

Physical therapist, nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D001424 - Bacterial Infections, D019919 - Prosthesis Implantation

Keywords

infection, infection control, infected joint replacement, periprosthestic joint infection (PJI), infection risk factor

Methodology

Number of Source Documents
279
Literature Search Start Date
March 1, 2017
Literature Search End Date
June 1, 2018