BESS PJI Guidelines - 10

S10

Shoulder & Elbow 10(1S)

Figure 1. Basic Treatment Algorithm for Shoulder PJI.

of PJI. Although it may be indicated in those patients
who are medically too compromised to consider surgery, its failure rates are high. However, DAIR may
be useful in those cases of PJI where early infection is
identiﬁed, however the long-term use of suppressive
antibiotics may still be necessary.21 DAIR and open
biopsy, could also be considered in the management
of the painful arthroplasty where all other potential
causes of pain, apart from occult infection, have been
excluded and all previous investigations have proven
unremarkable. However, it is important to note that
whilst elevated blood parameters (ESR/CRP) can
prove helpful in monitoring some infections, normal
results do not exclude the presence of infection.
Early PJI can be deﬁned as when infection is identiﬁed within six weeks of surgery and in those patients
who have only experienced symptoms or signs of infection for up to three weeks. In such circumstances, appropriate cases for DAIR include those in which the implant
is considered satisfactory and where the bacteria can be
identiﬁed and are of low virulence. Antibiotic treatment

should be withheld until operative specimens are taken,
in the manner previously described, following which a
thorough open debridement is undertaken with the
exchange of any modular components where applicable.
Arthroscopic debridement alone has been described, but
the outcome is questionable.22,23 Postoperative antibiotic
management should then be managed with the aid of a
Microbiology Multi-Disciplinary Team (MDT) and, if
necessary, Outpatient Parenteral Antibiotic Therapy
(OPAT) teams.
3.2.1b One Stage. There is little written in the medical
literature comparing one-stage to two-stage revision
and, further work is needed to determine the eﬃcacy
of each of these techniques in the management of PJI.
However, although infection eradication has been
reported, there is a greater risk of persistent pain and
complications when a one-stage revision is undertaken
compared to when a two-stage revision is utilised.24,25
The indications for a one-stage revision are where
the bacterium is known to be of low virulence or

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