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Treatment Outcomes and Attrition in Gram-Negative Periprosthetic Joint Infection
Irene L Kalbian1, Karan Goswami2, Timothy L Tan2
1Rothman Orthopaedic Institute, Philadelphia, PA; Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA.
Background:
While the prevailing belief is that periprosthetic joint infection (PJI) caused by Gram-negative (GN) organisms confers a poorer prognosis than Gram-positive (GP) cases, the current literature is sparse and inconsistent. The purpose of this study is to compare the treatment outcomes for GN PJI vs GP PJI and Gram-mixed (GM) PJI.
Methods:
A retrospective review of 1189 PJI cases between 2007 and 2017 was performed using our institutional PJI database. Treatment failure defined by international consensus criteria was compared between PJI caused by GN organisms (n = 45), GP organisms (n = 663), and GM (n = 28) cases. Multivariate regression was used to predict time to failure.
Results:
GM status, but not GN, had significantly higher rates of treatment failure compared to GP PJI (67.9% vs 33.2% failure; hazards ratio [HR] = 2.243, P = .004) in the multivariate analysis. In a subanalysis of only the 2-stage exchange procedures, both GN and GM cases were significantly less likely to reach reimplantation than GP cases (HR = .344, P < .0001; HR = .404, P = .013).
Conclusion:
Although there was no observed difference in the overall international consensus failure rates between GN (31.1% failure) and GP (33.2%) PJI cases, there was significant attrition in the 2-stage exchange GN cohort, and these patients were significantly less likely to reach reimplantation. Our findings corroborate the prevailing notion that GN PJI is associated with poorer overall outcomes vs GP PJI. These data add to the current body of literature, which may currently underestimate the overall failure rates of GN PJI treated via 2-stage exchange and fail to identify pre-reimplantation morbidity.
Insights
Gram-negative periprosthetic joint infection (PJI) shows poorer outcomes, especially in two-stage exchange procedures, compared to Gram-positive PJI. This highlights potential underestimation of failure rates in current literature.
Area of Science:
- Orthopedics
- Infectious Diseases
- Surgical Outcomes
Background:
- Periprosthetic joint infection (PJI) is a serious complication following joint replacement surgery.
- Existing literature on Gram-negative (GN) PJI prognosis is inconsistent.
- Gram-positive (GP) PJI is generally considered to have a better prognosis than GN PJI.
Purpose of the Study:
- To compare treatment outcomes between Gram-negative (GN) PJI, Gram-positive (GP) PJI, and Gram-mixed (GM) PJI.
- To investigate the impact of bacterial type on PJI treatment success.
- To clarify the prognosis of GN PJI versus GP PJI.
Main Methods:
- Retrospective review of 1189 PJI cases (2007-2017).
- Comparison of treatment failure rates based on causative organisms: GN (n=45), GP (n=663), and GM (n=28).
- Multivariate regression analysis to predict time to treatment failure.
Main Results:
- Gram-mixed (GM) PJI showed significantly higher treatment failure rates than GP PJI (67.9% vs 33.2%).
- Gram-negative (GN) PJI did not show a significantly higher overall failure rate than GP PJI (31.1% vs 33.2%).
- In two-stage exchange procedures, both GN and GM cases had significantly lower rates of reimplantation compared to GP cases.
Conclusions:
- While overall failure rates were similar between GN and GP PJI, GN PJI demonstrated significantly poorer outcomes in two-stage exchange procedures.
- Patients with GN PJI undergoing two-stage exchange were less likely to reach reimplantation.
- Findings suggest current literature may underestimate GN PJI failure rates, particularly in two-stage exchange, and overlook pre-reimplantation morbidity.
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