Controversies in the microbiological diagnosis and treatment of bone and joint infections

Recently, bone and joint infections such as fracture-related infection (FRI) and prosthetic joint infections (PJI) have been defined for clinical and research purposes. National and international guidelines are being produced to guide clinicians towards what is considered best practice. However, much of what we do regarding the microbiological diagnosis and management of orthopaedic infection is based on expert opinion, rather than evidence-based medicine. This is largely because, prior to the publication of the clinical definitions of orthopaedic infection, studies included a heterogeneous population making comparisons between them difficult. More recently the publication of large clinical trials in the antimicrobial management of orthopaedic infection has demonstrated that such clinical research is possible, and can both challenge the existing dogma in this field and lead to universal changes in clinical practice. There is robust evidence for microbiological sampling techniques and their interpretation in diagnosis of orthopaedic infection, as well as the choice of empiric broad-spectrum antibiotics and the non-inferiority of oral versus intravenous systemic antibiotics. For other elements of the diagnosis and management of orthopaedic infection this is not the case. For example, there are limited or no data to support recommendations regarding time off antibiotics prior to microbiological sampling, systemic antibiotic duration, when to do a joint aspirate in PJI revisions or the timing of definitive joint implantation in the two-stage management of PJI. In summary, this review highlights what is currently considered best practice within the field of orthopaedic infection and discusses both the evidence behind it and where there is controversy or where further research is warranted.