In most cases, these patients had received antibiotics before taking the samples for bacterial culture from the joint. The development of a PJI during bacteremia varied between different pathogens Table 1. It was most common for Staphylococcus aureus , beta-hemolytic streptococci, and viridans group streptococci, but rare for gram-negative bacteria and coagulase-negative staphylococci; 1. There were 11 PJIs as a consequence of bacteremia that occurred within 3 months of the previous surgery. Having more than 1 bacteremia during the study period increased the risk for developing a PJI Table 2.
Also, the risk for developing a PJI was higher for bacteremias occurring less than a year after the previous surgery than for bacteremias occurring later. Older age was associated with a lower risk of developing a PJI, but when the effect of bacteremias caused by E. This study shows that development of a PJI as a consequence of bacteremia is highly dependent on the type of pathogen causing the bacteremia.
The risk was the highest in bacteremias caused by Staphylococcus aureus , beta-hemolytic streptococci, and viridans group streptococci and was associated with repeated episodes of bacteremia. On the other hand, the development of a PJI during bacteremia caused by gram-negative bacteria, especially E. Patients with a bacteremia occurring within 1 year of previous surgery had a higher risk of developing a PJI than those with bacteremias occurring later.
Other studies examining the risk of developing a PJI during SAB [ 18—22 ] have reported slightly higher rates than in the current study. No other studies have examined the risk of developing a PJI during bacteremia caused by pathogens other than S. Interestingly, the risk of PJI was similar for bacteremias caused by Staphylococcus aureus and beta-hemolytic streptococci.
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However, it is not surprising, as streptococci have been reported to cause a considerable proportion of late hematogenous PJIs [ 1 , 2 , 16 ]. On the other hand, there were no PJIs during bacteremia caused by coagulase-negative staphylococci, even though they are significant pathogens that cause PJIs [ 1 ].
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Coagulase-negative staphylococcal bacteremias are mostly nosocomial [ 28 ], and it has been shown that nosocomial SABs are not associated with PJIs [ 20 , 21 ], making it likely that this is the case for coagulase-negative staphylococci as well. Unfortunately, the differentiation between community-acquired and nosocomial bacteremias was not possible in this study. Despite the commonness of urosepsis caused by E. Thus, patients with bacteremia caused by gram-negative bacteria do not warrant the special attention with respect to the development of a PJI paid to those with bacteremias caused by S.
This study demonstrates that viridans group streptococci can lead to the development of a hematogenous PJI, even though the absolute number was low. These bacteria are associated with dental or gastrointestinal sources [ 29 , 30 ]. No patient-related risk factors for the development of a PJI during bacteremia, such as chronic diseases, could be identified, and this has been the case in previous studies as well [ 14 , 20 ]. However, having more than 2 bacteremias during the study period increased the risk of developing a PJI during bacteremia.
An important observation, instead, is that the risk for developing a PJI as a consequence of bacteremia was highest for bacteremias occurring within 1 year of previous surgery.
Prosthetic Joint Infection
Large studies have shown that the overall risk of developing a PJI is highest for the first 2 years after surgery [ 7—9 ], and this is probably partly due to the increased risk for hematogenous PJIs. On the other hand, in a study by Rakow et al.
There are some limitations to this study. First, some of the patients could have had joint replacement surgery performed elsewhere, before the study period began, and thus all prosthetic joints at risk for infection could not be identified. In addition, there might have been other patients in the Pirkanmaa hospital district with joint replacements inserted at other hospitals who developed PJIs during bacteremia, but they could not be identified, and this might have resulted in lower incidence numbers. However, as the number of patients with surgery performed elsewhere was probably not very high, its effect can be assumed to be insignificant.
Second, due to the retrospective nature of this study, some of the data, such as dental procedures, were not available. To avoid other limitations related to retrospective data collection, such as missing PJI cases, multiple data sources were used. In addition, the source of bacteremia could not be investigated, and differentiation between recurrent and relapsing bacteremia was not possible in cases with multiple episodes of bacteremia. Third, it is impossible to say with absolute certainty whether all PJIs attributed to bacteremia were truly so, but patient charts were reviewed carefully to minimize this error.
The pathogens causing the early PJIs during bacteremia were not typical pathogens causing primary PJIs, thus supporting the fact that these PJIs were truly consequent to the bacteremia.
Fibrinogen – A Practical and Cost Efficient Biomarker for Detecting Periprosthetic Joint Infection
Finally, as there was a limited follow-up period for each joint maximum 12 years , PJIs as a consequence of bacteremia occurring after the study period were missed, thus potentially affecting the incidence numbers. In conclusion, this large study shows that the type of pathogen, history of infections, and timing of bacteremia should be taken into account when evaluating the risk of PJI in a patient with bacteremia.
Developing a PJI during an episode of bacteremia caused by Stapylococcus aureus or beta-hemolytic streptococci is fairly common, and viridans group streptococci can lead to PJIs during bacteremia. This should be taken into account when a patient with a joint replacement presents with bacteremia caused by these agents, especially during the first postoperative year. The authors wish to thank infection control nurse Jaana Sinkkonen for her help in gathering the data.
Financial support. Potential conflicts of interest. Eskelinen reports grants from DePuy Synthes, grants from Zimmer Biomet, and personal fees from Zimmer Biomet outside the submitted work. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.
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Article Navigation. Close mobile search navigation Article Navigation. Volume 6. Article Contents. Correspondence: M. Oxford Academic. Google Scholar.
Culture-Negative Periprosthetic Joint Infection: An Update o : JBJS Open Access
Matti Karppelin. Reetta Huttunen. Antti Eskelinen. If the patient is not a surgical candidate, antimicrobial suppression may be considered; this approach is unlikely to cure infection, so antimicrobial agents are often continued indefinitely. Staphylococcus aureus , and coagulase-negative Staphylococcus species account for more than half of prosthetic hip and knee infection cases.
Cutibacterium acnes are a common cause of shoulder arthroplasty infection, and Staphylococcus aureus is particularly common in patients with rheumatoid arthritis. Polymicrobial and culture-negative infections occur. The pathogenesis of prosthetic joint infection involves the formation of microbial biofilms. Bacteria, typically inoculated at the time of implantation, adhere to the implant and enter into a phenotypically unique, biofilm state in which they are relatively protected from conventional antimicrobial agents and the host immune system. Alternatively, microorganisms may seed the implant hematogenously, or via compromised local tissues.
Virulent organisms such as Staphylococcus aureus inoculated at implantation typically present acutely or, with hematogenous seeding of the implant, at any time following surgery, whereas less virulent organisms, such as coagulase negative staphylococci more often manifest several months or even years postoperatively as chronic infection. In infection caused by virulent bacteria, patients typically present with local and systemic signs and symptoms.
In contrast, chronic infection is generally characterized by subtle signs and symptoms, often not suggestive of infection, such as persistent pain alone, accompanied by loosening of the prosthesis, and sometimes by sinus tract formation with discharge.
Infections due to hematogenous seeding of the implant occur at any time postoperatively, typically presenting with sudden onset of joint pain. Although there is no universally accepted definition of prosthetic joint infection, criteria listed have been are described in the referenced publications. In the absence of underlying inflammatory conditions, C-reactive protein is the most useful preoperative blood test.
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Although C-reactive protein and erythrocyte sedimentation rate are elevated after uncomplicated arthroplasty surgery, C-reactive protein returns to preoperative levels earlier than does erythrocyte sedimentation rate. We examined preoperative C-reactive protein and erythrocyte sedimentation rate in patients with knee, hip or shoulder implant failure. Both were statistically significantly higher in the groups with prosthetic knee or hip infection compared to those with aseptic implant failure.
However, in the shoulder implant group, the erythrocyte sedimentation rate was not significantly different in the groups with prosthetic shoulder infection versus aseptic shoulder implant failure, and C-reactive protein was minimally elevated in the former compared to the latter group. C-reactive protein performed better than erythrocyte sedimentation rate for detection of prosthetic hip implant infection, and neither test performed well for detection of prosthetic shoulder implant infection. Overall, therefore, C-reactive protein is preferred to erythrocyte sedimentation rate, but neither test performs well for diagnosis of prosthetic shoulder infection.
Computed tomography and magnetic resonance imaging are hampered by artifacts produced by prostheses, although non-ferromagnetic i. Bone scans, including those performed as three-phase studies, are sensitive for detecting failed implants but cannot be used to determine the cause of failure, and may remain abnormal for more than a year after implantation. Combined bone and gallium scans offer improvement over bone scan alone, however, labeled leukocyte imaging combined with bone scans has better accuracy. In this patient whose images were also shown on the prior slide , Staphylococcus epidermidis and Finegoldia magna were isolated from peri-prosthetic tissue.
The most useful pre-operative diagnostic test is joint aspiration for total and differential cell count and aerobic and anaerobic culture. A synovial fluid leukocyte count of more than 1. Higher synovial fluid leukocyte count and neutrophil percentage cutoffs are applied for prosthetic hip infection diagnosis.
If an organism of questionable clinical significance is isolated, repeat synovial fluid aspiration for culture should be considered.