Polymicrobial Periprosthetic Joint Infections: Outcome of Treatment and Identification of Risk Factors
Authors: Tan Timothy L. , Kheir Michael M. , Tan Dean D. , Parvizi Javad 
Published: December 2016

Background:
The treatment outcomes of periprosthetic joint infection are frequently dependent on characteristics of the causative organism. The objective of this comparative study was to investigate the prevalence of and risk factors for development of polymicrobial periprosthetic joint infection, and the outcome of surgical treatment of these patients.

Methods:
All patients with polymicrobial, monomicrobial, or culture-negative periprosthetic joint infection treated from 2000 to 2014 were identified at a single institution. Ninety-five patients with a polymicrobial periprosthetic joint infection had a minimum follow-up of 12 months. We matched patients with a polymicrobial periprosthetic joint infection with the other cohorts using propensity score matching for several important parameters. Treatment success was defined according to the Delphi criteria; Kaplan-Meier survivorship curves were generated to demonstrate this. A multiple logistic regression analysis was performed to determine risk factors for a polymicrobial periprosthetic joint infection.

Results:
Overall, 10.3% (108 of 1,045) of the periprosthetic joint infections treated at our institution were polymicrobial in nature. Patients with a polymicrobial periprosthetic joint infection had a higher failure rate at 50.5% (48 of 95) compared with the monomicrobial periprosthetic joint infection cohort at 31.5% (63 of 200) and the culture-negative periprosthetic joint infection cohort at 30.2% (48 of 159) (p = 0.003). The survivorship of the polymicrobial periprosthetic joint infection group was 52.2% at the 2-year follow-up, 49.3% at the 5-year follow-up, and 46.8% at the 10-year follow-up. Patients with polymicrobial periprosthetic joint infection had a higher rate of amputation (odds ratio [OR], 3.80 [95% confidence interval (CI), 1.34 to 10.80]), arthrodesis (OR, 11.06 [95% CI, 1.27 to 96.00]), and periprosthetic joint infection-related mortality (OR, 7.88 [95% CI, 1.60 to 38.67]) compared with patients with monomicrobial periprosthetic joint infection. Isolation of gram-negative organisms (p < 0.01), enterococci (p < 0.01), Escherichia coli (p < 0.01), and atypical organisms (p < 0.01) was associated with polymicrobial periprosthetic joint infection. Only the presence of a sinus tract (OR, 2.20 [95% CI, 1.39 to 3.47]; p = 0.001) was a significant risk factor for polymicrobial periprosthetic joint infection on multivariate analysis.

Conclusions:
This study reveals that polymicrobial periprosthetic joint infection, occurring at a relatively low rate, is associated with poor outcomes when compared with monomicrobial and culture-negative periprosthetic joint infection. Patients with polymicrobial infections were more likely to require a salvage procedure or to have periprosthetic joint infection-related mortality. Polymicrobial periprosthetic joint infection was associated with soft-tissue defects such as a sinus tract and certain types of organisms, which should be considered when administering antibiotics to these patients.

Level of Evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.