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Updated: Jul 12, 2025
Author Spotlight: Advancing Research on Candida albicans Biofilm-Associated Prosthetic Joint Infections
Published on: February 2, 2024
Gram negative periprosthetic hip infection: nearly 25% same pathogen infection persistence at a mean of 2 years
Daniel Karczewski1, Johann Scholz2, Christian Hipfl1
1Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Chariteplatz 1, 10117, Berlin, Germany.
Purpose:
While gram negative (GN) periprosthetic joint infections (PJI) have previously been described as difficult to treat pathogens with high rates of reinfection, limited investigations have addressed midterm outcomes and risk of infection persistence by the same pathogen. This study analyzed (1) baseline demographics, treatment strategy, and midterm outcomes of GN PJIs, as well as (2) differences in reinfection and relapse rates compared to gram positive (GP) PJIs.
Methods:
We identified 29 patients that were revised for 30 GN PJIs of total hip arthroplasties (THAs) between 2010 and 2020 using a university-based hip registry. Mean age was 77 years, 63% were females (19), and mean BMI was 27 kg/m2. Major causative pathogens included Escherichia coli (12), Klebsiella pneumoniae (5), Pseudomonas aeruginosa (5), and Enterobacter cloacae complex (5). Mean follow-up was 3.5 years. Study outcomes included (1) Kaplan-Meier survivorship analyses of all 30 GN PJIs, and (2) comparison of 18 two-stage exchanges for GN PJIs and 104 two-stage exchanges for GP PJIs, performed during the time from 2013 to 2017.
Results:
(1) The 5-year survivorship free of recurrent PJI was 69%, and there were 7 recurrent PJIs at a mean of 2 years. There were 2 further suprafascial wound infections, resulting in a 61% survivorship free of any infection at 5-years. At a mean of 2 years, there were 7 patients with reinfection by the same GN pathogen (6 PJIs, one wound infection) as at index revision (23%). (2) Following two-stage exchange, the 5-year survivorship free of recurrent PJI (GN: 74%; GP: 91%; p = 0.072), any infection (GN: 61%; GP: 91%; p = 0.001), and reinfection by the same pathogen was significantly lower among GN PJIs (GN: 73%; GP: 98%; p < 0.001).
Conclusions:
Patients revised for GN PJIs are at increased risk of reinfection as opposed to GP infections. Affected patients must be counseled on the exceptionally high risk of infection persistence with one in four developing relapses.
Level Of Evidence:
Therapeutic Level III.
Insights
Gram-negative periprosthetic joint infections (PJIs) have a higher risk of recurrence than gram-positive PJIs. Patients undergoing revision surgery for gram-negative PJI face a significant risk of persistent infection, with approximately 25% experiencing relapses.
Area of Science:
- Orthopedic surgery
- Infectious diseases
- Biomedical engineering
Background:
- Periprosthetic joint infections (PJIs) pose significant challenges in orthopedic surgery.
- Gram-negative (GN) PJIs are often associated with high reinfection rates and difficult treatment.
- Midterm outcomes and pathogen persistence in GN PJIs require further investigation.
Purpose of the Study:
- To analyze the demographics, treatment strategies, and midterm outcomes of GN PJIs.
- To compare reinfection and relapse rates of GN PJIs versus gram-positive (GP) PJIs.
Main Methods:
- Retrospective analysis of 30 GN PJIs in total hip arthroplasties (THAs) from a university hip registry (2010-2020).
- Kaplan-Meier survivorship analysis for GN PJIs.
- Comparison of two-stage exchange outcomes between 18 GN PJIs and 104 GP PJIs (2013-2017).
Main Results:
- Five-year survivorship free of recurrent PJI was 69% for GN PJIs.
- Reinfection by the same GN pathogen occurred in 23% of cases within 2 years.
- Compared to GP PJIs, GN PJIs showed significantly lower 5-year survivorship free of any infection (61% vs. 91%) and reinfection by the same pathogen (73% vs. 98%).
Conclusions:
- Gram-negative PJIs have a substantially higher risk of reinfection and persistence compared to gram-positive PJIs.
- Patients with GN PJIs must be informed about the high likelihood of infection recurrence and the need for vigilant management.
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