Prosthetic joint infections: is guideline-consistent surgical treatment beneficial?

Abstract

Background: The diagnosis and treatment of prosthetic joint infection (PJI) remains challenging. In 2013, both the Infectious Diseases Society of America (IDSA) guidelines and an international consensus’ recommendation on PJI were published, providing a consistent approach to PJI management. We undertook a study to compare outcomes of PJI managed in accordance with IDSA versus those managed outside of the same. Methods: This retrospective cohort study of a consecutive series of patients who had total joint replacement (TJR) with subsequent deep PJI was undertaken to determine historical clinical variation relative to recently established management guidelines. All operations were completed at one arthroplasty center over a 5-year period predating IDSA guideline development. Results: Of 8505 patients who had TJR, 267 (3.1%) were diagnosed with subsequent PJI. Of these, 42/8505 (0.5%) had culture positive deep PJI, with 38/42 (90.5%) managed surgically. The odds of treatment failure among cases not managed in accordance with IDSA were 11 times greater as compared to guideline-accordant cases (OR 11, 95%CI 1.84-65.7; P=0.006). This difference was most pronounced among those who had irrigation and debridement. We could not demonstrate any significant difference in treatment success or failure for one-stage or two-stage exchange. Conclusions: Surgical management of PJI in accordance with existing guidelines can optimize success of PJI treatment. In particular, aggressive surgical treatment (including prosthesis removal) is likely warranted in patients who had symptoms of PJI for longer than 3 wk. In a patient in whom deviation from existing guidelines is considered, it is important for physicians to weigh the risk of inferior outcome and counsel the patient accordingly.