Differing Microorganism Profile in Early and Late Prosthetic Joint Infections Following Primary Total Knee Arthroplasty-Implications for Empiric Antibiotic Treatment

Background: Prosthetic joint infection (PJI) is the leading cause of revision following total knee arthroplasty (TKA). Prior to microorganism identification, the choice of the correct empiric antibiotics is critical to treatment success. This study aims to 1) compare the microorganism and resistance profile in early and late PJIs; 2) recommend appropriate empiric antibiotics.Methods: A multicentre retrospective review was performed over a 15-year period. First episode PJIs were classified by both the Tsukayama Classification and Auckland Classification. For each PJI case, the causative organism and antibiotic sensitivity were recorded.Results: Of eligible patients, 232 culture-positive PJI cases were included. Using either classification system, early PJIs (<4 weeks or <1 year since primary) were significantly more likely to be resistant and polymicrobial. The predominant organisms were coagulase-negative Staphylococci in early PJIs while Staphylococcus aureus was the most common in late PJIs. The distribution of gram-negative cases was higher in early Class-A than late Class-C PJIs (25% versus 6%, P 1/4 .004). Vancomycin provided significantly superior coverage when compared to Flucloxacillin for early infections, and addition of a gram-negative agent achieved coverage over 90% using both classification systems.Conclusion: Based on the microbiological pattern in Tsukayama criteria, Vancomycin with the consideration of Gram-negative agent should be considered for Class-A infections given the high proportion of resistant and polymicrobial cases. For Class-C infections, Cephazolin or Flucloxacillin is likely sufficient. We recommend antibiotics to be withheld in Class-B infections until cultures and sensitivities are known.(c) 2022 Elsevier Inc. All rights reserved.

Automated summary

Prosthetic joint infection (PJI) is a common complication following total knee arthroplasty (TKA). This study compared the microorganism and resistance profile between early and late PJI cases and recommended appropriate empiric antibiotics. The findings showed that early PJI cases were more resistant and polymicrobial, with coagulase-negative Staphylococci being the predominant organisms, while Staphylococcus aureus was more common in late PJI cases. The study recommended using Vancomycin with a Gram-negative agent for early infections and Cephazolin or Flucloxacillin for late infections. Antibiotics were advised to be withheld in intermediate infections until culture and sensitivity results were available.