Periprosthetic Joint Infection (PJI) Criteria and Management

prosthesis
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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

AND

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: https://josr-online.biomedcentral.com/articles/10.1186/s13018-019-1185-y/tables/1

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
Pathogenesis
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)
BiofilmImmatureMature
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.

Reference:
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). https://doi.org/10.1186/s13018-019-1185-y
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). https://doi.org/10.1007/s00264-019-04426-7


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