Empiric management of B&J infections:

Patients with B&J infections, especially chronic osteomyelitis and implant-associated infections often undergo multiple incomplete procedures and receive several courses of empiric antibiotics.

Whereas this practice should be strongly discouraged and every attempt should be made at a tissue diagnosis, fashioning empiric treatment based on the most likely cause is sometimes inevitable when cultures fail to isolate the organism or the patient is clinically unstable.

If ongoing/ recent receipt of empiric antimicrobials, surgery may be deferred for ≥ 2 weeks (antibiotic-free interval), to increase diagnostic yield in a stable patient.

Likely organisms after orthopaedic implant surgery/ PJI based on the interval between surgery and infection


Time of Onset- post implant

Likely Organisms

Clinical features

Very early infection
(<2 days )

Group A Streptococcus
Clostridium perfringens

High fever, shock, bullae, necrosis, gangrene

Early Infection
(<2 wks)

S.aureus
Gram-negative bacilli

Fever, inflammation, poor wound healing

Delayed  Infection
(3-10 wks)

CONS
NTM,
Propionibacterium acnes

Persistent pain, low grade fever, mechanical instability, sinus tract

Late Infection
(>10 Weeks)

  1. Acute
  2. Chronic

S. aureus
GNB
CONS
NTM
Polymicrobial
Fungal

-Hematogenous seeding
- sepsis, local inflammation
-Inadequately treated early infection
-signs of infection after bridging symptoms: pain, wound healing disturbances, nonunion

Empiric choices for B&J infections

Approach to Prosthetic Joint & Implant-associated Infections