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Novel Diagnostics in Revision Arthroplasty: Implant Sonication and Multiplex Polymerase Chain Reaction
Published on: December 3, 2017
Does pre-operative sampling predict intra-operative cultures and antibiotic sensitivities in knee replacements
Richard J Holleyman1,2, David J Deehan3,4, Andre Charlett5
1Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK. r.holleyman@googlemail.com.
Purpose:
This study examined a cohort of primary knee arthroplasties revised for peri-prosthetic infection to (1) determine whether the microorganisms isolated by sampling (up to 6 months pre-operatively) are representative of the microorganisms encountered at the time of knee revision, (2) determine whether the antibiotic sensitivity profiles of matching organisms correlate and (3) determine whether the proportion of organism and antibiotic sensitivity matches is influenced by the type of infection, timing of sample collection and the type of microorganism isolated.
Methods:
From the National Joint Registry database for England and Wales, a consecutive series of primary knee arthroplasties performed between 2003 and 2014 that went on to have a revision for peri-prosthetic infection were identified. Each case was then linked to a national microbiology database held by Public Health England. Following data linkage, intra-operative and pre-operative cultures were identified and compared in a group of 75 patients.
Results:
Pre-operative genus matched intra-operative genus in 56 of 75 cases (75 %). Of those 56, the corresponding antimicrobial sensitivities matched in 37 (66 % of cases). Overall, 37 of 75 cases (49 %) matched for both microorganism and antimicrobial sensitivity. The proportion of matches was highest in the pure Staphylococcal genus infections (genus match 88 %, sensitivity match 62 %, genus and sensitivity match 55 %) and lowest in those patients with mixed organism infections (genus match 29 %, sensitivity match 14 %).
Conclusion:
Pre-operative joint sampling obtained by either aspiration or tissue biopsy is advocated in cases where peri-prosthetic infection is suspected and provides the only means of determining infecting organism prior to revision. Overall, only half of all pre-operative cultures matched completely the findings of intra-operative samples in terms of both the microorganism(s) encountered and their corresponding antimicrobial sensitivity profile. Clinicians should be vigilant regarding the possibility of the patient acquiring further microorganisms or the development of new antibiotic resistance by the time of revision, especially in historic pre-operative cultures. Broad spectrum antibiotic therapies should therefore be employed until final microorganisms and antimicrobial sensitivities are confirmed from intra-operative samples.
Level Of Evidence:
IV.
Insights
Pre-operative joint sampling for suspected knee replacement infection showed a 49% match for both microorganism and antibiotic sensitivity compared to intra-operative samples. This highlights the need for broad-spectrum antibiotics until definitive intra-operative results are available.
Area of Science:
- Orthopedic Surgery
- Infectious Diseases
- Microbiology
Background:
- Periprosthetic joint infection (PJI) is a serious complication following knee arthroplasty.
- Accurate identification of causative microorganisms and their antibiotic sensitivities is crucial for effective treatment.
- Pre-operative diagnostic sampling aims to guide surgical and antimicrobial strategies before revision surgery.
Purpose of the Study:
- To assess the concordance between pre-operative (up to 6 months prior) and intra-operative microbial findings in knee arthroplasty revisions for PJI.
- To evaluate the correlation of antibiotic sensitivity profiles between pre-operative and intra-operative isolates.
- To determine if infection type, timing of sample collection, or microorganism influences match rates.
Main Methods:
- A cohort of 75 patients undergoing revision knee arthroplasty for PJI was identified from the National Joint Registry.
- Pre-operative joint fluid or tissue cultures were compared with intra-operative cultures.
- Microorganism genus and antimicrobial sensitivity data were linked from national microbiology databases.
Main Results:
- Microorganism genus matched between pre-operative and intra-operative samples in 75% of cases.
- Antimicrobial sensitivity matched in 66% of matching genera.
- Overall, only 49% of cases showed a complete match for both microorganism and sensitivity.
- Match rates were highest for pure Staphylococcal infections and lowest for mixed infections.
Conclusions:
- Pre-operative joint sampling is valuable for identifying potential pathogens before revision surgery.
- A significant discordance exists between pre-operative and intra-operative microbial and sensitivity profiles.
- Clinicians should consider potential microbial shifts and emerging resistance, advocating for broad-spectrum antibiotics initially.
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