The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.
Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, United Kingdom.
J Bone Joint Surg Am. 2019 Apr 17;101(8):739-744. doi: 10.2106/JBJS.18.00615.
It has been demonstrated that administration of antibiotics prior to performing diagnostic testing for periprosthetic joint infection can interfere with the accuracy of the standard diagnostic tests. Therefore, the purpose of this study was to evaluate the effects of antibiotic administration prior to performing the synovial leukocyte esterase strip test for periprosthetic joint infection.
We identified 121 patients who underwent revision hip or knee arthroplasty for a Musculoskeletal Infection Society (MSIS)-confirmed periprosthetic joint infection. All patients also had a leukocyte esterase strip test performed. Patients in one group (32%) took antibiotics prior to the diagnostic workup, whereas patients in another group (68%) did not receive antibiotics within 2 weeks of the diagnostic workup. The leukocyte esterase strip test, erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP), synovial white blood-cell (WBC) count, and polymorphonuclear neutrophil (PMN) percentage were collected and were compared between the 2 groups.
The median serum ESR (85 compared with 67 mm/hr for patients who did not and did receive antibiotics; p = 0.009), CRP (16.5 compared with 12.9 mg/L; p = 0.032), synovial WBC count (45,675 compared with 9,650 cells/µL; p < 0.0001), and PMN percentage (93% compared with 88%; p = 0.004) were all significantly lower for patients receiving antibiotics. Furthermore, the administration of antibiotics resulted in a significant decrease in the sensitivity of all tests, except leukocyte esterase: ESR (79.5% in the antibiotics cohort compared with 92.7% in the no-antibiotics cohort [relative risk (RR) for false-negative results, 2.8; p = 0.04]), CRP (64.2% compared with 81.8% [RR, 1.9; p = 0.03]), WBC count (69.3% compared with 93.4% [RR, 5.0; p = 0.001]), PMN percentage (74.4% compared with 91.5% [RR, 3.0; p = 0.01]), and leukocyte esterase (78% compared with 83% [RR, 1.6; p = 0.17]). The rate of negative cultures was higher in the antibiotics group at 30.7% compared with the no-antibiotics group at 12.1% (p = 0.015).
This current study and previous studies have demonstrated that the administration of premature antibiotics can compromise the results of standard diagnostic tests for periprosthetic joint infection, causing significant increases in false-negative results. However, in this study, the leukocyte esterase strip test maintained its performance even in the setting of antibiotic administration. Antibiotic administration prior to diagnostic workups for periprosthetic joint infection stands to interfere with diagnosis. The leukocyte esterase strip test can be used as a reliable diagnostic marker for diagnosing periprosthetic joint infection even when prior antibiotics are administered.
Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
已有研究证实，在进行人工关节感染的诊断性检查之前使用抗生素会干扰标准诊断性检查的准确性。因此，本研究旨在评估在进行人工关节感染的滑膜白细胞酯酶条检测之前使用抗生素对诊断的影响。
我们确定了 121 名因骨髓肌肉感染学会（MSIS）确诊的人工关节感染而行翻修髋关节或膝关节置换术的患者。所有患者均进行白细胞酯酶条检测。一组（32%）患者在诊断性检查前使用了抗生素，而另一组（68%）患者在诊断性检查前 2 周内未使用抗生素。收集白细胞酯酶条检测、红细胞沉降率（ESR）、血清 C 反应蛋白（CRP）、滑膜白细胞计数（WBC）和多形核中性粒细胞（PMN）百分比，并比较两组之间的差异。
接受抗生素治疗的患者血清 ESR 中位数（85mm/hr 与未接受抗生素治疗的患者的 67mm/hr；p = 0.009）、CRP 中位数（16.5mg/L 与 12.9mg/L；p = 0.032）、滑膜 WBC 计数中位数（45675 与 9650 细胞/µL；p < 0.0001）和 PMN 百分比中位数（93%与 88%；p = 0.004）均显著降低。此外，抗生素的使用显著降低了所有检测的敏感性，除白细胞酯酶检测外：ESR（抗生素组为 79.5%，无抗生素组为 92.7%[假阴性结果的相对风险（RR）为 2.8；p = 0.04]）、CRP（64.2%与 81.8%[RR，1.9；p = 0.03]）、WBC 计数（69.3%与 93.4%[RR，5.0；p = 0.001]）、PMN 百分比（74.4%与 91.5%[RR，3.0；p = 0.01]）和白细胞酯酶（78%与 83%[RR，1.6；p = 0.17]）。接受抗生素治疗的患者的阴性培养率为 30.7%，高于未接受抗生素治疗的患者的 12.1%（p = 0.015）。
本研究和既往研究均证实，提前使用抗生素会影响人工关节感染的标准诊断性检查结果，导致假阴性结果显著增加。然而，在本研究中，白细胞酯酶条检测在使用抗生素的情况下仍能保持其性能。人工关节感染诊断前的抗生素治疗可能会干扰诊断。白细胞酯酶条检测可作为一种可靠的诊断标志物，用于诊断人工关节感染，即使在使用抗生素的情况下。
诊断 III 级。有关证据水平的完整描述，请参见《作者须知》。
