Subscribe for unlimited access to DynaMed content, CME/CE & MOC credit, and email alerts on content you follow.

Already subscribed? Sign in now

Learn more about CME

Prosthetic Joint Infection

MoreVert
AddCircleOutlineFollow
ShareShare
AddCircleOutlineFollow
Follow
ShareShare
Share

General Information

Description

  • infection of a prosthetic joint, which may involve the joint space, adjacent bone, or periprosthetic tissue1,2,3
  • most common in patients receiving total knee or hip arthroplasty2
  • most common infecting organisms include Staphylococcus aureus, coagulase-negative staphylococci, streptococci, gram-negative bacilli, enterococci, and Propionibacterium acnes2,3

Definitions

  • infections categorized based on the time since initial surgery1,3
    • early infection develops < 3 months after surgery
    • delayed infection develops from 3 months to 2 years after surgery
    • late infection develops > 2 years after surgery

References

General references used

  1. Osmon DR, Berbari EF, Berendt AR, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013 Jan;56(1):e1-e25OpenInNewfull-textOpenInNew
  2. Del Pozo JL, Patel R. Clinical practice. Infection associated with prosthetic joints. N Engl J Med. 2009 Aug 20;361(8):787-94OpenInNew
  3. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004 Oct 14;351(16):1645-54OpenInNew

Recommendation grading systems used

  • Infectious Disease Society of America (IDSA) grading system for recommendations
    • strength of recommendation grades
      • Grade A - good evidence to support a recommendation for or against use
      • Grade B - moderate evidence to support a recommendation for or against use
      • Grade C - poor evidence to support a recommendation
    • quality of evidence ratings
      • I - evidence from ≥ 1 properly randomized, controlled trial
      • II - evidence from ≥ 1 well-designed clinical trial, without randomization; from cohort or case-controlled analytic studies (preferably from > 1 center); from multiple time-series; or from dramatic results from uncontrolled experiments
      • III - evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
  • American Society of Health-System Pharmacists/Infectious Diseases Society of America/Surgical Infection Society/Society for Healthcare Epidemiology of America (ASHP/IDSA/SIS/SHEA) grading system for recommendations
    • categories of recommendation
      • Category A - based on levels I-III
      • Category B - based on levels IV-VI
      • Category C - based on level VII
    • levels of evidence
      • Level I - evidence from large, well-conducted, randomized controlled clinical trials, or a meta-analysis
      • Level II - evidence from small, well-conducted, randomized controlled clinical trials
      • Level III - evidence from well-conducted cohort studies
      • Level IV - evidence from well-conducted case-control studies
      • Level V - evidence from uncontrolled studies that were not well conducted
      • Level VI - conflicting evidence that tends to favor the recommendation
      • Level VII - expert opinion or data extrapolated from evidence for general principles and other procedures
  • American Academy of Orthopaedic Surgeons/American Dental Association (AAOS/ADA) grading system for recommendations
    • Limited - quality of supporting evidence is unconvincing, or well-conducted studies show little clear advantage to 1 approach over another
    • Inconclusive - lack of compelling evidence with unclear balance between benefits and potential harm
    • Consensus - expert opinion supports recommendation despite no available empirical evidence meeting inclusion criteria of guideline's systematic review
    • Reference - AAOS/ADA joint guideline on prevention of prosthetic joint infection in dental procedures (23457068J Am Acad Orthop Surg 2013 Mar;21(3):180OpenInNew)

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • Frederick Lee, MD, PhD (Independent Consultant, Best Doctors; Massachusetts, United States)
  • Amir Qaseem, MD, PhD, MHA, FACP (Vice President of Clinical Policy, American College of Physicians; Pennsylvania, United States; President Emeritus, Guidelines International Network (GIN); Germany)
  • Dr. Qaseem declares no relevant financial conflicts of interest.
  • Alan Ehrlich, MD (Executive Editor; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States)
  • Dr. Ehrlich declares no relevant financial conflicts of interest.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T903638, Prosthetic Joint Infection; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T903638. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Definitions

  • KeyboardArrowRight

    Epidemiology

    • Incidence/Prevalence

    • Risk factors

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • Clinical presentation

    • KeyboardArrowRight

      History

      • History of present illness (HPI)

      • Medication history

      • Past medical history (PMH)

    • Physical

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • KeyboardArrowRight

      Blood tests

      • Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)

      • Other biochemical markers

      • Blood cultures

    • Imaging studies

    • KeyboardArrowRight

      Synovial fluid analysis

      • KeyboardArrowRight

        Total leukocyte count and differential

        • Diagnosis of initial infection

        • Diagnosis of persistent infection

      • Synovial fluid culture

      • Biomarkers

    • KeyboardArrowRight

      Biopsy and pathology

      • Synovial biopsy

      • KeyboardArrowRight

        Intraoperative testing

        • Histopathology

        • Bacterial culture

        • Combination testing strategies

  • KeyboardArrowRight

    Management

    • Management overview

    • Medications

    • KeyboardArrowRight

      Surgery and procedures

      • Debridement with retention of prosthesis

      • KeyboardArrowRight

        Reimplantation surgery

        • 2-stage procedure

        • 1-stage procedure

        • 1-stage vs. 2-stage

      • Permanent resection arthroplasty

      • Amputation

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • Prognosis

  • KeyboardArrowRight

    Prevention and Screening

    • Prevention

  • KeyboardArrowRight

    Quality Improvement

    • Physician Quality Reporting System Quality Measures

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • United States guidelines

      • European guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Frederick Lee MD, PhD
KeyboardArrowDown
Affiliations

Independent Consultant, Best Doctors; Massachusetts, United States

Recommendations Editor
Amir Qaseem MD, PhD, MHA, FACP
KeyboardArrowDown
Affiliations

Vice President of Clinical Policy, American College of Physicians; Pennsylvania, United States; President Emeritus, Guidelines International Network; Germany

Conflicts of Interest

Dr. Qaseem declares no relevant financial conflicts of interest.

Deputy Editor
Alan Ehrlich MD
KeyboardArrowDown
Affiliations

Executive Editor, DynaMed; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Ehrlich declares no relevant financial conflicts of interest.

Images in topic (1)

View all
Prosthetic joint infection

Prosthetic joint infection

CheckCircle
Subscribe for unlimited access to DynaMed content.
Already subscribed? Sign in

top