2018 International Consensus on Musculoskeletal Infection – Research Agenda Workgroup

The number of surgical site infections (SSI) following orthopedic procedures continues to rise, threatening the ultimate success of the procedures, causing avoidable morbidity and a critical socioeconomic burden.  Although research in the field continues, there is an immense gap in our knowledge related to many aspects of orthopedic infections. In fact, this issue was highlighted by the Center for Disease Control recently as they updated the SSI prevention Guidelines based on the International Consensus Meeting on Periprosthetic Joint Infection in 2013.

A second International Consensus Meeting, which was expanded to all areas of orthopaedics as an International Consensus Meeting on Musculoskeletal Infection (ICMMI), was held in Philadelphia, Pennsylvania on July 25-27, 2018. Over 800 delegates served in the consensus meeting. These delegates were actively involved in the Delphi process to generated the Consensus Statements (questions and responses/recommendations), which were voted on by 540 delegates in real time at the ICMMI. During the meeting, thirteen biofilm-associated implant-related, bone and joint infection questions were assigned to the Biofilm Workgroup. These questions with their responses and post meeting refined rationales are available below, with an overview summary and discussion will be available in Consensus Articles published in the Journal of Orthopaedic Research.

Schwarz EM, Parvizi J, Gehrke T, et al. 2019. 2018 International Consensus Meeting on Musculoskeletal Infection: Research Priorities from the General Assembly Questions. J Orthop Res 37:997-1006

Click on each question to view the complete document.

Question 1: What is the recommended time interval that would divide acute and chronic periprosthetic joint infection (PJI) (4 weeks, 90 days, etc.)?

Question 2: What is the definition of implant “colonization” vs. implant-related infection?

Question 3: What is the definition of persistent wound drainage?

Question 4: Which patient-specific factors (i.e., inflammatory arthritis, immunocompromised state) influence the thresholds for serum and synovial markers in acute and chronic periprosthetic joint infection (PJI)?

Question 5:  Can immunotherapy and immunoprophylaxis be used to prevent biofilm formation and implant-associated infections?

Question 6: What immune system-enhancing strategies can be employed to reduce the risk of surgical site infections/periprosthetic joint infections (SSIs/PJIs)?

Question 7: Do immunomodulatory disease-modifying medications (e.g., methotrexate or antitumor necrosis factor (anti-TNF) agents) need to be withheld preoperatively to reduce the risk for subsequent surgical site infection/periprosthetic joint infection (SSI/PJI)?

Question 8:  Is there a role for the use of antibiotic-loaded carriers (calcium sulfate/calcium phosphate (CaS/CaP) in the treatment of surgical site infection/periprosthetic joint infection (SSI/PJI)?

Question 9: What are the indications for dual perioperative antibiotic prophylaxis in patients undergoing orthopaedic procedures? What are the optimal combinations of antibiotics?

Question 10: What is the optimal choice and duration of antibiotic therapy in polymicrobial surgical site infection/periprosthetic joint infection (SSI/PJI)?

Question 11:  What is the most effective antibiotic in the treatment of C. acnes periprosthetic joint infection (PJI)?

Question 12:  What serum test(s) have the best diagnostic accuracy for periprosthetic joint infection (PJI)? Does the combination of any number of tests increase the diagnostic accuracy?

Question 13:  What methods can be utilized to increase the diagnostic yield of microbiological culture in surgical site infection/periprosthetic joint infection (SSI/PJI)?

Question 14: Should perioperative antibiotics be withheld prior to obtaining an intraoperative aspirate and/or tissue samples for culture in suspected infected revision total joint arthroplasty (TJA) cases?

Question 15: Is there a method to detect sessile microorganisms that have resulted in an infection following orthopaedic procedures?

Question 16:  How should divergent results between intraoperative tissue cultures (TCs) and sonication of the prosthesis be managed?

Question 17: What is the optimal time for culture processing of tissue or synovial aspirate samples? How long should routine cultures be kept before declared negative?

Question 18:  Is there a distinct microbiome in the joints?

Question 19:  Has the profile of organisms causing surgical site infection/periprosthetic joint infection (SSI/PJI) following orthopaedic procedures changed over recent years?

Question 20:  What methods can the Food and Drug Administration (FDA) and other regulatory bodies use to evaluate the efficacy of novel anti-infective technologies?

Question 21: What are some of the emerging pre-clinical methods for evaluating novel antimicrobial technologies?

Question 22:  Does an animal model for periprosthetic joint infection (PJI) exist?

Question 23: Are there any concerns regarding the use of joint registries or administrative databases to conduct infection studies?

Question 24:  Should routine dental clearance be obtained prior to total joint arthroplasty (hip/knee/shoulder/ankle)?

Question 25:  Is it necessary for a patient to postpone having an invasive dental procedure after total joint arthroplasty (TJA)?

Question 26: What is the role of prophylactic antibiotics for invasive procedures (dental, gastrointestinal (GI), urologic, etc.) in the presence of an arthroplasty to prevent subsequent periprosthetic joint infection (PJI)?

Question 27: Does vitamin D deficiency (VDD) increase the risk of subsequent surgical site infections/periprosthetic joint infections (SSIs/PJIs) in patients undergoing orthopaedic procedures?

Question 28: What is the most accurate marker for assessing glycemic control that best predicts surgical site infection/periprosthetic joint infection (SSI/PJI)?

Question 29:  Is there a link between opioid consumption and an increased risk for surgical site infection/periprosthetic joint infection (SSI/PJI)?

Question 30:  Should skin and hair around a planned surgical incision be removed? If so, what is the best method and timing of removal?

Question 31: Does additional skin cleansing after placement of surgical drapes have a role in reducing the rate of surgical site infections/periprosthetic joint infections (SSIs/PJIs)?

Question 32: Does surgical preparation of the skin on the whole limb instead of a partial limb reduce the rates of surgical site infections/periprosthetic joint infections (SSIs/PJIs)?

Question 33: Does the methicillin-resistant Staphylococcus aureus/epidermidis (MRSA/MRSE) colonization status of operating room (OR) personnel affect the hospital’s rate of surgical site infections/periprosthetic joint infections (SSIs/PJIs)?

Question 34: Can intraoperative or postoperative blood salvage be utilized in patients undergoing reimplantation for treatment of periprosthetic joint infection (PJI)?

Question 35: What is the optimal irrigation solution (i.e., type, volume, frequency) to be used during clean elective orthopaedic procedures?

Question 36:  What is the role for vacuum-assisted incisional dressings (iVAC) in orthopaedic patients?

Question 37: What surgical dressing (i.e., occlusive, silver impregnated, dry gauze) is associated with a lower risk of surgical site infection/periprosthetic joint infection (SSI/PJI) in patients undergoing orthopaedic procedures?

Question 38:  Does the type of venous thromboembolic (VTE) prophylaxis influence the risk of surgical site infection/periprosthetic joint infection (SSI/PJI) in patients undergoing orthopaedic procedures?

BMI Question:  Does the type of venous thromboembolic (VTE) prophylaxis influence the risk of surgical site infection/periprosthetic joint infection (SSI/PJI) in patients undergoing orthopaedic procedures?

Shoulder Question: What are the diagnostic criteria of shoulder periprosthetic joint infection (PJI)?

Shoulder Question Table: Minor criteria for the definition of shoulder PJI