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 Table of Contents  
Year : 2015  |  Volume : 29  |  Issue : 3  |  Page : 120-128

Prosthetic joint infection: A microbiological review

Department of Microbiology, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, India

Date of Web Publication1-Dec-2015

Correspondence Address:
Ralte Lalremruata
Room No 36, PG Mens Hostel, Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi - 110 002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-4958.170778

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Joint replacement is a highly effective intervention that significantly improves patients' quality of life, providing symptom relief, restoration of joint function, improved mobility, and independence. Prosthetic joint infection (PJI) remains one of the most serious complications of prosthetic joint implantation. PJI positions a substantial burden on individuals, communities, and the health-care system, and thus early diagnosis and appropriate intervention are extremely important. Determining the various host and environmental factors that put an individual at risk for development of PJI may reduce the morbidity and cost of total joint arthroplasties. Microbial agents implicated in the causation of PJI range from Gram-positive to Gram-negative bacteria. PJI with fungi is commonly seen in immunocompromised patients. Numerous novel, uncultivable, and fastidious organisms have been identified as potential pathogens with the use of non-culture techniques. The majority of cases of PJI require surgical treatment, while the use of antimicrobials is essential when prosthetic removal is not possible or contraindicated. The microbiology and treatment of PJI in the light of improved culture and diagnostic methods are reviewed.

Keywords: Antibiotic sensitivity, Diagnosis, microbiology, Prosthetic joint infection (PJI), Therapy

How to cite this article:
Lalremruata R. Prosthetic joint infection: A microbiological review. J Med Soc 2015;29:120-8

How to cite this URL:
Lalremruata R. Prosthetic joint infection: A microbiological review. J Med Soc [serial online] 2015 [cited 2021 Dec 8];29:120-8. Available from:

  Introduction Top

Joint replacement is a highly effective intervention that significantly improves patients' quality of life, providing symptom relief, restoration of joint function, improved mobility, and independence. Prosthetic joint infection (PJI) remains one of the most serious complications of prosthetic joint implantation. It presents as 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 painfree interval, in the first few years following implantation or if there is a history of prior wound-healing problems or superficial or deep infection. Blood cultures for aerobic and anaerobic organisms should be obtained if fever is present, if there is an acute onset of symptoms, or if the patient has a condition or suspected condition or concomitant infection or pathogen (e.g., Staphylococcus aureus) that would make the presence of a bloodstream infection more likely. [1] The management of PJI almost always necessitates surgical intervention and prolonged courses of intravenous or oral antimicrobial therapy. [2],[3] An essential component of the care of patients with PJI is strong collaboration among all involved medical and surgical specialists (e.g., orthopedic surgeons, plastic surgeons, infectious disease specialists, internists). It is anticipated that consideration of these guidelines can help reduce morbidity, mortality, and the costs associated with PJI. In this paper, current knowledge of the pathogenesis, diagnosis, and management of PJI is reviewed.

  Risk Factors Top

There are various factors that play a significant role in the development of PJI. It has been observed that PJI may either coexist with or result from bacteremia but remains undiagnosed until later. A study by Luessenhop et al. [4] noted that another infection (such as bacteremia, urinary tract infection, or infected decubitus ulcer) was present for a significantly greater percentage (i.e., 85%) of patients with multiple prosthetic infections after total joint arthroplasty, compared with patients with a single PJI. Polymicrobial PJIs are also associated with antibiotic prophylaxis spectra without activity against the subsequently isolated organisms, rheumatoid arthritis, and purulent wound discharge at presentation on univariate analysis. Rheumatoid arthritis and antibiotic prophylaxis spectra remain independent predictors of polymicrobial infections on multivariate analysis. [5]

Because the insertion of a large-sized device and injury at the site of surgical incision have been suggested as factors that predispose patients to hematogenous infection, [6] prosthetic joints may be particularly susceptible to hematogenous seeding, because of their large size as well as the greater likelihood of injury due to mobility. Surgical site infection (SSI) is another well-defined risk factor for PJI. [7],[8] An NNIS (National Nosocomial Infections Surveillance) System surgical patient risk index score of >1 is also an independent risk factor. [7] The NNIS System surgical patient risk index scores each operation by adding the number of risk factors among these three measurements. One point is given if the American Society of Anesthesiologists' preoperative assessment score is 3, 4, or 5; another point is given if the operation time is >3 h for prosthetic joint arthroplasty; a third point is given if the wound classification is 3 or 4. [9] Although studies performed by Wilson et al. [10] and Fitzgerald et al. [11] show that there is no association between the presence of malignancy and PJI, the case-control study conducted by Berbari et al. [7] noted their association. Possibilities for the association of malignancy and PJI include the immunosuppressive effects of treatment for malignancy that are unrelated to neutropenia or steroid therapy and simply unknown factors associated with the malignancy itself. [12] A history of joint arthroplasty on the index joint has been consistently recognized as a risk factor for PJI in various retrospective cohort studies. [13],[14] The risk of PJI increases with the number of previous joint arthroplasties. [14] Nonsurgical trauma to the prosthetic joint is shown to be associated with PJI, [8] whereas dental treatment does not increase the incidence of late PJIs. [15] Women are shown to have a lower risk of PJI than men. [16] Obesity is another independent risk factor for acute periprosthetic infection after primary hip arthroplasty. [17] Risk factors for the development of invasive candidal infections include immunosuppression, neutropenia, chronic or prolonged use of antibiotics, presence of indwelling intravenous catheters, parenteral hyperalimentation, malnutrition, diabetes mellitus, rheumatoid arthritis, cirrhosis, history of multiple abdominal surgeries, history of renal transplantation, severe burns, and injection drug use. [18],[19],[20],[21],[22],[23] Rheumatoid arthritis is also associated with PJI due to Gram-negative bacilli on univariate and multivariate models. Factors associated with PJI caused by methicillin-resistant Staphylococcus aureus (MRSA) on univariate analysis are nonglycopeptide antibiotic prophylaxis at the index arthroplasty, neck of femur fracture, and nursing home residence prior to arthroplasty. [5] The various risk factors are summarized in [Table 1].
Table 1: Risk factors for development of PJIs

Click here to view

  Causative Organisms Top

Microbial agents implicated in causation of PJI range from Gram-positive bacteria to Gram-negative bacteria. PJI with fungi is commonly seen in immunocompromised patients. The pathogens responsible for primary deep-space infections are usually distinct from normal commensal organisms on the skin, but it is precisely these commensal organisms on the skin that most commonly infect implantable biomedical devices. [24] PJIs have been classified as "early" and "late," although to these categories have been added the classifications of "acute hematogenous" and "positive intraoperative cultures," the latter indicating a group with positive cultures without prior suspicion of infections. [25] Early infections present acutely with overt wound infection; late infections present with worsening pain in the joint accompanied by loosening of the prosthesis at the bone-cement interface and sometimes by sinus tract formation with chronic discharge. The majority of PJIs reported are caused by a single organism, but Marculescu et al. [26] identified 19% of the PJIs in their study to be polymicrobial. In the study, MRSA and anaerobes were the most commonly isolated causative organisms of polymicrobial PJI; the presence of a soft-tissue defect/wound dehiscence, drainage, and age 65 years or older were the factors associated with polymicrobial PJIs. Rheumatoid arthritis has also been described to be associated with polymicrobial PJI. [5] The infection rate in hip prostheses is less than that in other joints, probably because of proximity to the skin surface in other joints and less experience in joint design. [27] Meanwhile, Berbari et al. [28] described culture-negative PJI, where the prosthetic infection is diagnosed solely by the presence of characteristic signs such as sinus tract communicating with the joint, periprosthetic purulence, or acute inflammation of periprosthetic tissue.

  Gram-Positive Bacteria Top

Gram-positive organisms that cause PJI range from virulent organisms such as Staphylococcus aureus and Streptococcus spp. to less virulent ones such as coagulase-negative Staphylococcus spp. (CoNS), Enterococcus spp., and Propionibacterium spp. Staphylococcus aureus and CoNS are the most frequent causes of PJI. [29] Berbari et al. showed the isolation rate of Staphylococcus aureus to be 28% and that of CoNS to be 30%. [30] Salgado et al. [31] reported Staphylococcus aureus to be the causative organism in 33% of PJIs, out of which 24% were methicillin-sensitive Staphylococcus aureus (MSSA) and 9% were MRSA. This finding differs significantly from that in the review by Peel et al., [5] who reported 45% of PJIs to be caused by MRSA. Razonable et al. [32] described a 70-year-old man who developed late PJI caused by Staphylococcus simulans. Cases of total knee arthroplasty infection caused by S. lugdunensis have also been reported. [33] S. lugdunensis is more virulent than other CoNS and in many clinical situations behaves like S. aureus. Although Staphylococcus aureus and CoNS cause PJI with approximately equal frequency, [24],[30] S. aureus is the predominant cause of PJI that results from hematogenous spread. [34]

Streptococcus spp. is commonly isolated from PJI. Berbari et al. [30] showed the isolation rate of Streptococcus spp. to be 4%. Duggan et al. [35] reported six cases of group B streptococcal PJIs and a single case of group C streptococcal PJI has also been reported. [36] In a study conducted by Meehan et al., [37] six PJIs were due to group G streptococci, seven were due to group B streptococci, four were due to viridans streptococci, and two were due to group A streptococci. Gaunt et al. [38] also reported two cases of PJI caused by group G streptococci.

Enterococcus spp. accounts for only 3% of PJI. [29],[30] Raymond et al. showed 11 enterococcal PJIs reported in the period 1966-1993 in their review literature. [39] Berbari et al. [30] reported three cases of PJI caused by Streptococcus pneumoniae. Another case report also stated the same infection in an 86-year-old woman with a total knee arthroplasty. [40] There have been reports on prosthetic shoulder joint infection by Corynebacterium bovis[41] and Corynebacterium jeikeium. [42]

There have also been several reports on PJIs caused by Mycobacterium tuberculosis, [43] which usually involve the hips or knees and can result from either local reactivation or, less often, hematogenous spread. Berbari et al. [44] reported seven tuberculous PJI cases over a 22-year period. The diagnosis of tuberculous prosthetic joint disease is often delayed, because a history of prior Mycobacterium tuberculosis septic arthritis is not known. The predisposing conditions include rheumatoid arthritis, chronic steroid use, and pulmonary diseases. [43] Eid et al. [45] reported eight cases of PJI due to rapidly growing Mycobacterium spp. (RGM) over the span of almost four decades. The RGMs reported are M. smegmatis, M. fortuitum, M. chelonae, and M. abscessus.[46],[47] Neuberger et al. [48] reported prosthetic knee joint infection by M. kansasii in an 82-year-old man. There has also been a case report of isolated PJI with Mycobacterium avium complex (MAC) in an immunosuppressed, failed kidney transplant recipient. [49] Cases of PJIs caused by Listeria monocytogenes[50] usually occur in patients who are immunocompromised due to malignancy or other illnesses or in nonimmunocompromised elderly patients. Other uncommon organisms causing PJI include a Gram-positive Nocardia-like bacilli Oerskovia xanthineolytica; [51] Tropheryma whippeli causing a prosthetic knee joint infection in a 58-year-old woman 2 years after she had been considered cured of Whipple's disease; [52] Lactococcus garvieae (formerly known as the lactic group of streptococci) causing a prosthetic hip joint infection in a 71-year-old woman who was a fishmonger; [53] and a Gram-positive coccus Rothia mucilaginosa, which is a normal commensal of the oral cavity and commonly mistaken as CoNS. [54]

  Gram-Negative Bacteria Top

Gram-negative bacteria, which are less commonly associated with PJI, account for 6-23% of all episodes. [55] Although such infections constitute a relatively minor proportion of all PJIs, they are of significant clinical importance because treatment of such infections is considered more complicated as a result of the virulence of the organisms, their growing resistance to antimicrobial agents, and the comorbid conditions of patients. [56] Members of the family Enterobacteriaceae and Pseudomonas aeruginosa are the Gram-negative pathogens most commonly isolated from PJIs. [57],[58] There has been a report of PJIs caused by Haemophilus influenzae[57] and Haemophilus parainfluenzae, which were followed by dental extractions that had not been covered by antibiotic prophylaxis. [59],[60] Vikram et al. reported a case of primary meningococcal arthritis in a woman with a prosthetic knee joint. [61]

Pasteurella multocida, a Gram-negative bacillus that forms part of the normal nasopharyngeal and gastrointestinal flora of cats and many other animals, has been reported to cause cat scratch-related prosthetic hip joint infections [62] and a prosthetic knee joint infection. [63] Most patients with PJIs caused by P. multocida are immunocompromised and all but one [64] of the reported cases of P. multocida PJIs have been in women. [65] Brucellosis, another zoonotic disease of worldwide distribution, is a systemic infection caused by Brucella species, whose association with PJI has also been reported. The species that have been isolated are B. melitensis and B. abortus.[66],[67] In contrast to those caused by P. multocida, PJIs caused by Brucella species are mostly seen in men. [66] Salmonella spp. have also been occasionally reported to cause PJIs. The species reported so far are S. dublin, S. Typhimurium, S. Newport, S. Muenchen, S. enteritidis, S. enterica, and S. hirschfeldii.[57],[68],[69],[70],[71] Legionella micdadei, one of the most frequent non-L. pneumophila species, has also been reported to cause PJI in an 83-year-old woman who underwent total knee arthroplasty due to rheumatoid arthritis. [72] Campylobacter spp. are also reported to cause PJIs, which usually occurs in immune-compromised patients, and the species that has been isolated are: C. fetus, from patients who had total hip arthroplasty; [73],[74] C. coli from a 60-year-old man, which presumably resulted from the ingestion of contaminated raw oysters; [75] C. jejuni from a patient who had AIDS and a hip prosthesis; [76] and C. lari from an immune-competent patient. [77] There has also been a report of PJI caused by an unusual Gram-variable coccus that is genetically related to Helcococcus pyogenica.[78]

  Anaerobes Top

Anaerobic bacteria are probably underestimated as agents of orthopedic foreign-body infections when culture is used as the only bacterial detection method. The importance of molecular detection methods in identifying these microorganisms in these circumstances cannot be overemphasized. Finegoldia magna, previously called Peptostreptococcus magnus, is the most commonly reported anaerobic coccus that causes PJI. Physicians should suspect F. magna infection in cases of infection that occur <4 months after hip or knee prosthesis implantation, particularly if cultures appear to be sterile. [79] Micromonas (Peptostreptococcus) micros, an organism frequently associated with periodontal infection, has also been described as a causative pathogen of PJI in a woman who had total hip arthroplasty. [80] Peptococcus saccharolyticus and Peptostreptococcus anaerobius have also been reported. [81] PJI caused by Actinomyces viscosus, which is an unusual Gram-positive threadlike organism, has been reported. [82] Late infections with Actinomyces israelii have also been described for prosthetic hip joints. [83] Propionibacterium acnes, a Gram-positive anerobic bacillus that is generally considered to be a commensal organism found in skin sites with high numbers of sebum-excreting sebaceous follicles, is a common contaminant of cultures and interpretation is difficult when it is isolated from a single specimen. [84] Studies show that P. acnes has been implicated in arthroplastic infections, [84],[85] and shoulder infections due to P. acnes have become an emerging problem, as documented in recent reports of 52 cases of prosthetic infection due to P. acnes.[86] Males are more predisposed to infections by Propionibacterium spp., which is probably due to the tropism of the organism for sebaceous glands and hair bulbs. [85]

Clostridium difficile has been described to cause PJI in an 83-year-old woman who developed culture-positive C. difficile-associated diarrhea. [87] Another case of C. difficile PJI has also been reported in a 16-year-old boy who had had a total knee arthroplasty due to osteosarcoma. [88] Clostridium perfringens has also been stated to cause delayed postbacteremic PJI. [89] Other anaerobes that have been reported to cause PJI are Veillonella dispar, [90] Bacteroides spp., and Staphylococcus saccharolyticus. [30]

  Fungi Top

Fungal PJI is rare, with Candida species being the most frequently reported pathogen in the medical literature. MacGregor et al. reported the first case of candidal PJI in 1979. During the past 21 years, only 30 cases of PJI due to Candida species have been reported in the medical literature. Despite knowledge regarding the risk factors of invasive candidal infections, approximately half of the reported cases of candidal PJI have no identifiable risk factor, and most patients with candidal PJIs present with an indolent onset of symptoms. [91] Candida parapsilosis[92] and Candida albicans[93] are the species commonly isolated from PJI. Noncandidal fungal PJI is very rare.

A prosthetic hip joint infection due to C. neoformans has been reported in an 84-year-old man with chronic lymphocytic leukemia. [94] A case report of prosthetic knee infection with Aspergillus fumigatus has been described in a low-grade osteosarcoma patient who was treated with a segmental distal femoral allograft prosthetic composite knee arthroplasty. [95] Fowler et al. [96] described the first case of PJI due to Histoplasma capsulatum complicating total hip arthroplasty. Berbari et al. [30] reported PJI caused by fungal pathogens such as Sporothrix schenckii and Coccidioidomycosis immitis.

  Clinical Features Top

The clinical diagnosis of PJI is challenging. In an uncompromised host, invading bacteria are usually eliminated by the innate immune response. If this initial response fails to eradicate the offending bacteria, a mountable immune response may be provoked, producing the characteristic signs and symptoms of infection. These may vary clinically from almost asymptomatic to superacute sepsis with erythema, edema, pain, effusions, local warmth, fever, and sinus tract formation. [97],[98] These clinical signs of infection can give rise to a high degree of suspicion, but cannot be relied upon alone for diagnosis and need not necessarily be present. [55],[99] Pain is the most common symptom of PJI, present in 90-100% of patients. The presence of fever is variable, with 4-43% of patients in most case series having documented elevated temperatures. [56],[100] As mentioned above, acute infections often present with erythema and swelling of the joint, but are less common in chronic infections. A discharging sinus is associated with chronic, indolent presentations. [101] Arthroplasty infections have been characterized as: Early (developing in the first 3 months after surgery), delayed (occurring 3-24 months after surgery), and late (greater than 24 months). [3]

  Microbiological Analysis Top

The microbiological confirmation of prosthetic PJIs, following their diagnosis by radiological investigations, provides useful information related to the antimicrobial therapy of PJIs.

Specimen collection and transport

Microbiologic diagnosis is often based on cultures of periprosthetic tissue. At least three and optimally five or six 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. [1] However, this method is insufficient because microorganisms are attached as a biofilm on the prosthesis. [102] In this condition, bacteria change their phenotype to a sessile form and adhere strongly to the device. They may remain surface-adherent even if the whole prosthesis is cultured in broth, leading to false-negative culture results. In contrast, sonication can dislodge pathogens from implants. [103] Recently, Trampuz et al. [104] showed that culture of samples obtained by sonication from removed hip and knee prostheses was more sensitive than conventional culture from periprosthetic tissue. However, as this method reveals isolates in sessile forms also, showing variations in both phenotypic appearance and biochemical reactions, [105] species identification of such bacteria may be false or misleading, which should be considered in routine laboratory testing.

Synovial joint fluid aspiration may be performed prior to surgical joint capsule incision in order to minimize the risk of false-positive results. A minimum of 1 mL should be collected, and transported in collection syringes. After opening the joint, sampling of granulation tissue from at least three different sites (i.e., one from the capsule and two from host bone beds) gives satisfactory results. Tissue samples must be deposited in sterile tubes, while swabs can be kept in transport medium (Amies medium/Stuart's medium/Cary-Blair medium). All materials are to be transported to the diagnostic laboratory immediately after sampling. Specimens should be processed by the laboratory within 2 h of collection. [81]

Intraoperative frozen sections of periprosthetic tissues are shown to perform well in predicting a diagnosis of culture-positive periprosthetic joint infection, but have moderate accuracy in ruling out this diagnosis. Frozen-section histopathology should, therefore, be considered a valuable part of the diagnostic work-up for patients undergoing revision arthroplasty, especially when the potential for infection remains after a thorough preoperative evaluation. [106]

Cultural and non-cultural techniques

One of the routinely used intraoperative tests for diagnosis of PJI is the Gram stain, which has little value in ruling out prosthetic infections. [107] The utility of joint fluid culture has also been repeatedly questioned based on high false-negative rates, [108] which may be due to bacteria-related factors, such as their paucity in the joint fluid, highly fastidious growth, the biofilm nature of PJI, or the impact of previous antibiotic therapy. Moreover, sampling factors such as the surgeon's experience, use of special transport medium, time delay, anaerobic environment, and improper laboratory practice may play some role as well. Therefore, there is a need for a method that will decrease the false-negative rate of culture assays or another method that could target the blind window of the culture technique. With regard to improving culture performance, new transport and diagnostic sets have been developed and are in use. [109] Alternatively, polymerase chain reaction (PCR)-based methods provide a theoretically more sensitive means of detecting and identifying infectious bacteria; a few copies of bacterial DNA may be enough to obtain a positive result. [110],[111] This method is dependent neither on the occurrence of viable bacteria in samples nor on antibiotic treatment history. The PCR technique, based on detection of highly-conserved 16S rDNA sequences common to all bacteria, was introduced into the diagnosis of PJI in the early 1990s, [112] and has met the demanding expectations of the orthopedic community. [81],[113] However, these techniques are cost-intensive and methodically cumbersome. Furthermore, the significance of genotypic characterization is severely restricted with regard to the evaluation of antibiotic susceptibility. Thus, at present, there is no reasonable alternative to classical microbiological culture. Periprosthetic tissue or synovial fluid culture with an incubation period of 2 weeks is a promising approach toward optimization of periprosthetic infection diagnostics. [114]

  Antimicrobial Treatment Top

The treatment of infections following total joint arthroplasty involves surgery and antimicrobial treatment. Complete removal of all foreign materials is essential, while simple surgical drainage coupled with a finite course of antibiotics is characterized by a high failure rate. A two-stage reimplantation is considered the standard surgical procedure in the treatment of septic prosthetic joints. However, when prosthetic removal is not possible or is contraindicated, suppressive antibiotic therapy with retention of the functioning joint arthroplasty may be considered. [115] The empirical antibiotic treatment depends on the most likely organism to be associated with the infection. Glycopeptides or linezolid cover all Gram-positive organisms, including MRSA, whereas infections due to Gram-negative organisms are treated with third-generation cephalosporins with antipseudomonal activity. [5]

Penicillins and cephalosporins

Local and international guidelines, at present, recommend a single dose of cefazolin or flucloxacillin at the time of induction based on data from randomized control trials performed in the 1970s and 1980s. [116],[117] However, the rate of polymicrobial infection and the isolation rate of MRSA affect the success rate of surgical antibiotic prophylaxis. In a study conducted by Peel et al., [7] the majority (88%) of patients received cefazolin as an antibiotic prophylaxis at the time of arthroplasty. In 63% of patients in this cohort, the microorganisms subsequently obtained were not susceptible to the antibiotic prophylaxis administered. The guidelines stipulate, therefore, that the antibiotics chosen as prophylaxis should be selected to cover the most frequently encountered pathogens. [117]


Recent data have demonstrated the efficacy of treating patients with early (symptoms for <21 days) staphylococcal orthopedic implant infections with retention and debridement of a stable prosthesis, combined with oral rifampicin and a fluoroquinolone. [118] Ciprofloxacin is a rational choice, given its good activity against Staphylococcus aureus, excellent oral absorption, and activity against adherent bacteria. [119] However, fluoroquinolone resistance is now at high levels in nosocomial strains of staphylococci, [120] thereby limiting the usefulness of rifampicin and fluoroquinolone combinations.


Gentamicin and tobramycin are commonly impregnated into poly(methyl methacrylate) for the treatment and prevention of PJI. Anguita-Alonso et al. [121] did a study to determine the minimum inhibitory value of 93 staphylococci from patients with PJI and found that 41% and 66% of the isolates were resistant to gentamicin and tobramycin, respectively. MRSA are more likely to be resistant to these drugs than their MSSA counterparts.

Rifampicin and fusidic acid

Rifampicin and fusidic acid have good activity against most staphylococci, and have retained activity against the majority of methicillin-resistant and fluoroquinolone-resistant staphylococci isolated in most parts of the world. [122] These antimicrobial agents are well absorbed after oral administration, and demonstrate excellent penetration into tissues and the intracellular space. [123] Rifampicin has demonstrated excellent efficacy against slow-growing organisms and organisms associated with biofilms, both of which are important in the pathogenesis of infections involving prosthetic material. [124] Resistance develops quickly in staphylococcal infections when either of these antibiotics is used alone. However, the risk of emergence of resistance is considerably reduced when the agents are used in combination. [122],[123],[124] Recommendations published recently include rifampicin in combination with fusidic acid as an option after debridement and prosthesis retention for the management of early PJI. [3] This option is particularly useful in the case of MRSA infections, where fluoroquinolone resistance is common, or where the patient shows intolerance to fluoroquinolones.


Linezolid is a recently approved agent for the treatment of MRSA infections. An important advantage of linezolid over glycopeptides is the oral administration that reduces time of hospitalization and increases the compliance, especially when the duration of therapy is considerable, as in the treatment of PJIs. Bassetti et al. have successfully used linezolid in two patients with MRSA PJIs. [125] The efficacy of linezolid in the long-term treatment of a case of methicillin-resistant S. epidermidis prosthetic hip infection has also emerged from another report. [126]

  Conclusion Top

PJI places a substantial burden on individuals, communities, and the health-care system, and thus, early diagnosis and appropriate intervention are extremely important. Determining the various host and environmental factors that put an individual at risk for development of PJI may reduce the morbidity and cost of total joint arthroplasties. Increased reliance on novel molecular techniques has enriched our knowledge of the diverse polymicrobial collections that cause PJI. At present, there is no consensus on gold-standard treatment, as evidenced by the wide variety of surgical protocols and prescription of antibiotics. Data available at present suggest that empirical antibiotic therapy should be tailored to the local ecology. Antimicrobials should be reserved for patients for whom prosthesis removal is not possible or is contraindicated. Given the high rate of isolation of methicillin-resistant organisms and the large number of infections involving Gram-negative organisms, it is suggested that empirical antibiotic therapy for patients who present with PJI should include a glycopeptide and an antipseudomonal beta-lactam antibiotic. [5]

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  References Top

Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, et al. Diagnosis and management of prosthetic joint infection: Clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2013;56:e1-25.  Back to cited text no. 1
Waldvogel FA, Bisno AL. Infections Associated with Indwelling Medical Devices. 3 rd ed. Washington, DC: American Society for Microbiology; 2000. p. 173-209.  Back to cited text no. 2
Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med 2004;351:1645-54.  Back to cited text no. 3
Luessenhop CP, Higgins LD, Brause BD, Ranawat CS. Multiple prosthetic infections after total joint arthroplasty: Risk factor analysis. J Arthroplasty 1996;11:862-8.  Back to cited text no. 4
Peel TN, Cheng AC, Buising KL, Choong PF. Microbiological aetiology, epidemiology, and clinical profile of prosthetic joint infections: Are current antibiotic prophylaxis guidelines effective? Antimicrob Agents Chemother 2012;56:2386-91.  Back to cited text no. 5
Darouiche RO. Treatment of infections associated with surgical implants. N Engl J Med 2004;350:1422-9.  Back to cited text no. 6
Berbari EF, Hanssen AD, Duffy MC, Steckelberg JM, Ilstrup DM, Harmsen WS, et al. Risk factors for prosthetic joint infection: Case-control study. Clin Infect Dis 1998;27:1247-54.  Back to cited text no. 7
Aslam S, Reitman C, Darouiche RO. Risk factors for subsequent diagnosis of prosthetic joint infection. Infect Control Hosp Epidemiol 2010;31:298-301.  Back to cited text no. 8
Culver DH, Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG, et al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System Am J Med 1991;91:152-7S.  Back to cited text no. 9
Wilson MG, Kelley K, Thornhill TS. Infection as a complication of total knee-replacement arthroplasty. Risk factors and treatment in sixty-seven cases. J Bone Joint Surg Am 1990;72:878-83.  Back to cited text no. 10
Fitzgerald RH Jr, Nolan DR, Ilstrup DM, Van Scoy RE, Washington JA 2 nd , Coventry MB. Deep wound sepsis following total hip arthroplasty. J Bone Joint Surg Am 1977;59:847-55.  Back to cited text no. 11
Smith RT. Cancer and the immune system. Pediatr Clin North Am 1994;41:841-50.  Back to cited text no. 12
Rand JA, Fitzgerald RH Jr. Diagnosis and management of the infected total knee arthroplasty. Orthop Clin North Am 1989;20:201-10.  Back to cited text no. 13
Ahnfelt L, Herberts P, Malchau H, Andersson GB. Prognosis of total hip replacement. A Swedish multicenter study of 4,664 revisions. Acta Orthop Scand Suppl 1990;238:1-26.  Back to cited text no. 14
Jacobson JJ, Millard HD, Plezia R, Blankenship JR. Dental treatment and late prosthetic joint infections. Oral Surg Oral Med Oral Pathol 1986;61:413-7.  Back to cited text no. 15
Kurtz SM, Ong KL, Lau E, Bozic KJ, Berry D, Parvizi J. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res 2010;468:52-6.  Back to cited text no. 16
Dowsey MM, Choong PF. Obesity is a major risk factor for prosthetic infection after primary hip arthroplasty. Clin Orthop Relat Res 2008;466:153-8.  Back to cited text no. 17
Edwards EE. Candida species. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and Practice of Infectious Diseases. Philadelphia: Churchill Livingstone; 2000. p. 2656-74.  Back to cited text no. 18
Brooks DH, Pupparo F. Successful salvage of a primary total knee arthroplasty infected with Candida parapsilosis. J Arthroplasty 1998;13:707-12.  Back to cited text no. 19
Hennessy MJ. Infection of a total knee arthroplasty by Candida parapsilosis: A case report of successful treatment by joint reimplantation with a literature review. Am J Knee Surg 1996; 9:133-6.  Back to cited text no. 20
Cardinal E, Braunstein EM, Capello WN, Heck DA. Candida albicans infection of prosthetic joints. Orthopedics 1996;19:247-51.  Back to cited text no. 21
Darouiche RO, Hamill RJ, Musher DM, Young EJ, Harris RL. Periprosthetic candidal infections following arthroplasty. Rev Infect Dis 1989;11:89-96.  Back to cited text no. 22
Koch AE. Candida albicans infection of a prosthetic knee replacement: A report and review of the literature. J Rheumatol 1988;15:362-5.  Back to cited text no. 23
Steckelberg JM, Osmon DR. Prosthetic joint infections. In: Bisno L, Waldvogel FA, editors. Infections Associated with Indwelling Medical Devices. 3 rd ed. Washington DC: American Society for Microbiology; 2000. p. 173-209.  Back to cited text no. 24
Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg Am 1996;78:512-23.  Back to cited text no. 25
Marculescu CE, Cantey JR. Polymicrobial prosthetic joint infections: Risk factors and outcome. Clin Orthop Relat Res 2008;466: 1397-404.  Back to cited text no. 26
Sanderson PJ. Infection in orthopaedic implantsTop of Form. J Hosp Infect 1991;18:(Suppl A):367-75.  Back to cited text no. 27
Berbari EF, Marculescu C, Sia I, Lahr BD, Hanssen AD, Steckelberg JK, et al. Culture-negative prosthetic joint infection. Clin Infect Dis 2007;45:1113-9.  Back to cited text no. 28
Steckelberg JM, Osmon DR. Prosthetic joint infections. In: Waldvogel FA, Bisno AL, editors. Infections Associated with Indwelling Medical Devices. 3 rd ed. Washington, DC: American Society of Microbiology; 2000. p. 173-200.  Back to cited text no. 29
Berbari EF, Osmon DR, Carr A, Hanssen AD, Baddour LM, Greene D, et al. Dental procedures as risk factors for prosthetic hip or knee infection: A hospital-based prospective case-control study. Clin Infect Dis 2010;50:8-16.  Back to cited text no. 30
Salgado CD, Dash S, Cantey JR, Marculescu CE. Higher risk of failure of methicillin-resistant staphylococcus aureus prosthetic joint infections. Clin Orthop Relat Res 2007;461:48-53.  Back to cited text no. 31
Razonable RR, Lewallen DG, Patel R, Osmon DR. Vertebral osteomyelitis and prosthetic joint infection due to Staphylococcus simulans. Mayo Clinic Proc 2001;76:1067-70.  Back to cited text no. 32
Sampathkumar P, Osmon DR, Cockerill FR 3 rd . Prosthetic joint infection due to Staphylococcus lugdunensis. Mayo Clin Proc 2000;75:511-2.  Back to cited text no. 33
Deacon JM, Pagliaro AJ, Zelicof SB, Horowitz HW. Prophylactic use of antibiotics for procedures after total joint replacement. J Bone Joint Surg Am 1996;78:1755-70.  Back to cited text no. 34
Duggan JM, Georgiadis G, VanGorp C, Kleshinski J. Group B streptococcal prosthetic joint infections. J South Orthop Assoc 2001;10:209-14.  Back to cited text no. 35
Kleshinski J, Georgiadis GM, Duggan JM. Group C streptococcal infection in a prosthetic joint. South Med J 2000;93:1217-20.  Back to cited text no. 36
Meehan AM, Osmon DR, Duffy MC, Hanssen AD, Keating MR. Outcome of penicillin-susceptible streptococcal prosthetic joint infection treated with debridement and retention of the prosthesis. Clin Infect Dis 2003;36:845-9.  Back to cited text no. 37
Gaunt PN, Seal DV. Group G streptococcal infection of joints and joint prostheses. J Infect 1986;13:115-23.  Back to cited text no. 38
Raymond NJ, Henry J, Workowski KA. Enterococcal arthritis: Case report and review. Clin Infect Dis 1995;21:516-22.  Back to cited text no. 39
Ryczak M, Sands M, Brown RB, Sklar JH. Pneumococcal arthritis in a prosthetic knee. A case report and review of the literature. Clin Orthop Relat Res 1987;224-7.  Back to cited text no. 40
Achermann Y, Trampuz A, Moro F, Wüst J, Vogt M. Corynebacterium bovis shoulder prosthetic joint infection: The first reported case. Diagn Microbiol Infect Dis 2009;64:213-5.  Back to cited text no. 41
Tleyjeh IM, Qutub MO, Bakleh M, Sohail MR, Virk A. Corynebacterium jeikeium prosthetic joint infection: Case report and literature review. Scand J Infect Dis 2005;37:151-3.  Back to cited text no. 42
Khater FJ, Samnani IQ, Mehta JB, Moorman JP, Myers JW. Prosthetic joint infection by Mycobacterium tuberculosis: An unusual case report with literature review. South Med J 2007;100:66-9.  Back to cited text no. 43
Berbari EF, Hanssen AD, Duffy MC, Steckelberg JM, Osmon DR. Prosthetic joint infection due to Mycobacterium tuberculosis: A case series and review of the literature. Am J Orthop (Belle Mead NJ) 1998;27:219-27.  Back to cited text no. 44
Eid AJ, Berbari EF, Sia IG, Wengenack NL, Osmon DR, Razonable RR. Prosthetic joint infection due to rapidly growing mycobacteria: Report of 8 cases and review of the literature. Clin Infect Dis 2007;45:687-94.  Back to cited text no. 45
Herold RC, Lotke PA, MacGregor RR. Prosthetic joint infections secondary to rapidly growing Mycobacterium fortuitum. Clin Orthop Relat Res 1987;183-6.  Back to cited text no. 46
Pring M, Eckhoff DG. Mycobacterium chelonae infection following a total knee arthroplasty. J Arthroplasty 1996;11:115-6.  Back to cited text no. 47
Neuberger A, Sprecher H, Oren I. Septic arthritis caused by Mycobacterium kansasii in a prosthetic knee joint. J Clin Microbiol 2006;44:2648-9.  Back to cited text no. 48
Gupta A, Clauss H. Prosthetic joint infection with Mycobacterium avium complex in a solid organ transplant recipient. Transpl Infect Dis 2009;11:537-40.  Back to cited text no. 49
Allerberger F, Kasten MJ, Cockerill FR 3 rd , Krismer M, Dierich MP. Listeria monocytogenes infection in prosthetic joints. Int Orthop 1992;16:237-9.  Back to cited text no. 50
Harrington RD, Lewis CG, Aslanzadeh J, Stelmach P, Woolfrey AE. Oerskovia xanthineolytica infection of a prosthetic joint: Case report and review. J Clin Microbiol 1996;34:1821-4.  Back to cited text no. 51
Frésard A, Guglielminotti C, Berthelot P, Ros A, Farizon F, Dauga C, et al. Prosthetic joint infection caused by Tropheryma whippelii (Whipple's Bacillus). Clin Infect Dis 1996;22:575-6.  Back to cited text no. 52
Aubin GG, Bémer P, Guillouzouic A, Crémet L, Touchais S, Fraquet N, et al. First Report of a Hip Prosthetic and Joint Infection Caused by Lactococcus garvieae in a woman fishmonger. J Clin Microbiol 2011;49:2074-6.  Back to cited text no. 53
Michels F, Colaert J, Gheysen F, Scheerlinck T. Late prosthetic joint infection due to Rothia mucilaginosa. Acta Orthop Belg 2007;73;263-7.   Back to cited text no. 54
Zimmerli W, Ochsner PE. Management of infection associated with prosthetic joints. Infection 2003;31:99-108.  Back to cited text no. 55
McDonald DJ, Fitzgerald RH Jr, Ilstrup DM. Two-stage reconstruction of a total hip arthroplasty because of infection. J Bone Joint Surg Am 1989;71:828-34.  Back to cited text no. 56
Hsieh PH, Lee MS, Hsu KY, Chang YH, Shih HN, Ueng SW. Gram-negative prosthetic joint infections: Risk factors and outcome of treatment. Clin Infect Dis 2009;49:1036-43.  Back to cited text no. 57
Aboltins CA, Dowsey MM, Buising KL, Peel TN, Daffy JR, Choong PF, et al. Gram-negative prosthetic joint infection treated with debridement, prosthesis retention and antibiotic regimens including a fluoroquinolone. Clin Microbiol Infect 2011;17:862-7.  Back to cited text no. 58
Manian FA. Prosthetic joint infection due to Haemophilus parainfluenzae after dental surgery. South Med J 1991;84:807-8.  Back to cited text no. 59
Jellicoe PA, Cohen A, Campbell P. Haemophilus parainfluenzae complicating total hip arthroplasty: A rapid failure. J Arthroplasty 2002;17:114-6.  Back to cited text no. 60
Vikram HR, Buencamino RB, Aronin SI. Primary meningococcal arthritis in a prosthetic knee joint. J Infect 2001;42:279-81.  Back to cited text no. 61
Mehta H, Mackie I. Prosthetic joint infection with pasturella multocida following cat scratch: A report of 2 cases. J Arthroplasty 2004;19: 525-7.  Back to cited text no. 62
Orton DW, Fulcher WH. Pasteurella multocida: Bilateral septic knee joint prostheses from a distant cat bite. Ann Emerg Med 1984;13:1065-7.  Back to cited text no. 63
Chikwe J, Bowditch M, Villar RN, Bedford AF. Sleeping with the enemy: Pasteurella multocida infection of a hip replacement. J R Soc Med 2000;93:478-9.  Back to cited text no. 64
Takwale VJ, Wright ED, Bates J, Edge AJ. Pasteurella multocida infection of a total hip arthroplasty following cat scratch. J Infect 1997;34:263-4.  Back to cited text no. 65
Weil Y, Mattan Y, Liebergall M, Rahav G. Brucella prosthetic joint infection: A report of 3 cases and a review of the literature. Clin Infect Dis 2003;36:e81-6.  Back to cited text no. 66
Jones RB, Berryhill WH, Smith J, Hofmann A, Rogers D. Secondary infection of a total hip replacement with Brucella abortus. Orthopedics 1983;6:184-6.  Back to cited text no. 67
Day LJ, Qayyum QJ, Kauffman CA. Salmonella prosthetic joint septic arthritis. Clin Microbiol Infect 2002;8:427-30.  Back to cited text no. 68
Samra Y, Shaked Y, Maier MK. Nontyphoid salmonellosis in patients with total hip replacement: Report of four cases and review of the literature. Rev Infect Dis 1986;8:978-83.  Back to cited text no. 69
Tattevin P, Crémieux AC, Joly-Guillou ML, Carbon C. First case of Salmonella hirschfeldii (paratyphi C) infection of a prosthetic hip. Clin Microbiol Infect 1998;4:228-30.  Back to cited text no. 70
Rae S, Webley M, Snaith ML. Salmonella typhimurium arthritis in rheumatoid disease. Rheumatol Rehab 1977;16:150-1.  Back to cited text no. 71
Fernández-Cruz A, Marín M, Castelo L, Usubillaga R, Martín-Rabadán P, Bouza E; GAIO (Group for the Assessment of Osteoarticular Infections) Study Group. Legionella micdadei, a new cause of prosthetic joint infection. J Clin Microbiol 2011;49:3409-10.  Back to cited text no. 72
Bates CJ, Clarke TC, Spencer RC. Prosthetic hip joint infection due to Campylobacter fetus. J Clin Microbiol 1994;32:2037.  Back to cited text no. 73
Yao JD, Ng HM, Campbell I. Prosthetic hip joint infection due to Campylobacter fetus. J Clin Microbiol 1993;31:3323-4.  Back to cited text no. 74
Sharp SE. Campylobacter coli prosthetic hip infection associated with ingestion of contaminated oysters. J Clin Microbiol 2009;47: 3370-1.   Back to cited text no. 75
Peterson MC, Farr RW, Castiglia M. Prosthetic hip infection and bacteremia due to Campylobacter jejuni in a patient with AIDS. Clin Infect Dis1993;16:439-40.  Back to cited text no. 76
Werno AM, Klena JD, Shaw GM, Murdoch DR. Fatal Case of Campylobacter lari prosthetic joint infection and bacteremia in an immunocompetent patient. J Clin Microbiol 2002;40:1053-5.   Back to cited text no. 77
Panackal AA, Houze YB, Prentice J, Leopold SS, Cookson BT, Liles WC, et al. Prosthetic joint infection due to "Helcococcus pyogenes" [corrected]. J Clin Microbiol 2004;42:2872-4.  Back to cited text no. 78
Levy PY, Fenollar F, Stein A, Borrione F, Raoult D. Finegoldia magna: A forgotten pathogen in prosthetic joint infection rediscovered by molecular biology. Clin Infect Dis 2009;49:1244-7.  Back to cited text no. 79
Bartz H, Nonnenmacher C, Bollmann C, Kuhl M, Zimmermann S, Heeg K, et al. Micromonas (Peptostreptococcus) micros: Unusual case of prosthetic joint infection associated with dental procedures. Int J Med Microbiol 2005;294:465-70.  Back to cited text no. 80
Gallo J, Kolar M, Dendis M, Loveckova Y, Sauer P, Zapletalova J, et al. Culture and PCR analysis of joint fluid in the diagnosis of prosthetic joint infection. New Microbiol 2008;31:97-104.  Back to cited text no. 81
Cohen OJ, Keiser JK, Pollner J. Prosthetic joint infection with Actinomyces viscosus. Infect Dis Clin Pract 1993;2:349-51.  Back to cited text no. 82
Zaman R, Abbas M, Burd E. Late prosthetic hip joint infection with Actinomyces israelii in an intravenous drug user: Case report and literature review. J Clin Microbiol 2002;40:4391-2.  Back to cited text no. 83
Levy PY, Fenollar F, Stein A, Borrione F, Cohen E, Lebail B, et al. Propionibacterium acnes postoperative shoulder arthritis: An emerging clinical entity. Clin Infect Dis 2008;46:1884-6.  Back to cited text no. 84
Kanafani ZA, Sexton DJ, Pien BC, Varkey J, Basmania C, Kaye KS. Postoperative joint infections due to Propionibacterium species: A case-control study. Clin Infect Dis 2009;49:1083-5.  Back to cited text no. 85
Lutz MF, Berthelot P, Fresard A, Cazorla C, Carricajo A, Vautrin AC, et al. Arthroplastic and osteosynthetic infections due to Propionibacterium acnes: A retrospective study of 52 cases, 1995-2002. Eur J Clin Microbiol Infect Dis 2005;24:739-44.  Back to cited text no. 86
McCarthy J, Stingemore N. Clostridium difficile infection of a prosthetic joint presenting 12 months after antibiotic-associated diarrhoea. J Infect 1999;39:94-6.  Back to cited text no. 87
Pron B, Merckx J, Touzet P, Ferroni A, Poyart C, Berche P, et al. Chronic septic arthritis and osteomyelitis in a prosthetic knee joint due to Clostridium difficile. Eur J Clin Microbiol Infect Dis 1995;14:599-601.  Back to cited text no. 88
Maniloff G, Greenwald R, Laskin R, Singer C. Delayed postbacterermic prosthetic joint infection. Clin Orthop Relat Res 1987;194-7.  Back to cited text no. 89
Marchandin H, Jean-Pierre H, Carrière C, Canovas F, Darbas H, Jumas-Bilak E. Prosthetic joint infection due to Veillonella dispar. Eur J Clin Microbiol Infect Dis 2001;20:340-2.  Back to cited text no. 90
Phelan DM, Osmon DR, Keating MR, Hanssen AD. Delayed Reimplantation arthroplasty for candidal prosthetic joint infection: A report of 4 cases and review of the literature. Clin Infect Dis 2002;34:930-8.  Back to cited text no. 91
Wada M, Baba H, Imura S. Prosthetic knee Candida parapsilosis infection. J Arthroplasty 1998;13:479-82.  Back to cited text no. 92
Merrer J, Dupont B, Nieszkowska A, De Jonghe B, Outin H. Candida albicans prosthetic arthritis treated with fluconazole alone. J Infect 2001;42:208-9.  Back to cited text no. 93
Johannsson B, Callaghan JJ. Prosthetic hip infection due to Cryptococcus neoformans: Case report. Diagn Microbiol Infect Dis 2009;64:76-9.  Back to cited text no. 94
Baumann PA, Cunningham B, Patel NS, Finn HA. Aspergillus fumigatus infection in a mega prosthetic total knee arthroplasty: Salvage by staged reimplantation with 5-year follow-up. J Arthroplasty 2001;16:498-503.  Back to cited text no. 95
Fowler VG Jr, Nacinovich FM, Alspaugh JA, Corey GR. Prosthetic joint infection due to Histoplasma capsulatum: Case report and review. Clin Infect Dis 1998;26:1017.   Back to cited text no. 96
Lonner JH, Siliski JM, Scott RD. Prodromes of failure in total knee arthroplasty. J Arthroplasty 1999;14:488-92.  Back to cited text no. 97
Schmalzried TP, Amstutz HC, Au MK, Dorey FJ. Etiology of deep sepsis in total hip arthroplasty. The significance of hematogenous and recurrent infections. Clin Orthop Relat Res 1992;200-7.  Back to cited text no. 98
Virolainen P, Lähteenmäki H, Hiltunen A, Sipola E, Meurman O, Nelimarkka O. The reliability of diagnosis of infection during revision arthroplasties. Scand J Surg 2002;91:178-81.  Back to cited text no. 99
Inman RD, Gallegos KV, Brause BD, Redecha PB, Christian CL. Clinical and microbial features of prosthetic joint infection. Am J Med 1984;77:47-53.  Back to cited text no. 100
Del Pozo JL, Patel R. Clinical practice. Infection associated with prosthetic joints. N Engl J Med 2009;361:787-94.  Back to cited text no. 101
Donlan RM. New approaches for the characterization of prosthetic joint biofilms. Clin Orthop Relat Res 2005;12-9.  Back to cited text no. 102
Tunney MM, Patrick S, Gorman SP, Nixon JR, Anderson N, Davis RI, et al. Improved detection of infection in hip replacements. A currently underestimated problem. J Bone Joint Surg Br 1998;80:568-72.  Back to cited text no. 103
Trampuz A, Piper KE, Jacobson MJ, Hanssen AD, Unni KK, Osmon DR, et al. Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med 2007;357:654-63.  Back to cited text no. 104
Van Houdt R, Michiels CW. Role of bacterial cell surface structures in Escherichia coli biofilm formation. Res Microbiol 2005;156: 626-33.  Back to cited text no. 105
Tsaras G, Maduka-Ezeh A, Inwards CY, Mabry T, Erwin PJ, Murad MH, et al. Utility of intraoperative frozen section histopathology in the diagnosis of periprosthetic joint infection: A systematic review and meta-analysis. J Bone Joint Surg Am 2012;94:1700-11.  Back to cited text no. 106
Ghanem E, Ketonis C, Restrepo C, Joshi A, Barrack R, Parvizi J. Periprosthetic infection: Where do we stand with regard to Gram stain? Acta Orthop 2009;80:37-40.  Back to cited text no. 107
Bernard L, Lübbeke A, Stern R, Bru JP, Feron JM, Peyramond D, et al. Value of preoperative investigations in diagnosing prosthetic joint infection: Retrospective cohort study and literature review. Scand J Infect Dis 2004;36:410-6.  Back to cited text no. 108
Ali F, Wilkinson JM, Cooper JR, Kerry RM, Hamer AJ, Norman P, et al. Accuracy of joint aspiration for the preoperative diagnosis of infection in total hip arthroplasty. J Arthroplasty 2006;21:221-6.  Back to cited text no. 109
Nazzal D, Yasin S, Abu-Elteen K. A rapid PCR-based method for identification of four important Candida species. New Microbiol 2005;28:245-50.  Back to cited text no. 110
Ortu S, Molicotti P, Sechi LA, Pirina P, Saba F, Vertuccio C, et al. Rapid detection and identification of Mycobacterium tuberculosis by Real Time PCR and Bactec 960 MIGT. New Microbiol 2006;29:75-80.  Back to cited text no. 111
Levine MJ, Mariani BD, Tuan RS, Booth RE Jr. Molecular genetic diagnosis of infected total joint arthroplasty. J Arthroplasty 1995;10:93-4.  Back to cited text no. 112
Vandercam B, Jeumont S, Cornu O, Yombi JC, Lecouvet F, Lefèvre P, et al. Amplification-based DNA analysis in the diagnosis of prosthetic joint infection. J Mol Diagn 2008;10:537-43.  Back to cited text no. 113
Fer PS, Fink B, Sandow D, Margull A, Berger I, Frommelt L. Prolonged bacterial culture to identify late periprosthetic joint infection: A promising strategy. Clin Infect Dis 2008;47:1403-9.   Back to cited text no. 114
Bassetti M, Vitale F, Melica G, Righi E, Di Biagio A, Molfetta L, et al. Linezolid in the treatment of gram-positive prosthetic joint infections. J Antimicrob Chemother 2005;55:387-90.  Back to cited text no. 115
Antibiotic Expert Group. Therapeutic Guidelines: Antibiotic. 14 th ed. Melbourne, Australia: Therapeutic Guidelines Limited; 2010.   Back to cited text no. 116
Bratzler DW, Houck PM; Surgical Infection Prevention Guidelines Writers Workgroup; American Academy of Orthopaedic Surgeons; American Association of Critical Care Nurses; American Association of Nurse Anesthetists; American College of Surgeons; American College of Osteopathic Surgeons, et al. Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004;38:1706-15.  Back to cited text no. 117
Zimmerli W, Widmer AF, Blatter M, Frei R, Oohsner PE. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: A randomised controlled trial. Foreign-Body Infection (FBI) Study Group. JAMA 1998;279:1537-41.  Back to cited text no. 118
Darley ES, MacGowan AP. Antibiotic treatment of gram-positive bone and joint infections. J Antimicrob Chemother 2004;53:928-35.  Back to cited text no. 119
Diekema DJ, Pfaller MA, Schmitz FJ. Survey of infections due to Staphylococcus species: Frequency of occurrence and antimicrobial susceptibility of isolates collected in the United States, Canada, Latin America, Europe, and the Western Pacific region for the SENTRY antimicrobial surveillance program, 1997-99. Clin Infect Dis 2001;32(Suppl 2):S114-32.  Back to cited text no. 120
Anguita-Alonso P, Hanssen AD, Osmon DR, Trampuz A, Steckelberg JM, Patel R. High Rate of Aminoglycoside Resistance among Staphylococci Causing Prosthetic Joint Infection. Clin Orthop Relat Res 2005;439: 43-7.  Back to cited text no. 121
Turnidge J, Collignon P. Resistance to fusidic acid. Int J Antimicrob Agents 1999;12(Suppl 2):S35-44.  Back to cited text no. 122
Kucers A, Crowe SM, Grayson ML, Hoy JF. The Use of Antibiotics: A Clinical Review of Antibacterial, Antifungal and Antiviral Drugs. 5 th ed. Oxford: Butterworth-Heinemann; 1997.  Back to cited text no. 123
Widmer AF, Frei R, Rajacic Z, Zimmerli W. Correlation between in vivo and in vitro efficacy of antimicrobial agents against foreign body infections. J Infect Dis 1990;162:96-102.  Back to cited text no. 124
Bassetti M, Di Biagio A, Cenderello G, Del Bono V, Palermo A, Cruciani M, et al. Linezolid treatment of prosthetic hip infections due to methicillin-resistant Staphylococcus aureus (MRSA). J Infect 2001;43:148-9.  Back to cited text no. 125
Jover-Sáenz A, Gaite FB, Ribelles AG, Porcel-Pérez JM, Garrido-Calvo S. Linezolid treatment of total prosthetic knee infection due to methicillin resistant Staphylococcus epidermidis. J Infect 2003;47: 87-8.  Back to cited text no. 126


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