The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print.
The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph Fig. I never thought it would be so easy. No hassles. Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly.
My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it. An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR". Rajendra Kumar Ghritlaharey "I wish to thank Dr. Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines.
All the research studies published were performed in accordance to the Declaration of Helsinki. Written consent was obtained from all the included subjects or the responsible next kin , where ever applicable. In case reports or any article which includes patients images, permission was sought from the patient or the responsible next kin for publication.
Whether or not this has been explicitly stated in the manuscript, this was declared by the authors at the time of submission of manuscript to the journal. In a rare event, if the consent could not be obtained due to loss of patient for follow up or death or loss of contact, even after reasonable effort, the editors then decided on case by case basis, weighing on the individual contribution the report will make to advancement of medical literature.
Users Online : Simple Search Advanced Search. Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination.
Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal. Salient features of the JCDR: It is a biomedical, multidisciplinary including all medical and dental specialities , e-journal, with wide scope and extensive author support.
There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb of its first issue, it contained 5 articles only, and now in its recent volume published in April , it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, as stated by Editor-in-chief in his preface to first edition i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care.
I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help.
JCDR provides authors help in this regards. Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc.
This is one of the great reasons for authors to submit their work with JCDR. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers. Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
Source: [ 5 ]. Preoperative Evaluation Figure 1. Suspect PJI in patients with any of the following B-III : A sinus tract or persistent wound drainage over a joint prosthesis, acute onset of a painful prosthesis, or any chronic painful prosthesis at any time after prosthesis implantation, particularly in the absence of a pain-free interval, in the first few years following implantation or if there is a history of prior wound healing problems or superficial or deep infection.
Items that should be obtained in the history include the type of prosthesis, date of implantation, past surgeries on the joint, history of wound healing problems following prosthesis implantation, remote infections, current clinical symptoms, drug allergies and intolerances, comorbid conditions, prior and current microbiology results from aspirations and surgeries, and antimicrobial therapy for the PJI including local antimicrobial therapy C-III.
A test for sedimentation rate or C-reactive protein CRP should be performed in all patients with a suspected PJI when the diagnosis is not clinically evident. A diagnostic arthrocentesis should be performed in all patients with suspected acute PJI unless the diagnosis is evident clinically and surgery is planned and antimicrobials can be safely withheld prior to surgery.
Arthrocentesis is also advised in patients with a chronic painful prosthesis in whom there is an unexplained elevated sedimentation rate or CRP level A-III or in whom there is a clinical suspicion of PJI. It may not be necessary if in this situation surgery is planned and the result is not expected to alter management. Synovial fluid analysis should include a total cell count and differential leukocyte count, as well as culture for aerobic and anaerobic organisms A-III.
A crystal analysis can also be performed if clinically indicated. In PJI where the patient is medically stable, withholding antimicrobial therapy for at least 2 weeks prior to collection of synovial fluid for culture increases the likelihood of recovering an organism B-III.
Blood cultures for aerobic and anaerobic organisms should be obtained if fever is present, there is an acute onset of symptoms, or if the patient has a condition or suspected condition or concomitant infection or pathogen eg Staphylococcus aureus that would make the presence of a bloodstream infection more likely B-III.
Imaging studies such as bone scans, leukocyte scans, magnetic resonance imaging, computed tomography, and positron emission tomography scans should not be routinely used to diagnose PJI B-III.
Preoperative and intraoperative diagnosis of prosthetic joint infection. Abbrevation: CRP, C-reactive protein. Intraoperative histopathological examination of periprosthetic tissue samples is a highly reliable diagnostic test provided that a pathologist skilled in interpretation of periprosthetic tissue is available. It should be performed at the time of revision prosthetic joint surgery, when available, if the presence of infection is in doubt based on the clinical suspicion of the surgeon and the results will affect management, for example, in deciding between revision arthroplasty and 2-stage exchange B-III.
At least 3 and optimally 5 or 6 periprosthetic intraoperative tissue samples or the explanted prosthesis itself should be submitted for aerobic and anaerobic culture at the time of surgical debridement or prosthesis removal to maximize the chance of obtaining a microbiologic diagnosis B-II. When possible see above , withholding antimicrobial therapy for at least 2 weeks prior to collecting intraoperative culture specimens increases the yield of recovering an organism A-II.
The presence of acute inflammation as seen on histopathologic examination of periprosthetic tissue at the time of surgical debridement or prosthesis removal as defined by the attending pathologist is highly suggestive evidence of PJI B-II. Two or more intraoperative cultures or combination of preoperative aspiration and intraoperative cultures that yield the same organism indistinguishable based on common laboratory tests including genus and species identification or common antibiogram may be considered definitive evidence of PJI.
Growth of a virulent microorganism eg, S. One of multiple tissue cultures or a single aspiration culture that yields an organism that is a common contaminant eg, coagulase-negative staphylococci, Propionibacterium acnes should not necessarily be considered evidence of definite PJI and should be evaluated in the context of other available evidence B-III. The ultimate decision regarding surgical management should be made by the orthopedic surgeon with appropriate consultation eg, infectious diseases, plastic surgery as necessary C-III.
Patients who do not meet these criteria but for whom alternative surgical strategies are unacceptable or high risk may also be considered for a debridement and retention strategy, but relapse of infection is more likely B-III. A 2-stage exchange strategy is commonly used in the United States and is indicated in patients who are not candidates for a 1-stage exchange who are medically able to undergo multiple surgeries and in whom the surgeon believes reimplantation arthroplasty is possible, based on the existing soft tissue and bone defects Figure 3 ; B-III.
Obtaining a prerevision sedimentation rate and CRP is recommended by the panel to assess the success of treatment prior to reimplantation C-III. The panel believes that in selected circumstances more than one 2-stage exchange if the first attempt fails can be successful C-III.
A 1-stage or direct exchange strategy for the treatment of PJI is not commonly performed in the United States but may be considered in patients with a total hip arthroplasty THA infection who have a good soft tissue envelope provided that the identity of the pathogens is known preoperatively and they are susceptible to oral antimicrobials with excellent oral bioavailability. There may be a greater risk of failure if bone grafting is required and effective antibiotic impregnated bone cement cannot be utilized Figure 3 ; C-III.
Permanent resection arthroplasty may be considered in nonambulatory patients; patients with limited bone stock, poor soft tissue coverage, or infections due to highly resistant organisms for which there is limited medical therapy; patients with a medical condition precluding multiple major surgeries; or patients who have failed a previous 2- stage exchange in which the risk of recurrent infection after another staged exchange is deemed unacceptable Figure 4 ; B-III.
Amputation should be the last option considered but may be appropriate in selected cases. Except in emergent cases, referral to a center with specialist experience in the management of PJI is advised before amputation is carried out Figure 4 ; B-III.
Management of prosthetic joint infection—removal of prosthesis. Abbreviation: THA, total hip arthroplasty. Management of prosthetic joint infection when patients are not a candidate for new prosthesis. Two to 6 weeks of a pathogen-specific intravenous antimicrobial therapy Table 2 in combination with rifampin — mg orally twice daily followed by rifampin plus a companion oral drug for a total of 3 months for a THA infection and 6 months for a total knee arthroplasty TKA infection A-I.
Secondary companion drugs to be used if in vitro susceptibility, allergies, intolerances, or potential intolerances support the use of an agent other than a quinolone include but are not limited to co-trimoxazole A-II , minocycline or doxycycline C-III , or oral first-generation cephalosporins eg, cephalexin or antistaphylococcal penicillins eg, dicloxacillin; C-III.
If rifampin cannot be used because of allergy, toxicity, or intolerance, the panel recommends 4—6 weeks of pathogen-specific intravenous antimicrobial therapy B-III. Monitoring of outpatient intravenous antimicrobial therapy should follow published guidelines A-II [ 6 ].
Indefinite chronic oral antimicrobial suppression may follow the above regimen with cephalexin, dicloxacillin, co-trimoxazole, or minocycline based on in vitro susceptibility, allergies, or intolerances Table 3 ; B-III. Rifampin alone is not recommended for chronic suppression, and rifampin combination therapy is not generally recommended. One member of the panel uses rifampin combination therapy for chronic suppression in selected situations A.
The recommendation regarding using suppressive therapy after rifampin treatment was not unanimous W. Clinical and laboratory monitoring for efficacy and toxicity is advisable. The decision to offer chronic suppressive therapy must take into account the individual circumstances of the patient including the ability to use rifampin in the initial phase of treatment, the potential for progressive implant loosening and loss of bone stock, and the hazards of prolonged antibiotic therapy; it is therefore generally reserved for patients who are unsuitable for, or refuse, further exchange revision, excision arthroplasty, or amputation.
Antimicrobials should be chosen based on in vitro susceptibility as well as patient drug allergies, intolerances, and potential drug interactions or contraindications to a specific antimicrobial. Clinical and laboratory monitoring for efficacy and safety should occur based on prior IDSA guidelines [6].
The possibility of prolonged QTc interval and tendinopathy should be discussed and monitored when using fluoroquinolones. The possibility of Clostridium difficile colitis should also be discussed when using any antimicrobial. Oxacillin can also be substituted. Recent guidelines [ , ] for the treatment of methicillin-resistant Staphylococcus aureus MRSA infections have been published.
These guidelines suggest that dosing of vancomycin be considered to achieve a vancomycin trough at steady state of 15 to Although this may be appropriate for MRSA PJI treated without rifampin or without the use of local vancomycin spacer, it is unknown if these higher trough concentrations are necessary when rifampin or vancomcyin impregnated spacers are utilized.
Trough concentrations of at least 10 may be appropriate in this situation. It is also unknown if treatment of oxacillin-resistant, coagulase-negative staphylococci require vancomycin dosing to achieve these higher vancomycin levels. Abbreviations: bid, twice daily; DS, double strength; PO, per oral; qid, 4 times daily; tid, 3 times daily. Four to 6 weeks of pathogen-specific intravenous or highly bioavailable oral antimicrobial therapy Table 2 ; B-II.
Indefinite chronic oral antimicrobial suppression may follow the above regimens Table 3 based on in vitro sensitivities, allergies, and intolerances B-III. Chronic suppression after fluoroquinolone treatment of PJI due to gram-negative bacilli was not unanimously recommended W.
Similar considerations regarding hazards and effectiveness apply to those above. Four to 6 weeks of pathogen-specific intravenous or highly bioavailable oral antimicrobial therapy is recommended Table 2 ; A-II. Two to 6 weeks of pathogen-specific intravenous antimicrobial therapy in combination with rifampin — mg orally twice daily followed by rifampin plus a companion oral drug for a total of 3 months is recommended Table 2 ; C-III.
Secondary companion drugs to be used if in vitro susceptibility, allergies, intolerances, or potential intolerances support the use of an agent other than a quinolone include but are not limited to co-trimoxazole A-II , minocycline or doxycycline B-III , or oral first-generation cephalosporins eg, cephalexin or antistaphylococcal penicillins eg, dicloxacillin; C-III.
If rifampin cannot be used because of allergy, toxicity, or intolerance, than the panel recommends 4—6 weeks of pathogen-specific intravenous antimicrobial therapy. Indefinite chronic oral antimicrobial suppression may follow the above regimen with either cephalexin, dicloxacillin, co-trimoxazole, or minocycline or doxycycline based on in vitro susceptibility, allergies, or intolerances Table 3 ; B-III. Rifampin alone is not recommended for chronic suppression, and rifampin combination therapy is also not generally recommended.
The recommendation regarding using suppressive therapy after rifampin treatment was not unanimous D. Indefinite chronic oral antimicrobial suppression should follow regimens in Table 3 and be based on in vitro sensitivities, allergies, and intolerances B-III.
Chronic suppression after fluoroquinolone treatment of gram-negative bacilli was not unanimously recommended D. Pathogen-specific antimicrobial therapy should be given until 24—48 hours after amputation assuming all infected bone and soft tissue has been surgically removed and there is no concomitant sepsis syndrome or bacteremia.
If sepsis syndrome or bacteremia are present, treatment duration is to be according to recommendations for these syndromes C-III. Four to 6 weeks of pathogen-specific intravenous or highly bioavailable oral antimicrobial therapy is recommended if, despite surgery, there is residual infected bone and soft tissue ie, hip disarticulation for THA infection, long-stem TKA prosthesis where the prosthesis extended above the level of amputation; Table 2 ; C-III.
Joint replacement is a highly effective intervention that significantly improves patients' quality of life, providing symptom relief, restoration of limb or joint function, improved mobility, and independence. The diagnosis of PJI can be difficult and utilizes many different diagnostic modalities including serologic, radiographic, and microbiologic diagnostic tests.
The management of PJI often necessitates the need for surgical interventions and prolonged courses of intravenous and oral antimicrobial therapy [ 1—4 ]. Despite a significant amount of basic and clinical research in this field, many questions pertaining to the optimal diagnostic strategies and management of these infections remain unanswered.
The primary focus of these guidelines will be to provide a consensus statement that addresses selected current controversies in the diagnosis and treatment of infections involving prosthetic joints.
In many situations, the panel has made recommendations based on expert opinion, realizing that the amount of data to support a specific recommendation is limited, and that there are diverse practice patterns which seem to be equally effective for a given clinical problem.
An essential component of this therapeutic approach is the strong collaboration between all involved medical and surgical specialists eg, orthopedic surgeons, plastic surgeons, infectious disease specialists, general internists. Proper referral may need to occur. What preoperative evaluation and intraoperative testing should be performed to diagnose PJI and what is the definition of PJI?
What different surgical strategies should be considered for treatment of a patient with PJI? What is the medical treatment for a patient with PJI following debridement and retention of the prosthesis? What is the medical treatment for a patient with PJI following resection arthroplasty with or without planned staged reimplantation? What is the medical treatment for a patient with PJI following 1-stage exchange? Attributes of good guidelines include validity, reliability, reproducibility, clinical applicability, clinical flexibility, clarity, multidisciplinary process, review of evidence, and documentation [ 12 ].
A panel of infectious disease specialists and an orthopedist, drawn from North America and Europe, who are experts in PJI was convened. The panelists had both clinical and laboratory experience with PJI. Two members of the panel D. The process included a systematic weighting of the quality of the evidence and the grade of recommendation Table 1 [ 5 ]. Recommendations for the medical management of PJI were derived primarily from case reports, nonrandomized retrospective case series, and 1 single-center randomized clinical trial.
This first draft was circulated electronically to all members of the panel for comments and review. Topics on which consensus could not be reached were discussed by the panel members electronically, by teleconferences, and in person. All members of the panel approved the final draft. Feedback from external peer reviews was obtained and changes made after review with the entire panel.
All members of the expert panel complied with the IDSA policy on conflicts of interest, which requires disclosure of any financial or other interest that might be construed as constituting an actual, potential, or apparent conflict.
Members of the expert panel were provided IDSA's conflicts of interest disclosure statement and were asked to identify ties to companies developing products that might be affected by promulgation of the guideline.
Information was requested regarding employment, consultancies, stock ownership, honoraria, research funding, expert testimony, and membership on company advisory committees. The panel made decisions on a case-by-case basis as to whether an individual's role should be limited as a result of a conflict.
At annual intervals, the panel chair, the SPGC liaison advisor, and the chair of the SPGC will determine the need for revisions to the guideline on the basis of an examination of the current literature. If necessary, the entire panel will be reconvened to discuss potential changes. Suspect PJI in patients with any of the following B-III : A sinus tract or persistent wound drainage over a joint prosthesis, acute onset of a painful prosthesis, or any chronic painful prosthesis at any time after prosthesis implantation, particularly in the absence of a pain-free interval in the first few years following implantation or if there is a history of prior wound healing problems or superficial or deep infection.
Arthrocentesis is also advised in patients with a chronic painful prosthesis in whom there is an unexplained elevated sedimentation rate or CRP A-III or in whom there is a clinical suspicion of PJI.
In PJI where the patient is medically stable, withholding antimicrobial therapy for at least 2 weeks prior to collecting synovial fluid for culture increases the likelihood of recovering an organism B-III. Blood cultures for aerobic and anaerobic organisms should be obtained if fever is present, there is an acute onset of symptoms, or if the patient has a condition or suspected condition or concomitant infection or pathogen eg, Staphylococcus aureus that would make the presence of a bloodstream infection more likely B-III.
The presence of acute inflammation as seen on histopathologic examination of the periprosthetic tissue at the time of surgical debridement or prosthesis removal as defined by the attending pathologist is highly suggestive evidence of PJI B-II. Classification schemes for PJI are based on the timing of infection after prosthesis implantation and a presumptive mechanism of infection [ 13 , 14 ].
These schemes may help the clinician decide on treatment options. Both types of infection are believed to be acquired most often during prosthesis implantation. Early infections often will present with local signs of cellulitis, erythema, swelling, pain, drainage, and delayed wound healing and may or may not have systemic symptoms such as fever and chills [ 4 , 15 ]. Delayed infection, as well as chronic infection occurring many years after prosthesis insertion, typically presents with vague symptoms such as chronic pain without systemic symptoms as well as a loose prosthesis.
These scenarios can be difficult to distinguish from aseptic loosening by history and physical exam. Although any painful prosthesis can represent a PJI, the absence of an obvious mechanical reason for a painful prosthesis in the first few years following implantation, a history of prior wound healing problems, or superficial or deep infection should also raise the suspicion of PJI.
Late infections that occur more than 1—2 years after prosthesis implantation are either due to hematogenous seeding of the prosthesis or a late manifestation of an infection acquired during prosthesis insertion. Hematogenous infections may also occur early after prosthesis insertion [ 16 ]. Late infections are often characterized by an acute septic arthritis syndrome with sudden onset of pain in the setting of concomitant or recent infection occurring elsewhere in the body eg, skin and soft tissue, respiratory tract, or urinary tract infections [ 13 , 14 , 16—18 ].
At the time of diagnosis of PJI, information related to the type of prosthesis, date of implantation, past surgeries on the joint, clinical symptoms, drug allergies and intolerances, comorbid conditions, and prior and current antimicrobial therapy for the PJI including local antimicrobial therapy should be obtained by the clinician [ 19 , 20 ]. A variety of laboratory and radiographic tests are available to aid the clinician in the diagnosis of PJI in situations where the diagnosis is unclear [ 21—23 ].
Plain radiographs are obtained in most if not all situations but lack sensitivity and specificity [ 24 ]. They rarely show clear evidence of infection such as transcortical sinus tract but can show other reasons for chronic pain and serve as a baseline for following any diagnostic or therapeutic procedures. Serial exams may be the most helpful. Radionuclide scans, CT, MRI, and FDG PET scanning are rarely utilized due to either their expense, lack of availability, or image distortion due to the prosthesis compared with other tests [ 1 , 4 , 22 ].
If any of these tests are utilized, a leukocyte scan in combination with a technetium-labeled bone scan is the most often used because of availability and reasonable sensitivity and specificity. The utility of the white blood cell count, CRP, and erythrocyte sedimentation rate have been discussed at length by multiple authors [ 1 , 4 , 21 , 25 , 26 ]. These tests are obviously not necessary to make a diagnosis when infection is evident, for example, when a sinus tract is present or there is an acute septic arthritis.
They are nonspecific tests and are associated with a significant false-positive rate particularly immediately after prosthesis implantation or in patients with inflammatory arthritis [ 21 ].
Cutoffs that predict PJI in this setting have recently been proposed but require validation [ 27 ]. Baseline values if available may be helpful. CRP seems to be more accurate than the sedimentation rate when evaluating a patient with a painful prosthesis and suspected chronic PJI [ 21 , 26 , 28 , 29 ].
Combining both the sedimentation rate and the CRP so that either both are positive or both are negative may provide the best combination of positive and negative predictive values [ 21 , 28—30 ].
There are much less data on the use of interleukin 6 IL-6 and procalcitonin, although IL-6 looks very promising [ 26 , 31 , 32 ]. Blood cultures to exclude concomitant bacteremia should be obtained if the patient is febrile, has a clinical condition or concomitant infection, or has a pathogen known to cause metastatic infection eg, S. Suspicion of infective endocarditis or the presence of a cardiac pacemaker, for example, should also warrant the consideration of obtaining blood cultures and, depending on the level of suspicion of the presence of infective endocarditis, a transesophageal echocardiogram.
Synovial fluid obtained by preoperative aspiration can be submitted for cell count and differential, Gram stain, and aerobic and anaerobic culture.
A diagnostic arthrocentesis should be performed in all patients with a suspected acute PJI unless the diagnosis is evident clinically and surgery is planned and antimicrobials can be withheld prior to surgery. Arthrocentesis is also advised in patients with a chronic painful prosthesis in whom there is an elevated sedimentation rate or CRP level or in whom there is a high clinical suspicion of PJI. It may not be necessary in this situation if surgery is planned and the result is not expected to alter management [ 19 , 21 , 22 , 30 , 33 ].
This cutoff is much lower than that used to suggest infection in native joint septic arthritis. Its utility in other types of prostheses is the subject of ongoing research.
Thus the cell count and its ability to predict infection must be interpreted in light of the type of prosthesis and the time from prosthesis implantation. Unfortunately, the results can be dependent on appropriate sampling of the tissue harboring the infection and the expertise of the pathologist since not all centers will have pathologists who are experienced in this type of histopathologic analysis.
There are recent data suggesting that acute inflammation is less common in infection due to low-virulence organisms [ 39 ]. At least 3 and optimally 5 or 6 periprosthetic intraoperative samples from the most suspicious areas of tissue as deemed by the orthopedic surgeon should be obtained for aerobic and anaerobic culture for the optimal diagnosis of PJI [ 40 , 41 ].
Submitting fewer than 5—6 specimens leads to a decrease in sensitivity of culture as a diagnostic test. There is no standard time that microbiology laboratories incubate periprosthetic tissue specimens. The optimal duration of incubation of periprosthetic tissue specimens is unknown, but prolonged incubation of up to 14 days may help with pathogen isolation, particularly Propionibacterium species, a common pathogen in total shoulder arthroplasty infection [ 42 ].
Novel processing techniques may also help with pathogen identification [ 43 ]. When possible, withholding antimicrobial therapy for at least 2 weeks prior to collecting the specimens increases the yield of recovering an organism [ 41 ]. The decision to withhold antimicrobial prophylaxis at the time of revision total joint surgery to optimize tissue culture ascertainment should be based on the preoperative risk of PJI.
If the risk is low based on the results of the history, exam, sedimentation rate, CRP level, and preoperative aspiration, then antimicrobial prophylaxis should be given normally according to standard guidelines.
If the risk of PJI is high, then withholding antimicrobial prophylaxis prior to revision total joint surgery seems appropriate to maximize the yield of tissue cultures.
The explanted prosthesis itself can also be submitted for Sonification and subsequent aerobic and anaerobic culture.
Sonication has been used to dislodge bacteria from the surface of the prosthesis, and culture of the prosthesis ultrasonicate can improve the sensitivity of aerobic and anaerobic culture compared to traditional tissue culture [ 41 , 44 ]. The sensitivity of a periprosthetic sonicate-fluid culture for the diagnosis of prosthetic hip and knee infection was higher than that of culturing a single sample of periprosthetic tissue, namely, This technique is not validated for the isolation of fungal and mycobacterial organisms.
The Gram stain is not routinely useful as a diagnostic test owing to low sensitivity on tissue specimens but has increased sensitivity on ultrasonicate fluid [ 40 , 41 , 45 , 46 ]. As with other uses, false-positive Gram stains due to laboratory contamination have been reported [ 47 ]. In the situation of a positive Gram stain and negative tissue cultures, the clinician will need to decide after review of the clinical circumstances of the specific case, including the use of prior antimicrobial therapy, and discussion with the microbiology laboratory if the Gram stain result is helpful in tailoring antimicrobial therapy.
Rapid diagnostic tests such as polymerase chain reaction are still not yet available for routine clinical application [ 48—50 ]. There is no standard definition of what constitutes PJI; therefore, interpretation of the literature related to the treatment of these infections is difficult [ 51 ].
The diagnosis of PJI is obvious if multiple cultures from specimens surrounding the prosthesis yield identical microorganisms, if the prosthesis ultrasonicate fluid is positive, if purulence is observed surrounding the prosthesis without another known etiology such as a failed metal-on-metal arthroplasty [ 52 ], or if a sinus tract that communicates with the prosthetic device is present.
The diagnosis of PJI can be more difficult if typical signs or symptoms of infection are lacking. For instance, the presence of periprosthetic loosening of a joint arthroplasty or joint pain can be the result of occult infection or other noninfectious etiologies. The presence of acute inflammation consistent with infection on histopathological examination as determined by a pathologist is highly suggestive evidence of the presence of PJI though it should be noted that there are multiple definitions of what constitutes acute inflammation of periprosthetic tissues at the time of revision arthroplasty and significant variability among pathologists in the interpretation of these specimens [ 21 , 36—38 , 53 ].
The panel is of the opinion that 2 or more positive cultures from intraoperative specimens represent definitive evidence of infection. Although a study by Atkins et al found an optimal posttest probability of infection with 3 or more positive cultures, they also demonstrated that at the time of revision hip or knee surgery, compared with histopathologic evidence of infection, 2 positive intraoperative cultures provided acceptable sensitivity and specificity without requiring an impractical amount of tissue specimens to be processed by the laboratory [ 40 ].
A single positive periprosthetic tissue culture that yields an organism that is a common contaminant eg, coagulase-negative staphylococci, Propionibacterium acnes should not necessarily be considered evidence of definite PJI and should be evaluated in the context of other available evidence [ 40 , 51 ]. The clinician should use clinical judgment when the presence of PJI is not obvious and decide if infection is present after reviewing the history, exam, and preoperative and intraoperative tests.
Patients diagnosed with a PJI who have a well-fixed prosthesis without a sinus tract who are within approximately 30 days of prosthesis implantation or fewer than 3 weeks of onset of infectious symptoms should be considered for a debridement and retention of prosthesis strategy Figure 2 ; A-II. The panel believes that in selected circumstances, more than one 2-stage exchanges can be successful if the first one fails C-III.
A 1-stage or direct exchange strategy for the treatment of PJI is not commonly performed in the United States but may be considered in patients with a THA infection who have a good soft tissue envelope provided that the identity of the pathogens is known preoperatively and susceptible to oral antimicrobials with excellent oral bioavailability.
Permanent resection arthroplasty may be considered in nonambulatory patients; patients with limited bone stock, poor soft tissue coverage, or infections due to highly resistant organisms for which there is limited medical therapy; patients with a medical condition precluding multiple major surgeries; or patients who have failed a previous 2-stage exchange in which the risk of recurrent infection after another staged exchange is deemed unacceptable Figure 4 ; B-III.
The most commonly used surgical treatments for PJI include debridement and retention of the prosthesis, 1- or 2-stage staged exchange, resection arthroplasty, arthrodesis, and amputation [ 54 ]. There are no published randomized clinical trials to address optimal selection of these surgical procedures. The available data consist of single-center noncomparative cohort studies and a decision analysis based on these cohort studies [ 55 ].
Infectious disease clinicians should work closely with the orthopedist to determine the ultimate surgical strategy selected for an individual patient. Many factors influence the ultimate surgical management chosen for a given patient.
Examples of these factors could include duration of symptoms, joint age early, delayed, or late , infecting pathogen and its susceptibility pattern, prosthesis stability, and the patient's preexisting medical comorbidities. Other factors, such as the quality of the periprosthetic soft tissue, the options available for successful reconstructive surgery after resection arthroplasty, the expertise of the clinician s , and the patient's preferences, also influence the surgical management.
Figures 1—3 show treatment algorithms for initial surgical management following these procedures that are based on published data and the panel's expert opinion. The final operative decision is up to the treating orthopedic surgeon after consultation with the patient. Debridement without removal of the infected prosthesis can be done via either an open arthrotomy or arthroscopy [ 55—80 ].
Open arthrotomy allows for an extensive debridement and polyethylene liner exchange and is the most extensively described technique. There are increasing data that arthroscopy provides worse outcomes compared with open arthrotomy [ 62 , 76 ]. There is an increased risk of treatment failure reported in patients with a sinus tract [ 2 , 67 ] and infections due to certain organisms such as S. MRSA , and gram-negative organisms [ 85—90 ]. Treatment failure following debridement and retention includes meeting the definition of infection mentioned previously as well as persistent pain that is intolerable to the patient.
Following an algorithmic approach seems to provide benefit in outcome and is encouraged by the panel, although different algorithms exist and individual judgment must be used in all situations [ 2 , 80 , 83 , 85 , 88 , 91 ].
There have been recent reports suggesting there may be a worse outcome for 2-stage exchange procedures following a failed debridement and retention procedure. Further data on this are warranted to help clinicians decide on the overall utility of the debridement and retention strategy [ 84 , 92 ].
A 1-stage exchange or revision procedure involves excision of all prosthetic components and poly methyl methacrylate cement, debridement of devitalized bone and soft tissues, prosthesis removal, and implantation of a new prosthesis. Most series use antibiotic impregnated cement to fix the new prosthesis [ 94 , 96 ].
A recent decision analysis favored direct exchange over 2-stage exchange [ 95 ]. There are much fewer data for the use of this procedure for prosthetic joints other than a THA or without antibiotic impregnated cement and with bone graft [ 94 , 97—99 ].
This difference may be owing to a low number of patients in the United States that are eligible for this type of procedure [ ]. Published criteria for these procedures have included a relatively healthy patient with adequate bone stock and soft tissues, and patients with an easily treatable organism, which usually has been defined as streptococci other than enterococci, methicillin-sensitive staphylococci, and nonpseudomonal gram-negative organisms. If you want any Medical books which are not on our list please do message us on Facebook.
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