Microbial landscape in different types of periprosthetic hip joint infection

Introduction Due to the steady increase in the number of primary total hip arthroplasties, the problem of eliminating periprosthetic joint infection (PJI) has become pressing. The rise of antimicrobial-resistant PJI pathogens significantly complicates and prolongs treatment, contributing to the development of chronic infection, sometimes with latent clinical manifestations.

The aim of this study was to identify the microbial landscape characteristics in different types of hip joint PJI.

Materials and Methods Microbiological studies of 96 patients with hip joint PJI were analyzed: Group 1 (n = 16) with type I PJI; Group 2 (n = 80) with type II and type III PJI. Patients in Group 1 underwent the DAIR procedure and those in Group 2 underwent two-stage revision hip replacement.

Results A total of 103 microbial isolates were obtained from 96 patients: 16 (15.5 %) Gr(–) and 87 (84.5 %) Gr(+). Among Gr(+), MRSA, MRSE, and MRSH were detected in 18 isolates, and among Gr(–), ESBL+ was detected in 16 isolates. The predominant pathogens in the PJI structure were S. aureus (52.9 %), S. epidermidis (19.5 %), E. cloacae (37.5 %), P. aeruginosa (18.6 %), and E. coli (18.6 %). Associations were more common in type 1 PJI (25 %) than in chronic forms (18.4 %). Microbial associations were detected in 20 cases (19.4 %). Culture-negative infection (CNI) was detected in 16 patients (16.7 %) in both groups. Relapse of PJI in patients with microbial associations occurred in three cases (15 %). In CNI cases, recurrence developed in four cases (25 %).

Discussion The growth of Gr(–) flora in early PJI exceeded that in the chronic one: 31.3 % and 9.2 %, respectively. DAIR is ineffective in such conditions. S. aureus, as a causative agent of bone and joint infections, exists in a quasi-dormant state which contributes to chronicity.

Conclusion Gram-negative microorganisms and their associations dominate in the etiology of early PJI (type I), while gram-positive pathogens predominated in chronic types (types II and III). Culture-negative infection was a more common cause of early PJI than of chronic types (25.0 % and 16.1 %, respectively). No statistically significant differences were found between the groups in the detection of methicillin-resistant staphylococci or gram-negative bacteria ESBL+.

1. Wildeman P, Rolfson O, Söderquist B, et al. What Are the Long-term Outcomes of Mortality, Quality of Life, and Hip Function after Prosthetic Joint Infection of the Hip? A 10-year Follow-up from Sweden. Clin Orthop Relat Res. 2021;479(10):2203-2213. doi: 10.1097/CORR.0000000000001838.

2. Premkumar A, Kolin DA, Farley KX, et al. Projected Economic Burden of Periprosthetic Joint Infection of the Hip and Knee in the United States. J Arthroplasty. 2021;36(5):1484-1489.e3. doi: 10.1016/j.arth.2020.12.005.

3. Bozhkova S.A., Tikhilov R.M., Artyukh V.A. Periprosthetic Joint Infection as a Socio-Economic Problem of Modern Orthopedics. Annals of the Russian academy of medical sciences. 2023;78(6):601-608. (In Russ.) doi:10.15690/vramn8370.

4. Kalbian I, Park JW, Goswami K, et al. Culture-negative periprosthetic joint infection: prevalence, aetiology, evaluation, recommendations, and treatment. Int Orthop. 2020;44(7):1255-1261. doi: 10.1007/s00264-020-04627-5.

5. Bozhkova SA, Tikhilov RM, Shubnyakov II, Borisov AM, Midaev AI. Routine preoperative examination for diagnosis of periprosthetic joint infection and its recurrence in revision hip arthroplasty. Pirogov Russian Journal of Surgery. 2022;(5):68-74. (In Russ.) doi: 10.17116/hirurgia202205168.

6. Ermakov AM, Bogdanova NA, Matveeva EL, Gasanova AG. Analysis of the microbial landscape in patients with periprosthetic infection of the hip joint. Genij Ortopedii. 2025;31(3):307-313. doi: 1028-4427-2025-31-3-307-313.

7. Liventsov VN, Bozhkova SA, Kochish AY, et al. Difficult-To-Treat Periprosthetic Hip Infection: Outcomes of Debridment. Traumatology and Orthopedics of Russia. 2019;25(4):88-97. doi: 10.21823/2311-2905-2019-25-4-88-97.

8. Sheraliev TU, Fedorov EA, Golnik VN, Pavlov VV. Periprosthetic infection in hip arthroplasty: features of modern etiology, problems and prospects of diagnostics: monograph. Krasnoyarsk: Research and Innovation Center; 2021:230. (In Russ.) doi: 10.12731/978-5-907208-50-6.

9. Li H, Fu J, Erlong N, et al. Characterization of periprosthetic environment microbiome in patients after total joint arthroplasty and its potential correlation with inflammation. BMC Infect Dis. 2023;23(1):423. doi: 10.1186/s12879-023-08390-x.

10. Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg Am. 1996;78(4):512-523. doi: 10.2106/00004623-199604000-00005.

11. Prokopyev DS, Levchik EY, Vinogradskiy AE, Borzunov DY. Surgical debridement of wounds using local negative pressure in the treatment of patients with periprosthetic infection of the hip joint. N.N. Priorov Journal of Traumatology and Orthopedics. 2024;31(4):507-516. (In Russ.) doi: 10.17816/vto625672.

12. Chau WW, Lo KC, Lau LC, et al. Single use Negative Pressure Wound Therapy (NPWT) system in the management of knee arthroplasty. BMC Musculoskelet Disord. 2023;24(1):351. doi: 10.1186/s12891-023-06470-2.

13. Kruk AM, Sitnik AA, Linov AL, et al. The use of negative pressure wound therapy in traumatology and orthopedics. Part 1. Justification of the methodology, technical features, general recommendations for use. Military medicine. 2024;(4):82-88. (In Russ.) doi: 10.51922/2074-5044.2024.4.82.

14. Ailaney N, Johns WL, Golladay GJ, et al. Closed Incision Negative Pressure Wound Therapy for Elective Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Arthroplasty. 2021;36(7):2402-2411. doi: 10.1016/j.arth.2020.11.039.

15. Dugdale EM, Uvodich ME, Osmon DR, et al. Laboratory Value Effectiveness in Predicting Early Postoperative Periprosthetic Joint Infection After Total Hip Arthroplasty. J Arthroplasty. 2022;37(3):574-580. doi: 10.1016/j.arth.2021.11.007.

16. De Maio F, Fidone G, Caterini A, et al. Monitoring of C-reactive protein level (CRP) and Erythrocyte sedimentation rate (ESR) after total hip and knee arthroplasty. J Biol Regul Homeost Agents. 2020;34(5 Suppl. 1):63-68. IORS Special Issue on Orthopedics.

17. Karbysheva S, Renz N, Yermak K, et al. New Methods in the Diagnosis of Prosthetic Joint Infection. Traumatology and Orthopedics of Russia. 2019.;25(4):56-63. doi: 10.21823/2311-2905-2019-25-4-56-63.

18. Signore A, Sconfienza LM, Borens O, et al. Consensus document for the diagnosis of prosthetic joint infections: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement). Eur J Nucl Med Mol Imaging. 2019;46(4):971-988. doi: 10.1007/s00259-019-4263-9.

19. Tsai Y, Chang CH, Lin YC, et al. Different microbiological profiles between hip and knee prosthetic joint infections. J Orthop Surg (Hong Kong). 2019;27(2):2309499019847768. doi: 10.1177/2309499019847768.

20. Van Erp JHJ, Heineken AC, Van Wensen RJA, et al. Optimization of the empirical antibiotic choice during the treatment of acute prosthetic joint infections: a retrospective analysis of 91 patients. Acta Orthop. 2019;90(5):455-459. doi: 10.1080/17453674.2019.1621595.

21. Tsiskarashvili AV, Melikova RE, Novozhilova EA. Analysis of six-year monitoring of common pathogens causing periprosthetic joint infection of major joints and the tendency to resistance. Genij Ortopedii. 2022;28(2):179-188. doi: 10.18019/1028-4427-2022-28-2-179-18.

22. Crowe B, Payne A, Evangelista PJ, et al. Risk Factors for Infection Following Total Knee Arthroplasty: A Series of 3836 Cases from One Institution. J Arthroplasty. 2015;30(12):2275-8. doi: 10.1016/j.arth.2015.06.058.

23. Bozhkova SA, Gordina EM, Schneider OV. et al.Resistance of carbapenemase-producing Klebsiella pneumoniae isolated from patients with orthopedic infection. Clinical Microbiology and Antimicrobial Chemotherapy. 2020;22(1):47-52. (In Russ.) doi: 10.36488/cmac.2020.1.47-52.

24. Wang FD, Wang YP, Chen CF, Chen HP. The incidence rate, trend and microbiological aetiology of prosthetic joint infection after total knee arthroplasty: A 13 years' experience from a tertiary medical center in Taiwan. J Microbiol Immunol Infect. 2018;51(6):717-722. doi: 10.1016/j.jmii.2018.08.011.

25. Burtsev AV, Tryapichnikov AS, Ermakov AM, et al. Primary data from the local registry of periprosthetic hip infection at the National Ilizarov Medical Research Centre for Traumatology and Orthopaedics, Traumatology and Orthopedics of Russia. 2024;30(2):16-28. doi: 10.17816/2311-2905-17431.

26. Pliska NN, Musina GA. Complication after endoprosthesis caused by the bacteria pseudomonas aeruginosa and the dynamics of its resistance increase. International journal of applied and fundamental research. 2025;(2):34-39. (In Russ.) doi: 10.17513/mjpfi.13694.

27. Usmanova GM, Davlatov KhS, Rafiev KhK, Abduazizov AA. Microbial landscape of the traumatology and surgical departments in a multidisciplinary hospital in Dushanbe. Bulletin of the Pedagogical University. 2014;(2):265-369. (In Russ.)

28. Sletov AM, Sivakon SV. Features of wound infection pathogens in a trauma hospital. Penza State University Bulletin. 2013;(2):65-70. (In Russ.)

29. Marculescu CE, Cantey JR. Polymicrobial prosthetic joint infections: risk factors and outcome. Clin Orthop Relat Res. 2008;466(6):1397-1404. doi: 10.1007/s11999-008-0230-7.

30. Tsaras G, Maduka-Ezeh A, Inwards CY, et al. Utility of intraoperative frozen section histopathology in the diagnosis of periprosthetic joint infection: a systematic review and meta-analysis. J Bone Joint Surg Am. 2012;94(18):1700-1711. doi: 10.2106/JBJS.J.00756.

31. Hischebeth GT, Randau TM, Ploeger MM, et al. Staphylococcus aureus versus Staphylococcus epidermidis in periprosthetic joint infection-Outcome analysis of methicillin-resistant versus methicillin-susceptible strains. Diagn Microbiol Infect Dis. 2019;93(2):125-130. doi: 10.1016/j.diagmicrobio.2018.08.012.

32. Tsikopoulos K, Meroni G. Periprosthetic Joint Infection Diagnosis: A Narrative Review. Antibiotics (Basel). 2023;12(10):1485. doi: 10.3390/antibiotics12101485.

33. Proctor RA, von Eiff C, Kahl BC, et al. Small colony variants: a pathogenic form of bacteria that facilitates persistent and recurrent infections. Nat Rev Microbiol. 2006;4(4):295-305. doi: 10.1038/nrmicro1384.

34. Abdel Karim M, Andrawis J, Bengoa F, et al. Hip and Knee Section, Diagnosis, Algorithm: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty. 2019;34(2S):S339-S350. doi: 10.1016/j.arth.2018.09.018.

35. Tai DBG, Patel R, Abdel MP, et al. Microbiology of hip and knee periprosthetic joint infections: a database study. Clin Microbiol Infect. 2022;28(2):255-259. doi: 10.1016/j.cmi.2021.06.006.

36. Lyubimova LV, Bozhkova SA, Pchelova NN, et al. The role of culture-negative infection among infectious complications after total knee arthroplasty. Genij Ortopedii. 2023;29(4):402-409. doi: 10.18019/1028-4427-2023-29-4-402-409.

37. Portillo ME, Salvadó M, Sorli L, et al. Multiplex PCR of sonication fluid accurately differentiates between prosthetic joint infection and aseptic failure. J Infect. 2012;65(6):541-548. doi: 10.1016/j.jinf.2012.08.018.

38. Kullar R, Chisari E, Snyder J, et al. Next-Generation Sequencing Supports Targeted Antibiotic Treatment for Culture Negative Orthopedic Infections. Clin Infect Dis. 2023;76(2):359-364. doi: 10.1093/cid/ciac733.