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Journal of Clinical Microbiology, October 1998, p. 2932-2939, Vol. 36, No. 10
0095-1137/98/$04.00+0
Copyright © 1998, American Society for Microbiology. All rights reserved.

Prospective Evaluation of Criteria for Microbiological Diagnosis of Prosthetic-Joint Infection at Revision Arthroplasty

Bridget L. Atkins,1,2 Nicholas Athanasou,3,4 Jonathan J. Deeks,5 Derrick W. M. Crook,2 Hamish Simpson,4,6 Timothy E. A. Peto,2 Peter McLardy-Smith,4 Anthony R. Berendt,2,4,* and The Osiris Collaborative Study Groupdagger

Public Health Laboratory,1 Department of Pathology,3 Nuffield Department of Orthopaedic Surgery,6 and Bone Infection Unit,4 Nuffield Orthopaedic Centre, Academic Unit of Microbiology and Infectious Diseases, John Radcliffe Hospital,2 and Centre for Statistics in Medicine, Institute of Health Sciences,5 Oxford, United Kingdom

Received 6 February 1998/Returned for modification 30 March 1998/Accepted 30 June 1998

A prospective study was performed to establish criteria for the microbiological diagnosis of prosthetic joint infection at elective revision arthroplasty. Patients were treated in a multidisciplinary unit dedicated to the management and study of musculoskeletal infection. Standard multiple samples of periprosthetic tissue were obtained at surgery, Gram stained, and cultured by direct and enrichment methods. With reference to histology as the criterion standard, sensitivities, specificities, and likelihood ratios (LRs) were calculated by using different cutoffs for the diagnosis of infection. We performed revisions on 334 patients over a 17-month period, of whom 297 were evaluable. The remaining 37 were excluded because histology results were unavailable or could not be interpreted due to underlying inflammatory joint disease. There were 41 infections, with only 65% of all samples sent from infected patients being culture positive, suggesting low numbers of bacteria in the samples taken. The isolation of an indistinguishable microorganism from three or more independent specimens was highly predictive of infection (sensitivity, 65%; specificity, 99.6%; LR, 168.6), while Gram staining was less useful (sensitivity, 12%; specificity, 98%; LR, 10). A simple mathematical model was developed to predict the performance of the diagnostic test. We recommend that five or six specimens be sent, that the cutoff for a definite diagnosis of infection be three or more operative specimens that yield an indistinguishable organism, and that because of its low level of sensitivity, Gram staining should be abandoned as a diagnostic tool at elective revision arthroplasty.

* Corresponding author. Mailing address: Bone Infection Unit, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7LD, United Kingdom. Phone: 00 44 1865 227779. Fax: 00 44 1865 227740. E-mail: tony.berendt{at}noc.anglox.nhs.uk.

dagger The members of the OSIRIS (Oxford Skeletal Infection Research and Intervention Service) Collaboration Study Group are M. Benson, A. Carr, D. Collopy, P. Cooke, J. Kenwright, P. McClardy-Smith, H. Simpson, R. de Steiger, R. Gundle, K. Willett, B. Atkins, A. Berendt, I. Bowler, C. Conlon, D. Crook, A. Emptage, T. Peto, J. Deeks, and N. Athanasou.

Journal of Clinical Microbiology, October 1998, p. 2932-2939, Vol. 36, No. 10
0095-1137/98/$04.00+0
Copyright © 1998, American Society for Microbiology. All rights reserved.


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Copyright © 1998 by the American Society for Microbiology. All rights reserved.