The impact of sonication cultures when the diagnosis of prosthetic joint infection is inconclusive.

Noreen J Hickok,Taiana Cunha Ribeiro,Emerson Kiyoshi Honda,Cely Barreto Da Silva,Giselle Burlamaqui Klautau,Mauro Jose Salles,Ricardo De Paula Leite Cury,Daniel Daniachi

doi:10.1371/journal.pone.0252322

Abstract

In the absence of a gold standard criterion for diagnosing prosthetic joint infections (PJI), sonication of the removed implant may provide superior microbiological identification to synovial fluid and peri-implant tissue cultures. The aim of this retrospective study was to assess the role of sonication culture compared to tissue cultures for diagnosing PJI, using different consensus and international guidelines for PJI definition. Data of 146 patients undergoing removal of hip or knee arthroplasties between 2010 and 2018 were retrospectively reviewed. The International Consensus Meeting (ICM-2018), Musculoskeletal Infection Society (MSIS), Infectious Diseases Society of America (IDSA), the European Bone and Joint Infection Society (EBJIS), and a modified clinical criterion, were used to compare the performance of microbiological tests. McNemar´s test and proportion comparison were employed to calculate p-value. Overall, 56% (82/146) were diagnosed with PJI using the clinical criteria. Out of these cases, 57% (47/82) tested positive on tissue culture and 93% (76/82) on sonication culture. Applying this clinical criterion, the sensitivity of sonication fluid and tissue cultures was 92.7% (95% CI: 87.1%- 98.3%) and 57.3% (95% CI: 46.6%-68.0%) (p<0.001), respectively. When both methods were combined for diagnosis (sonication and tissue cultures) sensitivity reached 96.3% (95% CI: 91.5%-100%). Sonication culture and the combination of sonication with tissue cultures, showed higher sensitivity rates than tissue cultures alone for all diagnostic criteria (ICM-18, MSIS, IDSA and EBJIS) applied. Conversely, tissue culture provided greater specificity than sonication culture for all the criteria assessed, except for the EBJIS criteria, in which sonication and tissue cultures specificity was 100% and 95.3% (95% CI: 87.8-100%), respectively (p = 0.024). In a context where diagnostic criteria available have shortcomings and tissue cultures remain the gold standard, sonication cultures can aid PJI diagnosis, especially when diagnostic criteria are inconclusive due to some important missing data (joint puncture, histology).

Highlights

Accurate diagnosis of prosthetic joint infection (PJI) is made even more challenging in clinical practice by the lack of a gold standard test
The sensitivity of sonication fluid and tissue cultures was 92.7% and 57.3% (p
There have been several PJI diagnostic criteria suggested by consensus and international guidelines based on a composite of clinical signs and symptoms, blood and synovial fluid inflammatory biomarkers, histopathological abnormalities, and microbiological identification

Summary

Introduction

Accurate diagnosis of prosthetic joint infection (PJI) is made even more challenging in clinical practice by the lack of a gold standard test. Joint aspiration for synovial fluid inflammatory biomarkers and microbiological analysis has been regarded as one of the crucial pre-operative tests for the diagnosis of PJI [2, 8]. In the absence of a gold standard criterion for diagnosing prosthetic joint infections (PJI), sonication of the removed implant may provide superior microbiological identification to synovial fluid and peri-implant tissue cultures. The aim of this retrospective study was to assess the role of sonication culture compared to tissue cultures for diagnosing PJI, using different consensus and international guidelines for PJI definition

Methods

Results

Conclusion