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Management and outcomes of culture-negative periprosthetic joint infection: a systematic review and meta-analysis
Farzad Pourghazi1, Seyed Mohammad Amin Alavi2, Takahiro Matsuo3
1Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA.
Abstract:
Introduction: Culture-negative periprosthetic joint infection (CN-PJI) remains a major diagnostic and therapeutic challenge because antimicrobial and surgical management are often empirical. Methods: We performed a systematic review and meta-analysis to evaluate treatment strategies and outcomes of CN-PJI. MEDLINE and Scopus were searched through 3 July 2025, and 27 cohort studies including 1399 CN-PJI patients were included. Results: Random-effect meta-analyses showed a pooled treatment success proportion of 83.6 % (95 % CI, 78.2-87.9), a pooled failure proportion of 17.2 % (95 % CI, 12.6-22.9), and a pooled mortality proportion of 2.4 % (95 % CI, 1.3-4.6). Subgroup analyses demonstrated lower success and higher failure with debridement, antibiotics, and implant retention compared with one-stage and two-stage exchange arthroplasty. Hip CN-PJI showed higher reported success than knee CN-PJI. Antimicrobial regimens were highly heterogeneous and were not suitable for pooled analysis. Conclusion: Overall, CN-PJI may have favorable outcomes, particularly with exchange arthroplasty, but prospective studies with standardized definitions and treatment reporting are needed.
Insights
Culture-negative periprosthetic joint infection (CN-PJI) treatment has a high success rate, especially with exchange arthroplasty. Further research is needed for standardized management of this challenging condition.
Area of Science:
- Orthopedics
- Infectious Diseases
- Medical Microbiology
Background:
- Culture-negative periprosthetic joint infection (CN-PJI) presents significant diagnostic and therapeutic hurdles.
- Current management often relies on empirical antimicrobial and surgical approaches.
Purpose of the Study:
- To systematically review and meta-analyze treatment strategies and outcomes for CN-PJI.
- To identify factors influencing treatment success and failure in CN-PJI patients.
Main Methods:
- Systematic review and meta-analysis of 27 cohort studies.
- Inclusion of 1399 patients diagnosed with CN-PJI.
- Searches conducted in MEDLINE and Scopus databases up to July 3, 2025.
Main Results:
- Pooled treatment success proportion of 83.6% (95% CI, 78.2-87.9).
- Pooled failure proportion of 17.2% (95% CI, 12.6-22.9) and mortality of 2.4% (95% CI, 1.3-4.6).
- Exchange arthroplasty demonstrated higher success rates than debridement, antibiotics, and implant retention; hip CN-PJI had better outcomes than knee CN-PJI.
Conclusions:
- CN-PJI can achieve favorable outcomes, particularly with exchange arthroplasty.
- Significant heterogeneity in antimicrobial regimens precludes pooled analysis.
- Prospective studies with standardized definitions and reporting are essential for advancing CN-PJI management.
