Subscribe to RSS
DOI: 10.1055/a-2337-2402
The Microbiology of Knee Prosthetic Joint Infection and its Influence on Persistent Infection
![](https://www.thieme-connect.de/media/jks/EFirst/lookinside/thumbnails/10-1055-a-2337-2402_23sep0104oa-1.jpg)
Abstract
Periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) is a severe complication causing a significant burden. The study aims were to establish the epidemiology of microorganisms in TKA PJI, the rate of persistent infection requiring further surgery, and the risk factors for this. Microbiological specimens between June 2002 and March 2017 at five regional hospital sites were identified with revision TKA procedures in the National Joint Replacement Registry. The time between procedures, type of revision strategy, and any subsequent further revision operations were collected. At minimum 2-year follow-up, 174 revision TKA were identified, with a mean patient age of 69 ± 11 years. A broad range of pathogens were identified. Fifty cases (29%) had persistent infection requiring at least one further operative procedure, 13 cases required 3 or more. Coagulase-negative Staphylococcus species (CNS) was seen most with failed surgery, polymicrobial infections also posing a significant risk factor. The best chance of a successful PJI surgical strategy was < 12 months from primary TKA, with the greatest risk between 3 and 5 years (p < 0.05). Younger age significantly increased the risk of further surgery (p < 0.05). Management varied; 103 (59%) debridement, antibiotic therapy and implant retention, with further surgery in 29%; 45 (17%) single-stage revision, with further surgery in 13%; and 26 (15%) two-stage revision, with further surgery in 12%. This study presents the most common causative pathogens for PJI in TKA, and the high rate of persistent infection after initial revision surgery. Risk factors for persistent infection and further revision surgery were polymicrobial and CNS infections, patients who presented between 3 and 5 years following primary TKA, and younger age. This study therefore raises important risk factors and areas for future research to reduce the burden of multiple operations after PJI.
Keywords
prosthetic joint infection - infected - total knee arthroplasty - revision total knee arthroplasty - microorganisms - unplanned revision - ageNote
Research carried out at Sydney Orthopaedic Research Institute.
Publication History
Received: 20 September 2023
Accepted: 22 May 2024
Accepted Manuscript online:
03 June 2024
Article published online:
26 June 2024
© 2024. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 Kapadia BH, McElroy MJ, Issa K, Johnson AJ, Bozic KJ, Mont MA. The economic impact of periprosthetic infections following total knee arthroplasty at a specialized tertiary-care center. J Arthroplasty 2014; 29 (05) 929-932
- 2 McNally M, Sousa R, Wouthuyzen-Bakker M. et al. The EBJIS definition of periprosthetic joint infection. Bone Joint J 2021; 103-B (01) 18-25
- 3 Bullock MW, Brown ML, Bracey DN, Langfitt MK, Shields JS, Lang JE. A bundle protocol to reduce the incidence of periprosthetic joint infections after total joint arthroplasty: a single-center experience. J Arthroplasty 2017; 32 (04) 1067-1073
- 4 Parsons T, French J, Oshima T. et al. International survey of practice for prophylactic systemic antibiotic therapy in hip and knee arthroplasty. Antibiotics (Basel) 2022; 11 (11) 1669
- 5 Holleyman RJ, Baker P, Charlett A, Gould K, Deehan DJ. Microorganisms responsible for periprosthetic knee infections in England and Wales. Knee Surg Sports Traumatol Arthrosc 2016; 24 (10) 3080-3087
- 6 Klasan A, Schermuksnies A, Gerber F, Bowman M, Fuchs-Winkelmann S, Heyse TJ. Development of antibiotic resistance in periprosthetic joint infection after total knee arthroplasty. Bone Joint J 2021; 103-B (6, Supple A): 171-176
- 7 Stevoska S, Himmelbauer F, Stiftinger J. et al. Significant difference in antimicrobial resistance of bacteria in septic revision between total knee arthroplasty and total hip arthroplasty. Antibiotics (Basel) 2022; 11 (02) 249
- 8 Stevoska S, Himmelbauer F, Stiftinger J. et al. Significant difference in antimicrobial resistance of coagulase negative periprosthetic joint infection in septic revision total knee arthroplasty between two major orthopedic centers. J Arthroplasty 2022; 37 (6S): S306-S312
- 9 Petretta R, Phillips J, Toms A. Management of acute periprosthetic joint infection of the knee - algorithms for the on call surgeon. Surgeon 2017; 15 (02) 83-92
- 10 Cochran AR, Ong KL, Lau E, Mont MA, Malkani AL. Risk of reinfection after treatment of infected total knee arthroplasty. J Arthroplasty 2016; 31 (09) 156-161
- 11 Nodzo SR, Boyle KK, Nocon AA, Henry MW, Mayman DJ, Westrich GH. The influence of a failed irrigation and debridement on the outcomes of a subsequent 2-stage revision knee arthroplasty. J Arthroplasty 2017; 32 (08) 2508-2512
- 12 Kim JG, Bae JH, Lee SY, Cho WT, Lim HC. The parameters affecting the success of irrigation and debridement with component retention in the treatment of acutely infected total knee arthroplasty. Clin Orthop Surg 2015; 7 (01) 69-76
- 13 Weston JT, Watts CD, Mabry TM, Hanssen AD, Berry DJ, Abdel MP. Irrigation and debridement with chronic antibiotic suppression for the management of infected total knee arthroplasty: a contemporary analysis. Bone Joint J 2018; 100-B (11) 1471-1476
- 14 Prasad N, Paringe V, Kotwal R, Ghandour A, Morgan Jones R. Two-stage revision for infected total knee arthroplasty: our experience with interval prosthesis. Eur J Orthop Surg Traumatol 2014; 24 (07) 1279-1283
- 15 Haddad FS, Ngu A, Negus JJ. Prosthetic joint infections and cost analysis?. Adv Exp Med Biol 2017; 971: 93-100
- 16 Stammers J, Kahane S, Ranawat V. et al. Outcomes of infected revision knee arthroplasty managed by two-stage revision in a tertiary referral centre. Knee 2015; 22 (01) 56-62
- 17 Khan M, Osman K, Green G, Haddad FS. The epidemiology of failure in total knee arthroplasty: avoiding your next revision. Bone Joint J 2016; 98-B (1, Suppl A): 105-112
- 18 Rodríguez-Merchán EC, Liddle AD. Microbiological concepts of the infected total knee arthroplasty. In: Rodríguez-Merchán EC, Oussedik S. eds. The Infected Total Knee Arthroplasty: Prevention, Diagnosis, and Treatment. UK: Springer International Publishing: UK; 2018: 11-17
- 19 Leclercq R, Cantón R, Brown DFJ. et al. EUCAST expert rules in antimicrobial susceptibility testing. Clin Microbiol Infect 2013; 19 (02) 141-160
- 20 Ayoade F, Li DD, Mabrouk A, Todd JR. Periprosthetic Joint Infection. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2024
- 21 Tande AJ, Patel R. Prosthetic joint infection. Clin Microbiol Rev 2014; 27 (02) 302-345
- 22 Nickinson RSJ, Board TN, Gambhir AK, Porter ML, Kay PR. The microbiology of the infected knee arthroplasty. Int Orthop 2010; 34 (04) 505-510
- 23 Tigani D, Trisolino G, Fosco M, Ben Ayad R, Costigliola P. Two-stage reimplantation for periprosthetic knee infection: influence of host health status and infecting microorganism. Knee 2013; 20 (01) 9-18
- 24 Vasso M, Schiavone Panni A, De Martino I, Gasparini G. Prosthetic knee infection by resistant bacteria: the worst-case scenario. Knee Surg Sports Traumatol Arthrosc 2016; 24 (10) 3140-3146
- 25 Mortazavi SMJ, Vegari D, Ho A, Zmistowski B, Parvizi J. Two-stage exchange arthroplasty for infected total knee arthroplasty: predictors of failure. Clin Orthop Relat Res 2011; 469 (11) 3049-3054
- 26 Muñoz-Gallego I, Meléndez-Carmona MÁ, Lora-Tamayo J. et al. Microbiological and molecular features associated with persistent and relapsing Staphylococcus aureus prosthetic joint infection. Antibiotics (Basel) 2022; 11 (08) 1119
- 27 Stefánsdóttir A, Johansson D, Knutson K, Lidgren L, Robertsson O. Microbiology of the infected knee arthroplasty: report from the Swedish Knee Arthroplasty Register on 426 surgically revised cases. Scand J Infect Dis 2009; 41 (11-12): 831-840
- 28 Lindberg-Larsen M, Pitter FT, Voldstedlund M, Schrøder HM, Bagger J. Microbiological diagnosis in revision of infected knee arthroplasties in Denmark. Infect Dis (Lond) 2017; 49 (11-12): 824-830
- 29 Nakano N, Matsumoto T, Ishida K. et al. Factors influencing the outcome of deep infection following total knee arthroplasty. Knee 2015; 22 (04) 328-332
- 30 Meehan JP, Danielsen B, Kim SH, Jamali AA, White RH. Younger age is associated with a higher risk of early periprosthetic joint infection and aseptic mechanical failure after total knee arthroplasty. J Bone Joint Surg Am 2014; 96 (07) 529-535
- 31 Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE. Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty 2009; 24 (06) 84-88
- 32 Papadimitriou-Olivgeris M, Senn L, Bertelli C, Grandbastien B, Steinmetz S, Boillat-Blanco N. Prevalence and factors associated with prosthetic joint infections in patients with Staphylococcus aureus bacteraemia: a 7-year retrospective study. Antibiotics (Basel) 2022; 11 (10) 1323
- 33 Bozzo A, Ekhtiari S, Madden K. et al; McMaster Arthroplasty Collaborative (MAC). Incidence and predictors of prosthetic joint infection following primary total knee arthroplasty: a 15-year population-based cohort study. J Arthroplasty 2022; 37 (02) 367-372.e1
- 34 Barrett L, Atkins B. The clinical presentation of prosthetic joint infection. J Antimicrob Chemother 2014; 69 (Suppl. 01) i25-i27
- 35 Premkumar A, Kolin DA, Farley KX. et al. Projected economic burden of periprosthetic joint infection of the hip and knee in the United States. J Arthroplasty 2021; 36 (05) 1484-1489.e3
- 36 Masters JP, Smith NA, Foguet P, Reed M, Parsons H, Sprowson AP. A systematic review of the evidence for single stage and two stage revision of infected knee replacement. BMC Musculoskelet Disord 2013; 14 (01) 222
- 37 Lichstein P, Su S, Hedlund H. et al. Treatment of periprosthetic knee infection with a two-stage protocol using static spacers. Clin Orthop Relat Res 2016; 474 (01) 120-125
- 38 Haddad FS, Sukeik M, Alazzawi S. Is single-stage revision according to a strict protocol effective in treatment of chronic knee arthroplasty infections?. Clin Orthop Relat Res 2015; 473 (01) 8-14
- 39 Nagra NS, Hamilton TW, Ganatra S, Murray DW, Pandit H. One-stage versus two-stage exchange arthroplasty for infected total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol Arthrosc 2016; 24 (10) 3106-3114
- 40 Kim YH, Park JW, Kim JS, Kim DJ. The outcome of infected total knee arthroplasty: culture-positive versus culture-negative. Arch Orthop Trauma Surg 2015; 135 (10) 1459-1467