The Algorithm for Diagnostic Evaluation and Treatment

  • Rihard TrebšeEmail author
  • Andrej Trampuž


The most important issue in treatment of PJI is the correct evaluation of the patients and the decision about the appropriate treatment strategy, namely, debridement and retention, one-stage exchange, two-stage exchange, permanent resection arthroplasty, and permanent antibiotic suppression. The chosen strategy determines the final functionality and clinical results but the probability of infection cure as well. In general, more aggressive treatment results in poorer functionality but better chance of eradication of infection. This is not true for all subsets of patients. The algorithm helps to discriminate which patients would have an acceptable probability for eradication with less invasive treatment strategy. The goal is to apply the strategy that gives the best function without trading-off the probabilities of permanent infection cure too much.


Algorithm Diagnosis Surgical strategy Medical treatment 


  1. 1.
    AAOS (American academy of orthopedic surgeons). The diagnosis of periprosthetic joint infections in the hip or knee. Guideline and evidence report. 1st ed. Rosemont: AAOS; 2010.
  2. 2.
    Berdal JE, Skramm I, Mowinckel P, Gulbrandsen P, Bjornholt JV. Use of rifampicin and ciprofloxacin combination therapy after surgical debridement in the treatment of early manifestation prosthetic joint infections. Clin Microbiol Infect. 2005;11:834–55.CrossRefGoogle Scholar
  3. 3.
    Brouqui P, Rousseau MC, Stain A, Drancourt M, Raoult D. Treatment of Pseudomonas aeruginosa-infected orthopedic prostheses with ceftazidime-ciprofloxacin antibiotic combination. Antimicrob Agents Chemother. 1995;39:2423–5.PubMedCrossRefGoogle Scholar
  4. 4.
    Carpenter CE, Chambers HF. Daptomycin: another novel agent for treating infections due to drug-resistant gram-positive pathogens. Clin Infect Dis. 2004;38:994–1000.PubMedCrossRefGoogle Scholar
  5. 5.
    Ceri H, Olson ME, Stremick C. The Calgary biofilm device: new technology for rapid determination of antibiotic susceptibility of bacterial biofilms. J Clin Microbiol. 1999;37:1771–6.PubMedGoogle Scholar
  6. 6.
    Drancourt M, Stein A, Argenson JN, Roiron R, Groulier P, Raoult D. Oral treatment of Staphylococcus spp. infected orthopaedic implants with fusidic acid or ofloxacin in combination with rifampicin. J Antimicrob Chemother. 1997;39:235–40.PubMedCrossRefGoogle Scholar
  7. 7.
    Dupont JA. Significance of operative cultures in total hip arthroplasty. Clin Orthop. 1986;211:122–7.PubMedGoogle Scholar
  8. 8.
    Engh CA, Massin P, Suthers KE. Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components. Clin Orthop. 1990;257:107–28.PubMedGoogle Scholar
  9. 9.
    Furustrand Tafin U, Majic I, Zalila Belkhodja C, Betrisey B, Corvec S, Zimmerli W, Trampuz A. Gentamicin improves the activities of daptomycin and vancomycin against Enterococcus faecalis in vitro and in an experimental foreign-body infection model. Antimicrob Agents Chemother. 2011;55:4821–7.PubMedCrossRefGoogle Scholar
  10. 10.
    Hallab N, Merritt K, Jacobs JJ. Metal sensitivity in patients with orthopedic implants. J Bone Joint Surg Am. 2001;83-a:428–36.PubMedGoogle Scholar
  11. 11.
    Isiklar ZU, Darouiche RO, Landon GC, Beck T. Efficacy of antibiotics alone for orthopaedic device related infections. Clin Orthop. 1996;332:184–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Kovac S, Trebše R, Milošev I, Pavlovčič V, Pišot V. Long-term survival of the straight titanium stem. J Bone Joint Surg Br. 2006;88-B:1567–73.CrossRefGoogle Scholar
  13. 13.
    Meehan AM, Osmon DR, Duffy CT, 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.PubMedCrossRefGoogle Scholar
  14. 14.
    Milosev I, Trebše R, Kovač S. Materials development and latest results of various bearings. In: Aoi T, Toshida A, editors. Hip replacements, approaches, complications and effectiveness. New York: Nova Science Publishers Inc; 2009.Google Scholar
  15. 15.
    Moojen DJ, van Hellemondt G, Vogely HC, Burger BJ, Walenkamp GH, Tulp NJ, Schreurs BW, de Meulemeester FR, Schot CS, van de Pol I, Fujishiro T, Schouls LM, Bauer TW, Dhert WJ. Incidence of low-grade infection in aseptic loosening of total hip arthroplasty. Acta Orthop. 2010;81:667–73.PubMedCrossRefGoogle Scholar
  16. 16.
    Ramage G, Tunney MM, Patrick S, Gorman SP, Nixon JR. Formation of Propionibacterium acnes biofilms on orthopaedic biomaterials and their susceptibility to antimicrobials. Biomaterials. 2003;24:3221–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Razonable RR, Osmon DR, Steckelberg JM. Linezolid therapy for orthopedic infections. Mayo Clin Proc. 2004;79:1137–44.PubMedGoogle Scholar
  18. 18.
    Segreti J, Nelson JA, Trenholme GM. Prolonged suppressive antibiotic therapy for infected orthopedic implants. Clin Infect Dis. 1998;27:711–3.PubMedCrossRefGoogle Scholar
  19. 19.
    Trampuz A, Zimmerli W. Prosthetic joint infections: update in diagnosis and treatment. Swiss Med Wkly. 2005;135:243–51.PubMedGoogle Scholar
  20. 20.
    Trampuz A, Zimmerli W. Antimicrobial agents in orthopedic surgery. Drugs. 2006;66:1089–105.PubMedCrossRefGoogle Scholar
  21. 21.
    Trebše R, Pisot V, Trampuz A. Treatment of infected, retained implants. J Bone Joint Surg Br. 2005;87-B:249–56.CrossRefGoogle Scholar
  22. 22.
    Trebše R. Treatment of orthopedic device related infection with device retention and defined antibiotic therapy. Thesis. University of Ljubljana, Ljubljana. 2010.Google Scholar
  23. 23.
    Tsukajama DT, Estrada R, Gustilo RB. Infections after total hip arthroplasty: a study of the treatment of one hundred and six infections. J Bone Joint Surg Am. 1996;78:512–23.Google Scholar
  24. 24.
    Zimmerli W, Trampuž A, Ochsner P. Prosthetic joint infections. N Engl J Med. 2004;351:1645–54.PubMedCrossRefGoogle Scholar
  25. 25.
    Zimmerli W, Widmer AF, Blatter M, Frei R, Ochsner PE. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. Foreign-Body Infection (FBI) Study Group. JAMA. 1998;279:1537–41.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2012

Authors and Affiliations

  1. 1.Department for Bone Infections and Adult ReconstructionsOrthopaedic Hospital ValdoltraAnkaranSlovenia
  2. 2.Division of Infectious Diseases & Septic UnitUniversity Hospital of LausanneLausanneSwitzerland

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