'All in a box' a concept for optimizing microbiological diagnostic sampling in prosthetic joint infections

Abstract

Background: Accurate microbial diagnosis is crucial for effective management of prosthetic joint infections. Culturing of multiple intraoperative tissue samples has increased diagnostic accuracy, but new preparatory techniques and molecular methods hold promise of further improvement. The increased complexity of sampling is, however, a tough challenge for surgeons and assistants in the operation theatre, and therefore we devised and tested a new concept of pre-packed boxes with a complete assortment of swabs, vials and additional tools needed in the operating theatre for non-standard samples during a clinical study of prosthetic joint infections.

Findings: The protocol for the clinical study required triplicate samples of joint fluid, periprosthetic tissue, bone tissue, and swabs from the surface of the prosthesis. Separate boxes were prepared for percutaneous joint puncture and surgical revision; the latter included containers for prosthetic components or the entire prosthesis. During a 2-year project period 164 boxes were used by the surgeons, 98 of which contained a complete set of samples. In all, 1508 (89%) of 1685 scheduled samples were received.

Conclusion: With this concept a high level of completeness of sample sets was achieved and thus secured a valid basis for evaluation of new diagnostics. Although enthusiasm for the project may have been a contributing factor, the extended project period suggests that the 'All in a box' concept is equally applicable in routine clinical settings with standardized but complex diagnostic sampling.

Figure 1

Sample boxes for joint puncture (A) and revision surgery (B). A: Joint fluid is both inoculated directly into a blood culture flask (BacT/Alert, bioMérieux, Marcy l’Etoil, France) and submitted for extensive culture examination and molecular diagnostics. B: Sample tubes are colour coded in the revision surgery box in order to assist the operation staff in achieving complete sample sets. Sample tubes had a broad neck in order to facilitate the deposition of the sample.