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Epidemiology and prevention of prosthetic joint infections

Elie Berbari, MD, FIDSA
Larry M Baddour, MD, FIDSA
Section Editor
Daniel J Sexton, MD
Deputy Editor
Elinor L Baron, MD, DTMH


Prosthetic joint infection (PJI) is one of the leading causes of arthroplasty failure. Treatment of these infections requires multiple surgical interventions and prolonged antibiotic therapy and is associated with a failure rate in upwards of 10 to 20 percent of cases. Given the difficulty in treating prosthetic joint infections, prevention of infection is clearly desirable.

The issues relating to the prevention of PJIs will be reviewed here; guidelines addressing these issues include the National Surgical Infection Prevention Project [1,2], guidelines from the Medical Letter (table 1) [3], guidelines from the American Society of Health-System Pharmacists (ASHP) [4], and an Advisory Statement from the American Academy of Orthopaedic Surgeons [5].

The clinical manifestations, diagnosis, and treatment of these infections are discussed separately. (See "Clinical manifestations and diagnosis of prosthetic joint infections" and "Treatment of prosthetic joint infections".)


Infection rates for hip and knee replacements, the most common joint arthroplasties, are typically less than 2 percent [6,7]. The risk of prosthetic joint infection is greater for knee arthroplasty than hip arthroplasty. Risk factors for prosthetic joint infection include [8-11]:



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Literature review current through: Sep 2016. | This topic last updated: Aug 24, 2016.
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  1. Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004; 38:1706.
  2. Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis 2006; 43:322.
  3. Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett 2012; 10:73.
  4. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195.
  5. American Academy of Orthopaedic Surgeons (AAOS). Advisory Statement. Recommendations for the use of intravenous antibiotic prophylaxis in primary total joint arthroplasty 2004 http://www.aaos.org/about/papers/advistmt/1027.asp (Accessed on January 09, 2012).
  6. Namba RS, Inacio MC, Paxton EW. Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees. J Bone Joint Surg Am 2013; 95:775.
  7. Edwards JR, Peterson KD, Mu Y, et al. National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009. Am J Infect Control 2009; 37:783.
  8. Matthews PC, Berendt AR, McNally MA, Byren I. Diagnosis and management of prosthetic joint infection. BMJ 2009; 338:b1773.
  9. Momohara S, Kawakami K, Iwamoto T, et al. Prosthetic joint infection after total hip or knee arthroplasty in rheumatoid arthritis patients treated with nonbiologic and biologic disease-modifying antirheumatic drugs. Mod Rheumatol 2011; 21:469.
  10. Berbari EF, Osmon DR, Lahr B, et al. The Mayo prosthetic joint infection risk score: implication for surgical site infection reporting and risk stratification. Infect Control Hosp Epidemiol 2012; 33:774.
  11. Tande AJ, Palraj BR, Osmon DR, et al. Clinical Presentation, Risk Factors, and Outcomes of Hematogenous Prosthetic Joint Infection in Patients with Staphylococcus aureus Bacteremia. Am J Med 2016; 129:221.e11.
  12. Bebko SP, Green DM, Awad SS. Effect of a preoperative decontamination protocol on surgical site infections in patients undergoing elective orthopedic surgery with hardware implantation. JAMA Surg 2015; 150:390.
  13. Kalmeijer MD, Coertjens H, van Nieuwland-Bollen PM, et al. Surgical site infections in orthopedic surgery: the effect of mupirocin nasal ointment in a double-blind, randomized, placebo-controlled study. Clin Infect Dis 2002; 35:353.
  14. Hacek DM, Robb WJ, Paule SM, et al. Staphylococcus aureus nasal decolonization in joint replacement surgery reduces infection. Clin Orthop Relat Res 2008; 466:1349.
  15. Kallen AJ, Wilson CT, Larson RJ. Perioperative intranasal mupirocin for the prevention of surgical-site infections: systematic review of the literature and meta-analysis. Infect Control Hosp Epidemiol 2005; 26:916.
  16. Prokuski L. Prophylactic antibiotics in orthopaedic surgery. J Am Acad Orthop Surg 2008; 16:283.
  17. van Rijen MM, Bonten M, Wenzel RP, Kluytmans JA. Intranasal mupirocin for reduction of Staphylococcus aureus infections in surgical patients with nasal carriage: a systematic review. J Antimicrob Chemother 2008; 61:254.
  18. Rao N, Cannella B, Crossett LS, et al. A preoperative decolonization protocol for staphylococcus aureus prevents orthopaedic infections. Clin Orthop Relat Res 2008; 466:1343.
  19. Kim DH, Spencer M, Davidson SM, et al. Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am 2010; 92:1820.
  20. Schweizer ML, Chiang HY, Septimus E, et al. Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery. JAMA 2015; 313:2162.
  21. Sousa R, Muñoz-Mahamud E, Quayle J, et al. Is asymptomatic bacteriuria a risk factor for prosthetic joint infection? Clin Infect Dis 2014; 59:41.
  22. Kapadia BH, Berg RA, Daley JA, et al. Periprosthetic joint infection. Lancet 2016; 387:386.
  23. Pieringer H, Stuby U, Biesenbach G. Patients with rheumatoid arthritis undergoing surgery: how should we deal with antirheumatic treatment? Semin Arthritis Rheum 2007; 36:278.
  24. AlBuhairan B, Hind D, Hutchinson A. Antibiotic prophylaxis for wound infections in total joint arthroplasty: a systematic review. J Bone Joint Surg Br 2008; 90:915.
  25. Southwell-Keely JP, Russo RR, March L, et al. Antibiotic prophylaxis in hip fracture surgery: a metaanalysis. Clin Orthop Relat Res 2004; :179.
  26. Boxma H, Broekhuizen T, Patka P, Oosting H. Randomised controlled trial of single-dose antibiotic prophylaxis in surgical treatment of closed fractures: the Dutch Trauma Trial. Lancet 1996; 347:1133.
  27. Trampuz A, Zimmerli W. Antimicrobial agents in orthopaedic surgery: Prophylaxis and treatment. Drugs 2006; 66:1089.
  28. Soriano A, Bori G, García-Ramiro S, et al. Timing of antibiotic prophylaxis for primary total knee arthroplasty performed during ischemia. Clin Infect Dis 2008; 46:1009.
  29. The diagnosis of periprosthetic joint infections of the hip and knee. Guidelines and evidence report. Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, June 18, 2010.
  30. Gillespie WJ. Prevention and management of infection after total joint replacement. Clin Infect Dis 1997; 25:1310.
  31. Nelson CL, Green TG, Porter RA, Warren RD. One day versus seven days of preventive antibiotic therapy in orthopedic surgery. Clin Orthop Relat Res 1983; :258.
  32. Parvizi J, Saleh KJ, Ragland PS, et al. Efficacy of antibiotic-impregnated cement in total hip replacement. Acta Orthop 2008; 79:335.
  33. Bourne RB. Prophylactic use of antibiotic bone cement: an emerging standard--in the affirmative. J Arthroplasty 2004; 19:69.
  34. Fish DN, Hoffman HM, Danziger LH. Antibiotic-impregnated cement use in U.S. hospitals. Am J Hosp Pharm 1992; 49:2469.
  35. Engesaeter LB, Lie SA, Espehaug B, et al. Antibiotic prophylaxis in total hip arthroplasty: effects of antibiotic prophylaxis systemically and in bone cement on the revision rate of 22,170 primary hip replacements followed 0-14 years in the Norwegian Arthroplasty Register. Acta Orthop Scand 2003; 74:644.
  36. van Kasteren ME, Manniën J, Ott A, et al. Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor. Clin Infect Dis 2007; 44:921.
  37. Jiranek W. Antibiotic-loaded cement in total hip replacement: current indications, efficacy, and complications. Orthopedics 2005; 28:s873.
  38. Hanssen AD. Prophylactic use of antibiotic bone cement: an emerging standard--in opposition. J Arthroplasty 2004; 19:73.
  39. Block JE, Stubbs HA. Reducing the risk of deep wound infection in primary joint arthroplasty with antibiotic bone cement. Orthopedics 2005; 28:1334.
  40. Cummins JS, Tomek IM, Kantor SR, et al. Cost-effectiveness of antibiotic-impregnated bone cement used in primary total hip arthroplasty. J Bone Joint Surg Am 2009; 91:634.
  41. Roberts DW. What is the role of antibiotic-containing cement in total knee arthroplasty? J Bone Joint Surg Am 2013; 95:e62.
  42. Westberg M, Frihagen F, Brun OC, et al. Effectiveness of gentamicin-containing collagen sponges for prevention of surgical site infection after hip arthroplasty: a multicenter randomized trial. Clin Infect Dis 2015; 60:1752.
  43. Watters W 3rd, Rethman MP, Hanson NB, et al. Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures. J Am Acad Orthop Surg 2013; 21:180.
  44. Wahl MJ. Myths of dental-induced prosthetic joint infections. Clin Infect Dis 1995; 20:1420.
  45. Berbari EF, Osmon DR, Carr A, et al. Dental procedures as risk factors for prosthetic hip or knee infection: a hospital-based prospective case-control study. Clin Infect Dis 2010; 50:8.
  46. Young H, Hirsh J, Hammerberg EM, Price CS. Dental disease and periprosthetic joint infection. J Bone Joint Surg Am 2014; 96:162.
  47. Skaar DD, O'Connor H, Hodges JS, Michalowicz BS. Dental procedures and subsequent prosthetic joint infections: findings from the Medicare Current Beneficiary Survey. J Am Dent Assoc 2011; 142:1343.
  48. Eskinazi D, Rathbun W. Is systematic antimicrobial prophylaxis justified in dental patients with prosthetic joints? Oral Surg Oral Med Oral Pathol 1988; 66:430.
  49. Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners--a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2015; 146:11.
  50. Simmons NA, Ball AP, Cawson RA, et al. Case against antibiotic prophylaxis for dental treatment of patients with joint prostheses. Lancet 1992; 339:301.
  51. Gupta A, Osmon DR, Hanssen AD, et al. Genitourinary Procedures as Risk Factors for Prosthetic Hip or Knee Infection: A Hospital-Based Prospective Case-Control Study. Open Forum Infect Dis 2015; 2:ofv097.
  52. American Urological Association, American Academy of Orthopaedic Surgeons. Antibiotic prophylaxis for urological patients with total joint replacements. J Urol 2003; 169:1796.
  53. ASGE STANDARDS OF PRACTICE COMMITTEE, Banerjee S, Shen B, et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2008; 67:791.