Should all patients with a culture-negative periprosthetic joint infection be treated with antibiotics?
Maxime van Sloten, Joan Gómez-Junyent, Tristan Ferry, Nicolò Rossi, Sabine Petersdorf, Jeppe Lange, Pablo Corona, Miguel Araújo Abreu, Olivier Borens, Ovidiu Zlatian, Dhanasekaran Soundarrajan, S. Rajasekaran, Marjan Wouthuyzen-Bakker, On behalf of the ESCMID Study Group of Implant Associated Infections (ESGIAI)Ankle Elbow Hip Knee Shoulder Wrist
Aims
The aim of this study was to analyze the prevalence of culture-negative periprosthetic joint infections (PJIs) when adequate methods of culture are used, and to evaluate the outcome in patients who were treated with antibiotics for a culture-negative PJI compared with those in whom antibiotics were withheld.
Methods
A multicentre observational study was undertaken: 1,553 acute and 1,556 chronic PJIs, diagnosed between 2013 and 2018, were retrospectively analyzed. Culture-negative PJIs were diagnosed according to the Muskuloskeletal Infection Society (MSIS), International Consensus Meeting (ICM), and European Bone and Joint Society (EBJIS) definitions. The primary outcome was recurrent infection, and the secondary outcome was removal of the prosthetic components for any indication, both during a follow-up period of two years.
Results
None of the acute PJIs and 70 of the chronic PJIs (4.7%) were culture-negative; a total of 36 culture-negative PJIs (51%) were treated with antibiotics, particularly those with histological signs of infection. After two years of follow-up, no recurrent infections occurred in patients in whom antibiotics were withheld. The requirement for removal of the components for any indication during follow-up was not significantly different in those who received antibiotics compared with those in whom antibiotics were withheld (7.1% vs 2.9%; p = 0.431).
Conclusion
When adequate methods of culture are used, the incidence of culture-negative PJIs is low. In patients with culture-negative PJI, antibiotic treatment can probably be withheld if there are no histological signs of infection. In all other patients, diagnostic efforts should be made to identify the causative microorganism by means of serology or molecular techniques.
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