Periprosthetic Joint Infection (PJI) Criteria and Management

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The 2013 ICM criteria for defining Periprosthetic joint infection (PJI) can be remembered using the mnemonic below:

Mnemonic: 1 tract or 2 bact. and 3 of ABCDEF

1 sinus tract communication with the joint OR

2 positive periprosthetic cultures with phenotypically identical bacteria


3 of the following six minor criteria:

a. Acute phase reactants: CRP >10 mg/L and ESR >30 mm/hr

b. Biopsy of periprosthetic tissue: >5 neutrophils/hpf in 5 high power fields

c. Culture positive: Single

d. Differential count in synovial fluid: >80% PMN

e. Esterase: Leukocyte esterase ++

(2011 MSIS criteria uses purulence in the affected joint as a minor criterion insted of leukocyte esterase and would require 4 out of six insted of 3 out of six minor criteria for diagnosis)

f. Full count in synovial fluid: >3000 WBC/microlitre

The 2018 PJI definition is based on scoring system and is diagnosed with score of 6 or more preoperatively or intraoperatively. The new 2018 definition of PJI is available here:

Trampuz and Zimmerli classifies PJI as:

  1. Early: Upto 3 months postoperatively
  2. Delayed: 3-24 months from index surgery
  3. Late: After 24 months from index surgery
PJI management
Source: Li C, Renz N, Trampuz A. Management of Periprosthetic Joint Infection. Hip Pelvis. 2018 Sep;30(3):138-146. doi: 10.5371/hp.2018.30.3.138. Epub 2018 Sep 4. PMID: 30202747; PMCID: PMC6123506.

Another classification of PJI:

Acute PJIChronic PJI
a. Perioperative<4 weeks after surgery (early)≥4 weeks after surgery (delayed/low-grade)
b. Hematogenous or per continuitatem<3 weeks of symptom duration ≥3 weeks of symptom duration
Clinical featuresAcute pain, fever, red/swollen joint, prolonged postoperative discharge (7-10 days)Chronic pain, loosening of prosthesis, sinus tract (fistula)
Causative organismHighly virulent: Staphylococcus aureus, gram negative bacteria (E.coli, Klebsiella, Pseudomonas)Low virulent: Coagulase negative staphylococci (Staph. epidermidis), Cutibacterium acnes
Surgical treatmentDebridement and retention of prosthesis (change of mobile parts)Complete removal of prosthesis (exchange in 1 or 2 stages)

Examples of biofilm active antibiotics:

  1. Gram positive organisms: Rifampicin
  2. Gram negative rods: Ciprofloxacin

These should be reserved for the period after implantation of the definitive implant.

1. Guan, H., Fu, J., Li, X. et al. The 2018 new definition of periprosthetic joint infection improves the diagnostic efficiency in the Chinese population. J Orthop Surg Res 14, 151 (2019).
2. Li, C., Renz, N., Trampuz, A. et al. Twenty common errors in the diagnosis and treatment of periprosthetic joint infection. International Orthopaedics (SICOT) 44, 3–14 (2020).

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