History and Physical Examination

In the presence of wound drainage, erythema, and swelling about the hip associated with systemic symptoms (fever, chills, and generalized malaise), the diagnosis of an infected total hip arthroplasty (THA) can be relatively straightforward. Unfortunately, many periprosthetic infections do not exhibit obvious signs and symptoms of infection.^{[41, 42]}

In the absence of obvious indicators, a thorough history and a detailed examination of the patient should suggest the possibility of infection. A high index of suspicion is necessary. Often, the only symptom is the acute onset of pain in a previously well-functioning joint.

The American Academy of Orthopaedic Surgeons (AAOS) clinical guidelines are helpful for guiding the management of prosthetic joint infection.^[43] These guidelines have also been endorsed by the Infectious Diseases Society of America (IDSA).

Criteria for periprosthetic joint infection

The Musculoskeletal Infection Society proposed the following criteria for periprosthetic joint infections (PJIs)^[44]:

A sinus tract is communicating with the prosthesis
Two separate tissue or fluid samples yield a positive culture from the joint
Four of the following six criteria exist: (1) elevated erythocyte sedimentation rate (ESR) and C-reactive protein (CRP); (2) elevated synovial leukocyte count; (3) elevated synovial neutrophil percentage; (4) frank purulence in the joint; (5) one culture positive; (6) more than five neutrophils per high-power field (HPF) in five HPFs observed in periprosthetic tissue magnification at ×400

Types of arthroplasty-associated infection

Tsukayama et al classified arthroplasty-associated infections into four types according to the most common presenting patterns; they also recommended treatments for each type, as follows^[45]:

Type I - Positive intra operative cultures in a hip undergoing revision for aseptic loosening, without previous indications of infection; two positive cultures out of a minimum of five are necessary to make the diagnosis; revision surgery in these patients is already performed for a presumed aseptic failure when the culture results become available
Type II - Early postoperative infection occurring within 1 month of the index procedure; classic symptoms and signs of infection may be present; the infection may be either superficial (because of fat necrosis) or deep-seated, and the two must be distinguished
Type III - Acute infection in a well-functioning joint; often, there is a recent history of an infection elsewhere in the body or an invasive procedure (eg, tooth extraction); immunocompromised patients are susceptible to these infections, which may be preventable if antibiotic prophylaxis is routinely provided when these patient undergo total joint arthroplasty
Type IV - Deep infection that presents insidiously at least 1 month and as much as 2 years after the index procedure; often, there are no systemic symptoms, and persistent pain may be the only local problem

Workup

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Media Gallery

Final radiograph after stage II revision.
Stage I revision with antibiotic spacer made from mold.
Radiograph of 50-year-old patient for whom bipolar arthroplasty was done elsewhere for displaced fracture of neck of femur. Patient came with severe pain hip 1 year after procedure. Severe osteolysis and superior migration of prosthesis are seen.
Infected total knee arthroplasty with sinus.
Lateral radiograph showing lysis and loosening of prosthesis.
Frankly infected tissue around prosthesis.
Cement spacer application.
Radiograph after stage I revision.
Stage II revision. Bone loss at femoral side; allograft used.
Astemmed femoral prosthesis and allograft used for bone loss.
Final radiograph after stage II revision.

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Table 1. Microorganisms Causing Prosthetic Joint Infections

Microorganism	Frequency (%)
Coagulase-negative staphylococci	30-43
Staphylococcus aureus	12-23
Streptococci	9-10
Enterococci	3-7
Gram-negative bacilli	3-6
Anaerobes	2-4
Multiple pathogens (polymicrobial)	10-12
Unknown	10-11

Table 2. Concise Approach to Treatment of Prosthetic Joint Infections

Status of Prosthetic Joint Infection	Treatment
Duration of symptoms < 3 wk and stable implant and absence of sinus tract and susceptibility to antibiotics with activity against surface-adhering microorganisms	Débridement with retention
Intact or only slightly damaged soft tissue	1-stage exchange
Damaged soft tissue, abscess, or sinus tract	2-stage exchange with short interval (2-4 wk), spacer
Microorganism resistant or difficult to treat*	2-stage exchange with long interval (6-8 wk), no spacer
Inoperable, debilitated, or bedridden	Long-term suppressive antimicrobial treatment
No functional improvement by exchange of implant	Implant removal without replacement

Table 3. Advantages and Disadvantages of Direct and Delayed Exchange

Direct Exchange

Delayed Exchange

Advantages

• Less morbidity

• Reduced cost

• Improved mechanical stability

• Less complicated technique

• Shorter duration of disability

Disadvantages

• Inability to use sensitive antibiotic to mix with cement while fixation

Contraindications

• Immunocompromise

• Major soft tissue or skin defect

• Gram-negative organisms

• Actively discharging sinus or overt purulence

Advantages

• Ability to identify organisms, determine sensitivities, and give adequate antibiotics before reimplantation

• Ability to repeat débridement if necessary

• Ability to identify and correct other foci of infection and inciting factors

Disadvantages

• Technical difficulty resulting from extensive scarring and contracture

• Hardships of resection arthroplasty

• Increased cost and hospital stay

• Delayed rehabilitation

Table 4. Antibiotic Regimens for Various Pathogens Causing Prosthetic Infections

Microorganism		Antimicrobial Agent¹	Dosage	Route
Staphylococcus aureus or coagulase-negative staphylococci
Methicillin-susceptible	Rifampin plus (flu)eloxacillin²		450 mg q12hr 2 g q6hr		PO/IV IV
	For 2 wk, followed by
	Rifampin plus ciprofloxacin or levofloxacin		450 mg q12hr 750 mg q12hr 750 mg q24hr to 500 mg q12hr	PO PO PO PO
Methicillin-resistant	For 2 wk, followed by
	Rifampin plus ciprofloxacin³ or levofloxacin³ or teicoplanin⁴ or fusidic acid or trimethoprim-sulfamethoxazole or minocycline		450 mg q12hr 750 mg q12hr 750 mg q24hr to 500 mg q12hr 400 mg q24hr 500 mg q8hr 1 forte tablet q8hr 100 mg q12hr	PO PO PO IV/IM PO PO PO
Streptococcus spp (except S agalactiae)	Penicillin G³ or ceftriaxone		5 million U q6hr 2 g q24hr	IV IV
	For 2-4 wk, followed by
	Amoxicillin		750-1000 mg q8hr	PO
Enterococcus spp (penicillin-susceptible) and S agalactiae	Penicillin G or ampicillin or amoxicillin plus aminoglycoside⁵		5 million U q6hr 2 g q4-6hr	IV IV
	For 2-4 wk, followed by
	Amoxicillin		750-1000 mg q8hr	PO
Enterobacteriaceae (quinolone-susceptible)	Ciprofloxacin		750 g q12hr	PO
Nonfermenters (eg, Pseudomonas aeruginosa)	Cefepime or ceftazidime plus aminoglycoside⁵		2 g q8hr	IV
	For 2-4 wk, followed by
	Ciprofloxacin		750 g q12hr	PO
Anaerobes⁶	Clindamycin		600 mg q6hr	PO
	For 2-4 wk, followed by
	Clindamycin		300 mg q6hr	PO
Mixed infections (without methicillin-resistant staphylococci)	Amoxicillin-clavulanate or piperacillin-tazobactam or imipenem or meropenem		2.2 g q8hr 4.5 g q8hr 500 mg q6hr 1 g q8hr	IV IV IV IV
	For 2-4 wk, followed by individual regimens according to antimicrobial susceptibility
PO= orally; IV= intravenously; IM= intramuscularly; forte tablet = trimethoprim 160 mg plus sulfamethoxazole 800 mg; MRSA = methicillin-resistant S aureus. 1. If implant retention or one-stage exchange is performed, the total duration of antimicrobial treatment is 3 months for hip prosthesis and 6 months for knee prosthesis. 2. In patients with delayed hypersensitivity, cefazolin (2 g IV q8hr) may be administered. In patients with immediate hypersensitivity, penicillin should be replaced with vancomycin (1 g q12hr). 3. MRSA should not be treated with quinolones, because antimicrobial resistance might emerge during treatment. 4. On the first day of treatment, the teicoplanin dose should be increased to 800 mg IV (loading dose). 5. Aminoglycosides can be administered in a single daily dose. 6. Alternatively, penicillin G (5 million U IV q6hr) or ceftriaxone (2 g IV q24hr) may be used for gram-positive anaerobes (eg, Propionibacterium acnes), and metronidazole (500 mg IV or PO q8hr) for gram-negative anaerobes (eg, Bacteroides spp).