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Diagnosis and Treatment of Culture-Negative Periprosthetic Joint Infection

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Authors/contributors
Abstract
Identification of the causative organism(s) in periprosthetic joint infection (PJI) is a challenging task. The shortcomings of traditional cultures have been emphasized in recent literature, culminating in a clinical entity known as “culture-negative PJI.” Amidst the growing burden of biofilm infections that are inherently difficult to culture, the field of clinical microbiology has seen a paradigm shift from culture-based to molecular-based methods. These novel techniques hold much promise in the demystification of culture-negative PJI and revolutionization of the microbiology laboratory. This article outlines the clinical implications of culture-negative PJI, common causes of this diagnostic conundrum, established strategies to improve culture yield, and newer molecular techniques to detect infectious organisms.
Publication
The Journal of Arthroplasty
Date
08/2022
DOI
10.1016/j.arth.2022.01.061
URL
https://linkinghub.elsevier.com/retrieve/pii/S0883540322000778
Notes

Key findings:

  1. Approximately 20%-50% of patients with clinical and laboratory evidence of PJI have negative cultures, leading to a diagnostic challenge known as "culture-negative PJI."
  2. Culture-negative PJI can result in higher rates of treatment failure. Empiric treatment involves broad-spectrum antimicrobials, risking systemic toxicity and contributing to antimicrobial resistance.
  3. Antibiotic treatment before sampling, introduction of bacteriostatic substances during the procedure, and inadequate incubation time are common causes of CN PJI.
  4. Strategies to improve culture yield include obtaining multiple intraoperative samples, sonication, extending incubation periods, using specialized media for atypical organisms, and avoiding swab cultures.
  5. Molecular methods, such as multiplex PCR, 16S rRNA gene sequencing, NGS, MG-NGS, and MT-NGS, offer improved sensitivity compared to traditional culture methods. Challenges include the need for specific primers, potential detection of DNA in non-infected joints, and difficulty distinguishing between active and treated infections.

Clinical implications/strengths:

  1. Topic review of culture negative PJI

Limitations:

  1. Review article

Level of evidence: Low (symposium review article)

Citation
1.
Goh GS, Parvizi J. Diagnosis and Treatment of Culture-Negative Periprosthetic Joint Infection. The Journal of Arthroplasty. 2022;37(8):1488-1493.
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