Louis Pasteur once said that: “Fortune favours the prepared mind.” As one of the great scientists who contributed to the fight against infection, he emphasised the importance of being prepared at all times to recognise infection and deal with it. Despite the many scientific discoveries and technological advances, such as the advent of antibiotics and the use of sterile techniques, infection continues to be a problem that haunts orthopaedic surgeons and inflicts suffering on patients.
The medical community has implemented many practices with the intention of preventing infection and treating it effectively when it occurs. Although high-level evidence may support some of these practices, many are based on little to no scientific foundation. Thus, around the world, there is great variation in practices for the prevention and management of periprosthetic joint infection.
This paper summaries the instigation, conduct and findings of a recent International Consensus Meeting on Surgical Site and Periprosthetic Joint Infection.
Cite this article: Bone Joint J 2013;95-B:1450–2.
Prior to the annual meeting of the Musculoskeletal Infection Society and supported by the same organisation and the European Bone and Joint Infection Society (EBJIS), more than 400 experts from many disciplines including orthopaedic surgery, infectious disease, musculoskeletal pathology, microbiology, anaesthetics, dermatology, nuclear medicine, rheumatology, musculoskeletal radiology, veterinary surgery, pharmaceutics, and scientists with an interest in orthopaedic infections came together to evaluate the available evidence, when present, or reach consensus regarding current practices for the management of surgical site infection (SSI) and periprosthetic joint infection (PJI). Fifteen working groups were organised with each group being led by two or three leaders. A liaison for each working group was responsible for reviewing the literature and the initial drafting of the consensus statements that were continuously debated among delegates and eventually presented to the general assembly for voting.
During the ten months prior to the meeting, the members of each working group communicated electronically to evaluate the current literature related to infection in Orthopaedic Surgery from more than 3500 publications and to devise consensus statements on current practices for preventing, diagnosing and managing SSI and PJI, depending on specific questions formulated for each group. More than 23 500 emails were exchanged, and more than 200 delegates communicated through an online forum dedicated to discussing the consensus statements. Within this forum, 31 discussion pages were developed, 131 members posted comments or started a discussion on the forum, and there were a total of 25 196 page views.
After synthesising the literature and assembling a preliminary draft of the consensus statement, more than 300 delegates from 52 countries gathered in Philadelphia to discuss these topics between July 31 and August 1 2013. They first met in their small groups to resolve any discrepancies and finalise their statements. They then met in the general assembly to discuss and comment on the statements developed by the other working groups. After revising the consensus statements, the finalised statement was assembled and presented for voting the next day.
The voting process was conducted with electronic keypads, where one could agree or disagree with the statement, or abstain. The strength of the consensus was judged on the following scale: 1) simple majority: no consensus (50.1% to 59% agreement), 2) majority: weak consensus (60% to 65% agreement), 3) super majority: strong consensus (66% to 99% agreement) and 4) unanimous: 100% agreement.
Of the 207 questions, one question received a unanimous vote – 100% agreement was reached on the statement that operating room traffic should be kept to a minimum. At the other end of the spectrum, only one question did not reach a simple majority. The statement: “The incidence of SSI and PJI may be lower with the use of porous metal (tantalum) implants at revision arthroplasty compared to titanium” received 44% agreement, with 33% disagreeing and 23% abstaining. Consensus was weak for three questions. All the remaining 198 questions reached strong consensus. Examples of some questions that were addressed and for which consensus was developed are shown in Tables I to III.
|Question||Consensus statement||Strength of consensus (agreement in %)|
|What is the role of oral hygiene for patients undergoing an elective arthroplasty?||All patients undergoing elective arthroplasty should be screened for evidence of active infection. This may be performed by administration of a questionnaire or dental examination.||Strong (80)|
|What should the process be for methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA) screening?||While this workgroup does NOT recommend universal screening and decolonisation of all patients undergoing joint arthroplasty, it accepts that pre-operative screening for Staphylococcus aureus (MSSA and MRSA) and decolonisation decreases the rate of SSI and the incidence of staphylococcal and non-staphylococcal infections.||Strong (85)|
|What is the role of routine urine screening in patients undergoing an elective arthroplasty?||Routine urine screening is NOT warranted for patients undergoing elective arthroplasty. Urine screening prior to elective arthroplasty should be reserved for patients with a present history or symptoms of a urinary tract infection (UTI).||Strong (74)|
|Should disease-modifying agents be stopped prior to elective total joint arthroplasty (TJA)?||Yes. Disease-modifying agents should be stopped prior to elective TJA. The timing of drug discontinuation should be based on the specific medication and the individual patient. The cessation of immunosuppressant medications should be performed in consultation and under the direction of the treating physician.||Strong (92)|
|What type and when should pre-operative skin cleansing with an antiseptic be implemented?||We recommend that whole-body skin cleansing should start at least the night prior to elective arthroplasty. It is a consensus that after bathing, patients are advised to sleep in clean garments and bedding without the application of any topical products.||Strong (85)|
|How should the surgeon and assistants wash their hands?||The surgeon and operating room personnel should mechanically wash their hands with an antiseptic agent for a minimum of 2 minutes for the first case. A shorter period may be appropriate for subsequent cases.||Strong (71)|
|Is there an optimal antibiotic that should be administered for routine peri-operative surgical prophylaxis?||A first or second-generation cephalosporin (cefazolin or cefuroxime) should be administered for routine peri-operative surgical prophylaxis. Isoxazolyl penicillin is used as an appropriate alternative.||Strong (89)|
|Is there evidence to support the routine use of vancomycin for pre-operative prophylaxis?||No. Routine use of vancomycin for pre-operative prophylaxis is not recommended.||Strong (93)|
|Does antibiotic-impregnated cement reduce the incidence of PJI following elective primary TJA?||Yes. Antibiotic-impregnated polymethylmethacrylate cement (ABX-PMMA) reduces the incidence of PJI following TJA and should be used in patients at high risk for PJI following elective arthroplasty.||Strong (90)|
|What are the indications for reoperation for a persistently draining wound after TJA?||A wound that has been persistently draining for greater than 5 to 7 days from the time of diagnosis should be re-operated on without delay.||Strong (77)|
|Question||Consensus statement||Strength of consensus (agreement in %)|
|What is the definition of a periprosthetic joint infection (PJI)?||Two positive periprosthetic cultures with phenotypically identical organisms, or A sinus tract communicating with the joint, or Having 3 of the following minor criteria:- Elevated serum; C-reactive protein (CRP) AND erythrocyte sedimentation rate (ESR); Elevated synovial fluid white blood cell (WBC) count; OR ++ change on leukocyte esterase test strip; Elevated synovial fluid polymorphonuclear neutrophil percentage (PMN%); Positive histological analysis of periprosthetic tissue; A single positive culture||Strong (85)|
|What should the threshold be for ESR, serum CRP, PMN%, and WBC count for CHRONIC PJI?||The approximate cutoffs listed below apply to tests obtained more than six weeks from the most recent surgery: ESR > 30 mm/hr; CRP > 10 mg/L; Synovial WBC count > 3,000 cells per/μL; and Synovial PMN% > 80%.||Strong (81)|
|How long should routine cultures be kept?||We recommend that routine cultures should be maintained between 5 and 14 days. In cases of suspected PJI with low virulence organisms or if pre-operative cultures have failed to show bacterial growth and the clinical picture is consistent with PJI (suspected culture-negative PJI) the cultures should be maintained for 14 days or longer.||Strong (93)|
|How many intra-operative tissue samples should be sent for culture in suspected PJI cases and cases of suspected aseptic failure?||During revision procedures, more than three but not more than six distinct intra-operative tissue samples should be sent for aerobic and anaerobic culture.||Strong (88)|
|Is there a role for routine sonication of the prosthesis? If so, in which group of patients should this be done?||NO. We do not recommend routine sonication of explants. Its use should be limited to cases of suspected or proven PJI (based upon presentation and other testing) in which pre-operative aspiration does not yield positive culture and antibiotics have been administered within the previous two weeks.||Strong (84)|
|Is there a role for imaging modalities in the diagnosis of PJI?||Plain radiographs should be performed in all cases of suspected PJI. Magnetic resonance imaging (MRI), computed tomography (CT), and nuclear imaging currently do not have a direct role in the diagnosis of PJI but may be helpful in the identification of other causes of joint pain/failure.||Strong (93)|
|Question||Consensus statement||Strength of consensus (agreement in %)|
|Which antibiotic should be used and how much of it should be added to cement spacers?||The type of antibiotic and the dose needs to be individualised for each patient based on the organism profile and antibiogram (if available) as well as the patient’s renal function and allergy profile. However, most infections can be treated with a spacer with Vancomycin (1 to 4 g per 40 g package of cement) and gentamicin or tobramycin (2.4 g to 4.8 g per 40 g package of cement). We provide a list of all available antibiotics and the range of doses to be used against common infecting organisms.||Strong (89)|
|When can irrigation and debridement (I& D) be considered?||I& D may be performed for early postoperative infections that occur within three months of index primary arthroplasty with less than three weeks of symptoms.||Strong (84)|
|What are the contraindications for I& D?||The inability to close a wound or the presence of a sinus tract are absolute contraindications to performing an I& D and retention of the prosthesis. Another absolute contraindication is the presence of a loose prostheses.||Strong (95)|
|Is joint aspiration necessary prior to reimplantation?||There is no conclusive evidence to support mandatory joint aspiration prior to reimplantation. It may be useful in selected cases. We recommend against infiltration of any liquids into the affected joint and reaspiration in patients with an initial dry aspirate.||Strong (89)|
|What are the indications and contraindications for one-stage exchange arthroplasty?||One stage-exchange arthroplasty is a reasonable option for the treatment of PJI in circumstances where effective antibiotics are available but not in patients with systemic manifestations of infection (sepsis) in whom resection arthroplasty and reduction of bioburden may be necessary. Relative contraindications to performing a one-stage exchange may include lack of identification of an organism pre-operatively, the presence of a sinus tract or severe soft-tissue involvement that may lead to the need for flap coverage.||Strong (78)|
|What is the optimal interval between two stages?||There is no definitive evidence in the literature as to the optimal time interval between the two stages. Reports vary from two weeks to several months.||Strong (87)|
|How many I& Ds are reasonable before implant removal is considered?||Following failure of one I& D, the surgeon should give consideration to implant removal.||Strong (94)|
Infection is a disease state that knows no boundaries and can affect any patient who undergoes surgical treatment. The development of an international community to consider infection in orthopaedic surgery will allow representatives from different countries to discuss pertinent topics, share ideas, and devise appropriate multinational studies to help in the management of these infections. In doing so, it is our hope that orthopaedic infections can be minimised and that this devastating complication may even be eliminated.
The purpose of the Infection Consensus Meeting was to bring together international experts with the intention of agreeing on ways of preventing, diagnosing and treating SSIs and PJIs. Cultural differences and barriers were discussed and addressed. The consensus process was designed to agree on what we know, agree on what we do not know, and look further into what we need to do. The final document, which contains 362 pages, provides a comprehensive approach to addressing some of the issues that face the medical community on a daily basis in this area. The statements were developed after thorough review of all the available literature with an unprecedented number of exchanges and discussions among experts. Surprisingly, consensus was reached on all but four questions. The knowledge and collective wisdom that is summarised in the document will now be available to all those involved in the care of orthopaedic patients. We hope that this initiative will accomplish its intended goal of reducing the burden of PJI and by minimising variations in care across the globe, and reduce wasted resources in healthcare.
While developing this consensus can be considered to have been extremely successful, challenges still lie ahead. This initiative has further confirmed that there are vast areas of Orthopaedic Surgery for which little evidence exists and suggests another way of gathering information and evidence that is relevant to every day practice.
This article has been written on behalf of the International Consensus Group on Peri-prosthetic Joint Infection. The meeting was funded by Zimmer, 3M, Link, Biomet, CeramTec, Convatec, Exactech, Tecres, Stryker, Aesculap, Endoklinik, Rothman Institute, Thomas Jefferson University, Merete, Smith & Nephew, Arthrex, and Musculoskeletal Infection Society, Arthrex, Molnlycke, Boehringer Ingelheim, Cempra, Cubist, Medtronics and Nimbic Systems.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Supplementary material. The full report from the International Consensus on Periprosthetic Joint Infection is available with the electronic version of this article on our website www.bjj.boneandjoint.org.uk.