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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
Group
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.
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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