BESS PJI Guidelines - 7

Rangan et al.

emergency referral for:
. Acute severe pain þ/À redness þ/À swelling after a
recent joint replacement.
. Increasing/worsening pain in a recent joint replacement with features of systemic symptoms/illness.
. New acute severe pain þ/À redness þ/À swelling in a
previously well-functioning joint replacement.
. Any increase in pain from a replaced joint if accompanying systemic symptoms/illness.

2.4 Indications for urgent referral within 2 weeks
Many PJI are chronic in nature with the patient
being well but presenting over months with pain,
poor function and gradual loosening and failure of
the implant. Such patients do not require same day
emergency referral but they do warrant prompt referral
to the secondary care provider that carried out the joint
replacement.

2.5 Treatment in Primary Care & Community
Triage Services
Whilst shared decision-making is important, and individual patients' needs are diﬀerent, prompt referral to
secondary care is indicated.
If the patient is well (particularly if a chronic presentation) antibiotics should be avoided as this can be
detrimental to optimum secondary care management
which requires precise isolation of causative organisms.
Specimens are therefore usually obtained before antibiotics are administered.
If an acute infection is present and the patient is
unwell then emergency secondary care referral should
be made as highlighted in the section above. Antibiotics
should be discussed with the on-call orthopaedic team if
in doubt.

3. Treatment in Secondary Care
3.1 Microbiology & Medical Management
3.1.1 General Principles. Eﬀective management of PJI
usually includes careful and complete surgical debridement and removal of all non-vital tissue. Where this
is not possible, there is a substantially higher risk of
treatment failure, irrespective of the choice or dose
of antibiotic.12 Under some circumstances, the aims
of therapy may shift towards long-term suppression
rather than cure. A clear operation note detailing the
surgical ﬁndings and procedure, and close collaboration between the surgical team and infection specialists, are therefore indispensable for the optimal
management of bone and joint infection.

S7
3.1.2 Tissue sampling in secondary care. If there is clinical
suspicion of infection, or persistent/progressive pain of
unexplained origin, investigations for PJI are indicated.
Joint aspiration should be considered in all patients
with suspected infection irrespective of whether the
implant is well ﬁxed. Radiologically guided percutaneous biopsy may be indicated in certain circumstances.
Examples include cases in which the diagnosis of
infection cannot be conﬁrmed clinically, cases in
which surgery is not feasible but clinicians need to
establish optimal directed suppressive therapy, or
in cases where it is important to establish the choice
of local antibiotic to be incorporated into cement or
void ﬁller at the time of operation. Where there is
clear indication for surgery intra-operative tissue
sampling should be performed in preference to preoperative sampling. Examples of such cases include
suspected infection with implant loosening, and
debridement with implant retention in response to a
deﬁnitive clinical diagnosis of infection with a wellﬁxed implant. For intra-operative sampling, ﬁve separate tissue samples for culture and two further samples
for histology are the minimum recommended. Tissue
samples should be obtained using a sampling set,
which should include separate knives and forceps and
sterile tissue pots for each of the samples. Synovial
ﬂuid, if sampled, should be added to aerobic and anaerobic blood culture bottles. Samples obtained should be
subject to prolonged cultures for at least 8 days to
detect presence of slow growing organisms. Speciﬁc
requests for culture of mycobacteria, fungi and nocardia should be considered where epidemiological and
clinical risk factors for these organisms exist.
3.1.3 Choice of antimicrobial agent. Although antibiotic
guidelines are undoubtedly helpful, selection of the
most appropriate agents necessarily has to be individualized, taking into consideration bacterial, host and
drug factors. Bacterial factors include local epidemiology, antimicrobial susceptibilities and capacity for
bioﬁlm formation. For example, the presence of
Propionibacterium acnes or Staphylococci in a patient
undergoing Debridement, Antibiotics and Implant
Retention (DAIR) would point towards inclusion of
rifampicin in the treatment regimen because of its
eﬀectiveness in bioﬁlm associated infection.13
Host factors that inﬂuence choice of antimicrobial agent include comorbidities, allergies and physiological status. For example, a patient with signiﬁcant
renal impairment might mandate avoidance or dose
adjustment of potentially nephrotoxic antimicrobials.
Drug factors, such as bioavailability, side eﬀects,
tissue or bone penetration, half-life and drug-drug
interactions, also inﬂuence choice of antimicrobial
agent. An example might be the avoidance of

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