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Reinfection Patterns Following Two-Stage Exchange for Periprosthetic Joint Infection: A Retrospective Analysis
Calvin C Chandler1, Andrew J Clair2, Rory W Metcalf2
1Atrium Health Musculoskeletal Institute, Charlotte, North Carolina.
Background:
Periprosthetic joint infection (PJI) is a challenging complication following total joint arthroplasty. A two-stage exchange has been the gold standard in the treatment of chronic PJI. However, when this fails, further treatment options become limited. In patients who fail two-stage exchange, the reinfecting organism is different from the original in 50 to 80% of the occurrences. This study aimed to understand reinfection patterns in an attempt to better predict reinfecting organisms to improve the management of PJI.
Methods:
A retrospective query of our institution's PJI registry identified 185 patients (188 procedures, 110 knees, and 78 hips) who underwent a first-time two-stage exchange for culture-positive chronic PJI of total knee and hip arthroplasties from January 2010 to December 2020. Patients who had polymicrobial infections, culture-negative results, or fungal infections were excluded. The primary outcome variable was reoperation for reinfection and comparing the index organism to the reinfecting organisms.
Results:
Of the 188 procedures, 31 (16.5%) failed due to reinfection. Among reinfections, 30 (96.8%) were gram-positive, with Staphylococcus aureus species accounting for 22 (71.0%) of the cases. The most common organisms cultured were for methicillin-sensitive S. Aureus, methicillin-resistant S. Aureus, coagulase-negative staphylococcus, and streptococcus. Of reinfections, 19 (61.3%) had a different organism, eight (25.8%) had the same organism, and four (12.9%) were culture-negative. Patients experiencing reinfection were significantly younger (P = 0.012), with no other patterns or predictors identified.
Conclusions:
The majority of reinfections following a two-stage exchange for PJI occur with a different organism than the index infection. We did not find a reliable method to predict the reinfecting organisms based on the initial infecting organism alone. However, the same four gram-positive organisms were the most frequently encountered in both the primary infection and the reinfection. Further research is required to understand factors contributing to reinfection and help guide prevention strategies.
Insights
Most periprosthetic joint infection (PJI) recurrences after two-stage exchange involve different bacteria. Younger patients were more prone to reinfection, but predicting the specific organism remains challenging.
Area of Science:
- Orthopedic Surgery
- Infectious Disease
- Microbiology
Background:
- Periprosthetic joint infection (PJI) is a serious complication of total joint arthroplasty.
- Two-stage exchange is the standard treatment for chronic PJI, but treatment failures limit options.
- Reinfection with a different organism occurs in 50-80% of cases after failed two-stage exchange.
Purpose of the Study:
- To analyze reinfection patterns after two-stage exchange for PJI.
- To identify predictors of reinfecting organisms.
- To improve the management of PJI.
Main Methods:
- Retrospective review of 188 two-stage exchange procedures for chronic PJI (knees and hips) from 2010-2020.
- Exclusion of polymicrobial, culture-negative, and fungal infections.
- Comparison of index and reinfecting organisms.
Main Results:
- 16.5% of procedures failed due to reinfection.
- Most reinfections (96.8%) were gram-positive, primarily Staphylococcus aureus (71.0%).
- Reinfecting organisms differed from the index infection in 61.3% of cases; younger patients were more susceptible.
Conclusions:
- Reinfection after two-stage exchange often involves a different organism than the initial infection.
- Predicting reinfecting organisms based solely on the index organism is unreliable.
- Further research is needed to understand reinfection factors and guide prevention.
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