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Microbiology, Treatment, and Postoperative Outcomes of Gram-Negative Prosthetic Joint Infections-A Systematic Review
Marcos R Gonzalez1, Julian Gonzalez, Roshan V Patel
1From the Department of Orthopaedic Surgery, Division of Orthopaedic Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (MR Gonzalez, J Gonzalez, Patel, Werenski, and Lozano-Calderon), and the Rothman Institute of Orthopaedics at Thomas Jefferson University Hospital Philadelphia, PA (Lizcano).
Introduction:
Gram-negative prosthetic joint infections (PJIs) represent 10% to 25% of all PJIs and are associated with worse outcomes than gram-positive infections. We sought to assess the microbiology, surgical treatment, and outcomes of patients with gram-negative PJIs.
Methods:
A systematic review using the PubMed and Embase databases was conducted. Our study was conducted following the PRISMA guidelines. Included studies were assessed for quality using the STROBE checklist. The primary outcome of analysis was treatment failure.
Results:
A total of 593 patients with gram-negative PJIs were included. Two-year survival free of treatment failure for hip and knee PJIs was 66% and 68% for acute infections, 39% and 78% for acute hematogenous infections, and 75% and 63% for chronic infections, respectively. Two-year survival free of treatment failure for acute infections treated with débridement, antibiotics, and implant retention was 65% and 67% for hip and knee PJIs, respectively. Exchange of the polyethylene during débridement, antibiotics, and implant retention was associated with higher treatment success ( P = 0.045). Chronic PJIs treated with two-stage revision had a two-year treatment success rate of 87% and 65% for the hip and knee, respectively. Risk factors of treatment failure were chronic obstructive pulmonary disease and C-reactive protein ≥30 mg/L in acute PJIs and female sex, knee infection, and previously revised implant in chronic PJIs. Acute PJIs caused by Pseudomonas spp. were associated with lower treatment failure rates.
Conclusion:
Gram-negative PJIs are associated with a high treatment failure rate. Patient comorbidities, preoperative biochemical tests, microorganism etiology, and PJI characteristics affected the treatment success rate.
Insights
Gram-negative prosthetic joint infections (PJIs) have high failure rates. Treatment success depends on infection type, patient factors, and surgical approach, with two-stage revision showing promise for chronic cases.
Area of Science:
- Orthopedics
- Infectious Diseases
- Surgical Innovation
Background:
- Gram-negative prosthetic joint infections (PJIs) comprise 10-25% of all PJIs.
- These infections are linked to poorer outcomes compared to gram-positive PJIs.
Purpose of the Study:
- To evaluate the microbiology, surgical management, and outcomes of gram-negative PJIs.
- To identify factors influencing treatment success in gram-negative PJIs.
Main Methods:
- Systematic review of PubMed and Embase databases.
- Adherence to PRISMA guidelines and STROBE checklist for quality assessment.
- Primary outcome was treatment failure.
Main Results:
- Included 593 patients with gram-negative PJIs.
- Two-year survival free of treatment failure varied by infection type (acute, hematogenous, chronic) and joint (hip/knee).
- Two-stage revision for chronic PJIs showed 87% (hip) and 65% (knee) success; polyethylene exchange during debridement, antibiotics, and implant retention improved success (P=0.045).
- Risk factors for failure included comorbidities (COPD, CRP levels), patient sex, and infection site.
Conclusions:
- Gram-negative PJIs are associated with significant treatment failure rates.
- Treatment success is influenced by patient comorbidities, preoperative biomarkers, causative microorganisms, and PJI characteristics.
