General

General section questions and answers

General

Table of contents

Prevention

Host Related (Local)

  • Question 1: Does the presence of skin lesions (i.e. boils, grazes, folliculitis, etc.), either in the proximity or distant to the surgical site, predispose patients to SSIs/PJIs? If so, is it necessary for patients with these skin lesions to undergo treatment prior to elective total joint arthroplasty (TJA)?
  • Question 2: Does poor dental hygiene increase the risk of subsequent SSI/PJI? If yes, is there a role for obtaining dental clearance in patients with poor dental hygiene to reduce the risk of SSI/PJI?
  • Question 3: Should routine dental clearance be obtained prior to total joint arthroplasty (hip/knee/shoulder/ankle)?
  • Question 4: Does the use of a urinary catheter during orthopaedic surgery increase the risk of subsequent SSI/PJI?
  • Question 5: Is routine urinary screening indicated prior to elective total joint arthroplasty (TJA)? If so, how should asymptomatic bacteriuria be treated prior to undergoing elective joint arthroplasty?
  • Question 6: How should a patient with a symptomatic pre-operative urinary tract infection (UTI) be managed prior to undergoing elective joint arthroplasty?
  • Question 7: Does pre-operative urinary tract infection (symptomatic and asymptomatic) increase the risk for subsequent SSI/PJI?
  • Question 8: Does a patient with a colostomy have an increased risk for SSI/PJI?

Host Related (General)

  • Question 1: What modifiable and non-modifiable host factors contribute to an increased risk of SSI/PJI?
  • Question 2: Are there any genetic factors that predispose patients to SSI/PJI or predict the success of the treatment for SSI/PJI?
  • Question 3: Does current tobacco use increase the risk of SSI/PJI recurrence?
  • Question 4: Do underweight patients (BMI <18.5Kg/m2) have a higher risk of SSI/PJI following orthopaedic procedures? If yes, does increasing the body mass index in underweight patients reduce the risk of SSI/PJI?
  • Question 5: a) What upper body mass index threshold is associated with an increased risk of SSI/PJI? b) Does implementation of these cut-offs reduce the incidence of SSI/PJI?
  • Question 6: Does bariatric surgery reduce the risk of SSI/PJI in patients with obesity?
  • Question 7: Does human immunodeficiency virus (HIV) predispose patients to SSI/PJI? If so, what optimization should be undertaken prior to operating on patients with HIV?
  • Question 8: Do immunomodulatory disease-modifying medications (e.g. methotrexate, anti-TNF agents) need to be withheld pre-operatively to reduce the risk for subsequent SSI/PJI?
  • Question 9: Does liver disease (hepatitis C, cirrhosis, etc.) predispose patients to SSI/PJI? If so, what optimization should be undertaken prior to operating on patients with liver disease?
  • Question 10: Is there a link between opioid consumption and an increased risk for SSI/PJI?
  • Question 11: Does the presence of anxiety/depression and mood disorders increase the risk of SSIs/PJIs? If so, what are the considerations that should be implemented to reduce the risk of SSIs/PJIs?
  • Question 12: Does vitamin D deficiency increase the risk of subsequent SSIs/PJIs in patients undergoing orthopaedic procedures?
  • Question 13: Is preoperative anemia a risk factor for SSI/PJI?
  • Question 14: What preoperative optimization for anemia can be done to increase the hemoglobin concentration?
  • Question 15: Does an effort to increase preoperative hemoglobin concentration influence the rate of postoperative SSIs/PJIs?

Host Risk Mitigation (Local)

  • Question 1: Does a prior surgical procedure (with or without retained hardware) in the same joint as the arthroplasty increase the risk of subsequent SSI/PJI?
  • Question 2: In patients with prior septic arthritis what strategies should be undertaken to minimize the risk of subsequent SSI/PJI?
  • Question 3: Does the presence of prior projectile missile/bullet fragments in a joint predispose the patient to a higher risk of subsequent SSI/PJI? If so, what should be done to reduce the risk of SSI/PJI?

Host Risk Mitigation (General)

  • Question 1: Can immunotherapy and immunoprophylaxis be used to prevent biofilm formation and implant-associated infections?
  • Question 2: Does routine screening for diabetes and glycemic control reduce the risk of SSI/PJI?
  • Question 3: What is the most accurate marker for assessing glycemic control that best predicts SSI/PJI?
  • Question 4: What is the threshold for HbA1C that is predictive of subsequent SSI/PJI in patients undergoing orthopaedic procedures?
  • Question 5: Is thrombocytosis associated with an increased risk of SSIs/PJIs in patients undergoing orthopaedic procedures?

Risk Mitigation (Local)

  • Question 1: Is pre-operative methicillin resistant S. aureus (MRSA) decolonization effective at reducing SSIs/PJIs in patients undergoing orthopaedic procedures? If so, is pre-operative MRSA decolonization cost-effective?
  • Question 2: What methods for MRSA/MSSA decolonization exist? What are the benefits and risks associated with the use of each?
  • Question 3: After a patient undergoes MRSA decolonization, is there a need to re-screen the patient?

Risk Mitigation (General)

  • Question 1: Does prior SSI/PJI of a joint increase the risk of subsequent infection in another joint? If so, should elective arthroplasty of the joint be withheld in patients with active or treated PJI of another joint?
  • Question 2: What immune system enhancing strategies can be employed to reduce the risk of SSIs/PJIs?
  • Question 3: For patients awaiting organ transplant who need elective arthroplasty, should the arthroplasty be done before or after the organ transplant?

Antimicrobials (Systemic)

  • Question 1: Should patients with penicillin or cephalosporin allergies routinely undergo allergy testing, desensitization, or a test dose before administering alternative antibiotic prophylaxis?
  • Question 2: What is the alternative choice of prophylactic antibiotic when the patient has an anaphylactic allergy to penicillin/cephalosporins?
  • Question 3: What is the optimal antibiotic for perioperative prophylaxis in patients who are methicillin resistant Staphylococcus aureus (MRSA) carriers and who are undergoing orthopaedic procedures?
  • Question 4: What patient factors (allergy status, weight, etc.) should be utilized to alter the choice of perioperative antibiotic prophylaxis?
  • Question 5: What are the indications for dual perioperative antibiotic prophylaxis in patients undergoing orthopaedic procedures? What are the optimal combinations of antibiotics?
  • Question 6: Should extended (beyond 24 hours) antibiotic prophylaxis be administered to patients with surgical drain(s) in place?
  • Question 7: Does the presence of implants from prior surgery in the affected joint alter the perioperative antibiotic prophylaxis?
  • Question 8: Can ceftriaxone be utilized as an alternative to cefazolin in the treatment of orthopaedic infections caused by methicillin sensitive Staphylococcus aureus (MSSA)? If so, what dosing is recommended?

Antimicrobials (Local)

  • Question 1: Is there a difference in the bioavailability of vancomycin when administered through the intravenous route or intraosseous regional route in total knee arthroplasty (TKA)?
  • Question 2: Can local antibiotic delivery alone be effective in the treatment of musculoskeletal infections?
  • Question 3: Does the local administration of vancomycin powder to wound during surgery reduce the risk of subsequent SSI/PJI? If so, what are the risk factors associated with its use?
  • Question 4: Is there a role for the use of antibiotic-loaded carriers (calcium sulfate/phosphate) in the treatment of SSI/PJI?
  • Question 5: Can fresh frozen allograft be used as a carrier to deliver local antibiotics during revision arthroplasty?

Surgical Site Preparation

  • Question 1: Does preoperative skin cleansing at home prior to orthopaedic surgery have a role in reduction of subsequent SSI/PJI?
  • Question 2: Should skin and hair around a planned surgical incision be removed? If so, what is the best method and timing of removal?
  • Question 3: Does additional skin cleansing after placement of surgical drapes have a role in reducing the rate of SSIs/PJIs?
  • Question 5: Does surgical preparation of the skin on the whole limb instead of a partial limb reduce the rates of SSIs/PJIs?
  • Question 6: Does surgical skin preparation starting from the surgical site, proximal portion of the extremity, or distal portion of the extremity affect the rate of SSIs/PJIs?
  • Question 7: Does the type of surgical drape (disposable vs. non-disposable) used affect the risk of subsequent SSIs/PJIs in patients undergoing orthopaedic surgery?
  • Question 8: Does the use of incise draping reduce the incidence of SSIs/PJIs? Is there a difference in efficacy between incise drapes?
  • Question 9: Does the use of cloth or impervious stockinettes around the ankle and extremity affect the rate of subsequent SSIs/PJIs in patients undergoing orthopaedic procedures?

Operating Room (Anesthesia)

  • Question 1: Does the type of anesthesia (general vs. neuraxial) influence the risk of subsequent SSIs/PJIs?
  • Question 2: Can regional anesthesia be administered to patients with orthopaedic infections?
  • Question 3: Is it safe to perform a neuraxial anesthesia in patients with active musculoskeletal infection?

Operating Room (Personnel)

  • Question 1: Does the number of individuals in the operating room affect the rate of SSI/PJI? If so, what strategies should be implemented to reduce traffic in the operating room?
  • Question 2: Does the risk of SSI/PJI increase when the surgeon performing the arthroplasty procedure has an upper respiratory infection?
  • Question 3: Does the technique, duration, or agent used for surgical hand scrubbing by the surgeon and OR personnel alter the patient’s risk of SSIs/PJIs?
  • Question 4: Does the type of cap worn by the operating room (OR) personnel matter?
  • Question 5: Should surgeons and personnel in the operating room (OR) wear a mask and a cap in the operating room?
  • Question 6: Does the presence of exposed facial hair (beard and mustache) on any OR staff or surgeon influence the rate of SSIs/PJIs in patients undergoing orthopaedic procedures?
  • Question 7: Does strict adherence to not wearing operating room (OR) attire outside the hospital or outside the restricted OR area reduce the risk of SSIs/PJIs?
  • Question 8: Does the Methicillin-resistant Staphylococcus aureus/epidermidis (MRSA/MRSE) colonization status of operating room (OR) personnel affect the hospital’s rate of SSIs/PJIs?

Operating Room Environment

  • Question 1: Does the use of laminar air flow (LAF) in the operating room reduce the risk of subsequent SSIs/PJIs in patients undergoing orthopaedic procedures?
  • Question 2: Does the use of forced air warming during orthopaedic procedures increase the risk of subsequent SSIs/PJIs?
  • Question 3: Does the operating room temperature affect the rate of subsequent SSIs/PJIs?
  • Question 4: Does perioperative normothermia affect the rate of subsequent SSIs/PJIs?
  • Question 5: Is there a relationship between levels of airborne microorganisms in the operating room and the risk of periprosthetic joint infections (PJIs)?
  • Question 6: What method(s) are available to verify the microbiological cleanliness of the operating room?
  • Question 7: Does the use of ultraviolet (UV) light decontamination in the operating room reduce the risk of subsequent SSIs/PJIs in patients undergoing orthopaedic procedures?
  • Question 8: Are light handles a source of contamination during orthopaedic procedures?
  • Question 9: Is there a role for banning all handheld devices/mobile phones in the operating room?

Operating Room (Surgical Attire)

  • Question 1: Does changing surgical gowns during prolonged operations reduce the risk of SSIs/PJIs? If so, how frequently should gowns be changed during the procedure?
  • Question 2: Does the type of surgical gown (disposable or reusable) used by the operating room (OR) personnel affect the rate of subsequent SSIs/PJIs in patients undergoing orthopaedic procedures?
  • Question 3: Does the use of occlusive strips at the sleeves of the surgical gowns reduce the risk of SSI/PJI?
  • Question 4: Should patients wear a mask and surgical cap in the operating room to reduce the risk of subsequent SSIs/PJIs?
  • Question 5: Does changing gloves during prolonged operations reduce the risk of SSIs/PJIs? If so, how frequently should gloves be changed during the procedure?
  • Question 6: Does shoe wear (i.e. operating room (OR) dedicated shoes, uncovered outside shoes, covered outside shoes) of the surgeon and operating room staff affect the rate of SSIs/PJIs in patients undergoing orthopaedic procedures?

Operating Room (Surgical Field)

  • Question 1: When should instrument trays be opened during surgery to minimize the risk of contamination?
  • Question 2: Does the use of a splash basin increase contamination of instruments and the rate of subsequent SSIs/PJIs in patients undergoing orthopaedic procedures?
  • Question 3: Does changing the electrocautery tip during surgery reduce the rate of subsequent SSIs/PJIs?
  • Question 4: Should suction tips be regularly changed during surgery? If so, how frequently?
  • Question 5: Should suction tips enter the intramedullary canal during orthopaedic surgery?

Antiseptic Irrigation Solution

  • Question 1: What antiseptics can be used to prevent biofilm formation?
  • Question 2: What is the optimal irrigation solution (i.e. type, volume, frequency) to be used during clean elective orthopaedic procedures?
  • Question 3: Does the pressure of the pulsatile delivery mechanism for irrigation fluid influence the efficacy of the irrigation solution to eradicate infecting organisms in the wound?
  • Question 4: Does the addition of topical antibiotics (polymyxin and/or bacitracin) to irrigation solution offer additional antibacterial properties?
  • Question 5: Is there a role for non-antibiotic natural antiseptic agents (e.g. honey, vinegar) as an irrigation solution during surgical debridement for periprosthetic joint infections (PJIs)?

Operating Room (Surgical Technique)

  • Question 1: Should the knife blade be changed after skin incision for deep dissection?
  • Question 2: Does operative time affect the risks of SSIs/PJIs?
  • Question 3: Do antibiotic coatings on implants reduce the rates of SSIs/PJIs?
  • Question 4: Does the size of an implant (volume) used during orthopaedic procedures influence the incidence of subsequent SSIs/PJIs?
  • Question 5: Does the use of C-arm intraoperatively increase the risk for subsequent SSI/PJI in patients undergoing orthopaedic procedures?
  • Question 6: Does the use of recently introduced technologies (navigation, robots, etc.) influence the incidence of SSI/PJI after orthopaedic procedures?

Blood Conservation

  • Question 1: Does allogeneic blood transfusion increase the risk of SSI/PJI?
  • Question 2: Can intra-operative or postoperative blood salvage be utilized in patients undergoing reimplantation for treatment of PJI?
  • Question 3: Do antiplatelet drugs need to be withheld pre-operatively to reduce the risk for subsequent SSI/PJI?
  • Question 4: Is there a role for administration of erythropoietin, hemotinics, or other agents for patients with orthopaedic infections?
  • Question 5: Does the use of tranexamic acid reduce blood loss and need for allogeneic blood transfusion during primary total joint arthroplasty?
  • Question 6: Does the use of tranexamic acid reduce blood loss and need for allogeneic blood transfusion during revision total joint arthroplasty?
  • Question 7: Does the use of tranexamic acid reduce the incidence of SSI/PJI following orthopaedic procedures?

Wound Management

  • Question 1: Does the type of wound closure (technique and material) affect the incidence of subsequent SSI/PJI?
  • Question 2: What is the role for vacuum-assisted incisional dressings in orthopaedic patients?
  • Question 3: Do antibacterial-coated sutures reduce the risk of subsequent SSI/PJI?
  • Question 4: Does the use of topical incisional sealants (i.e. integuseal, dermabond, etc.) reduce the incidence of subsequent PJI/SSI in patients undergoing orthopaedic procedures?
  • Question 5: Does the use of surgical suction drains increase the risk of subsequent SSI/PJI?
  • Question 6: What surgical dressing (i.e. occlusive, silver impregnated, dry gauze) is associated with a lower risk of SSI/PJI in patients undergoing orthopaedic procedures?
  • Question 7: When should sterile surgical dressings be removed and how frequently should subsequent dressings be changed following orthopaedic procedures?
  • Question 8: Do patients need to refrain from getting the surgical incision wet or submerged in water to prevent SSI/PJI? If so, for how long postoperatively?
  • Question 9: What is the definition of persistent wound drainage?

Postoperative Factors

  • Question 1: Is early mobilization after orthopaedic procedures associated with an increased risk of wound drainage or SSI/PJI?
  • Question 2: Is it necessary for a patient to postpone having an invasive dental procedure after TJA?
  • Question 3: What is the role of prophylactic antibiotics for invasive procedures (dental, GI, urologic, etc) in the presence of an arthroplasty to prevent subsequent PJI?
  • Question 4: Does the type of venous thromboembolic (VTE) prophylaxis influence the risk of SSI/PJI in patients undergoing orthopaedic procedures?

Hospital Environment

  • Question 1: Does prolonged hospitalization prior to elective total joint arthroplasty increase the risk of subsequent SSI/PJI?
  • Question 2: Does placement of patients with an infection in private hospital rooms decrease the risk of subsequent SSI/PJI for patients undergoing orthopaedic procedures?

Diagnosis

Definitions

  • Question 1: What is the recommended time interval that would divide acute and chronic PJI (four weeks, 90 days, etc)?
  • Question 2: What is the definition of implant “colonization” vs implant-related infection?
  • Question 3: What is the definition of a sinus tract?

Laboratory Test

  • Question 1: What serum test(s) have the best diagnostic accuracy for periprosthetic joint infection? Does the combination of any number of tests increase the diagnostic accuracy?
  • Question 2: Which patient-specific factors (i.e. inflammatory arthritis, immunocompromised state) influence the thresholds for serum and synovial markers in acute and chronic PJI?
  • Question 3: Does prior use of antibiotics influence the accuracy of tests used to diagnose PJI?
  • Question 4: Does the type of organism (i.e. Fungi, C. acnes, S. aureus) influence the thresholds for serum and synovial markers in acute and chronic PJI?
  • Question 5: What is the diagnostic accuracy of intra-operative Gram stain for the diagnosis of SSI/PJI?
  • Question 6: Is there a role for procalcitonin blood test in the diagnosis of SSI/PJI in orthopaedic patients?

Pathogen Isolation (Culture)

  • Question 1: What is the optimal methodology for obtaining intra-operative cultures?
  • Question 2: What methods can be utilized to increase the diagnostic yield of microbiological culture in SSI/PJI?
  • Question 3: What is the optimal time for culture processing of tissue or synovial aspirate samples? How long should routine cultures be kept before declared negative?
  • Question 4: What is the recommended standardized laboratory culture protocol to minimize differences between medical centers?
  • Question 5: Does preoperative swabbing of a sinus tract have a role in isolation of the infecting organism?
  • Question 6: How should synovial fluid sample be sent (via laboratory vacuum tube, syringe, blood culture tubes, etc.) for culture to increase the culture yield?
  • Question 7: Should perioperative antibiotics be withheld prior to obtaining an intra-operative aspirate and/or tissue samples for culture in suspected infected revision total joint arthroplasty cases?
  • Question 8: How should divergent results between intraoperative tissue cultures and sonication of the prosthesis be managed?
  • Question 9: Is there a role for routine acid-fast bacilli (AFB) and fungal testing in suspected SSI/PJI cases?

Pathogen Isolation

  • Question 1: Is there a method to detect sessile microorganisms that have resulted in an infection following orthopaedic procedures?
  • Question 2: What is the preferred type of sample (tissue, fluid, etc.) for molecular analysis in diagnosis of orthopaedic infections?
  • Question 3: What is the best diagnostic method for identifying a C. acnes SSI/PJI?
  • Question 4: Should organisms (e.g. Treponema spp., Corynebacteria spp.) identified through molecular or genetic testing be treated the same as the pathogens isolated by culture?

Imaging

  • Question 1: What imaging modalities are available to help evaluate the extent of an infection and guide bone resection?
  • Question 2: What are the radiological signs indicative of infection in patients with an arthroplasty component in place?
  • Question 3: What is the role of nuclear medicine imaging modalities (three phase bone scintigraphy, bone marrow scintigraphy, white blood cell scintigraphy (with 99mTc or 111In), anti-granulocyte monoclonal antibody scintigraphy, and FDG-PET/CT scan) in diagnosing PJI?
  • Question 4: What is the diagnostic accuracy of MRI for osteomyelitis in the presence and absence of implants?

Treatment

Antimicrobials

  • Question 1: What is the optimal choice and duration of antibiotic therapy in polymicrobial PJI/SSI?
  • Question 2: What systemic antibiotic therapies should be used in patients with SSI/PJI caused by resistant organisms?
  • Question 3: Should PJI caused by C. acnes be treated the same as other bacterial causes of PJI?
  • Question 4: What is the most effective antibiotic in the treatment of Cutibacterum acnes PJI?
  • Question 5: What antibiotic therapy and duration should be used in SSI/PJI caused by Mycobacterium tuberculosis?
  • Question 6: Which antifungal agents are heat stable and what dose of these agents should be used in cement spacers for fungal PJI?

Multidisciplinary Issues

  • Question 1: Should PJI cases be referred to a regional center to improve the outcome of treatment and decrease cost?
  • Question 2: What intraoperative findings during surgical management of orthopaedic infections need to be communicated with the ID specialist?
  • Question 3: What quality of life (QOL) measures should be used when determining the functional outcomes of PJI treatment?

Research Caveats

  • Question 1: Is there a distinct microbiome in the joints?
  • Question 2: Has the profile of organisms causing SSI/PJI following orthopaedic procedures changed over recent years?
  • Question 3: What methods can the FDA and other regulatory bodies use to evaluate the efficacy of novel anti-infective technologies?
  • Question 4: What are some of the emerging pre-clinical methods for evaluating novel antimicrobial technologies?
  • Question 5: Does an animal model for PJI exist?
  • Question 6: Are there any concerns regarding the use of joint registries or administrative databases to conduct infection studies?