title: Periprosthetic joint infection in patients with inflammatory joint disease: a review of risk factors and current approaches to diagnosis and management.
abstract: BACKGROUND
  Prevention, early identification, and effective management of periprosthetic joint infection (PJI) in patients with inflammatory joint disease (IJD) present unique challenges for physicians. Discontinuing disease-modifying anti-rheumatoid drugs (DMARDs) perioperatively may reduce immunosuppression and infection risk at the expense of increasing disease flares. Interpreting traditional diagnostic markers of PJI can be difficult due to disease-related inflammation.
  
  
  OBJECTIVE
  This review is designed to answer how to (1) manage immunosuppressive/DMARD therapy perioperatively, (2) diagnose PJI in patients with IJD, and (3) treat PJI in this population.
  
  
  METHODS
  The PubMed database was searched for relevant articles with subsequent review by independent authors.
  
  
  RESULTS
  While there is evidence to support the use of methotrexate perioperatively in RA patients, it remains unclear whether using anti-tumor necrosis factor medications perioperatively increases the risk of surgical site infections. Serum erythrocyte sedimentation rate and C-reactive protein can be useful for diagnosis of PJI in this population, but only as part of comprehensive workup that ultimately relies upon sampling of joint fluid. Management of PJI depends on several clinical factors including duration of infection and the likelihood of biofilm presence, the infecting organism, sensitivity to antibiotic therapy, and host immune status. The evidence suggests that two-stage revision or resection arthroplasty is more likely to eradicate infection, particularly when MRSA is the pathogen.
  
  
  CONCLUSIONS
  Immunosuppression and baseline inflammatory changes in the IJD population can complicate the prevention, diagnosis, and treatment of PJI. Understanding the increase in risk associated with IJD and its treatment is essential for proper management when patients undergo lower extremity arthroplasty.
authors.affiliation: Jefferson Medical College, 1025 Walnut Street, Philadelphia, PA 19107 USA.
authors.forename: Todd A
authors.initials: TA
authors.lastname: Morrison
authors.affiliation: Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Figgie
authors.affiliation: Division of Infectious Diseases, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA.
authors.forename: Andy O
authors.initials: AO
authors.lastname: Miller
authors.affiliation: Department of Rheumatology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA.
authors.forename: Susan M
authors.initials: SM
authors.lastname: Goodman
keywords: inflammatory arthritis; periprosthetic joint infection; total joint arthroplasty