Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
Biofilm around an implant resists host defence and antibiotics, while an acute infected arthroplasty can produce shock, wound failure and rapid tissue destruction; indiscriminate antibiotics in a stable patient can obscure the organism needed for definitive reconstruction.
Action: For sepsis, obtain urgent blood cultures, start parenteral protocol antibiotics and arrange experienced emergency drainage as soon as safe and within six hours when acutely unwell; for a stable patient, withhold antibiotics, obtain consultant review within 48 hours and secure synovial plus multiple deep tissue samples before antimicrobial treatment.
Synopsis
Recognise acute and indolent infection around joint replacement, separate septic instability from stable diagnostic sampling, protect deep-culture yield, classify evidence coherently, and select DAIR, staged exchange or salvage through a specialist implant-infection team.
Classify the clinical syndrome before prescribing: acute postoperative, acute haematogenous, chronic indolent and septic presentations have different sampling and surgical opportunities.
In sepsis, take blood cultures urgently and start parenteral protocol antibiotics, then drain emergently; current BOASt targets surgery within six hours for an acutely unwell patient when safe.
Do not give antibiotics to a stable patient until diagnostic synovial or deep tissue samples are obtained, unless a documented competing infection requires treatment.
Key red flags
Hypotension, confusion, lactate elevation, purulent drainage, rapidly spreading erythema or acute severe prosthetic-joint pain with bacteraemia requires immediate sepsis, orthopaedic and anaesthetic escalation.
Investigation priorities
01
First-line FBC, CRP and renal functionFirst stepFirst line
Measure systemic inflammation, sepsis severity and treatment safety.
02
First-line plain radiographsFirst line
Assess component position, loosening, osteolysis, fracture and baseline bone stock.
Management branches
SepticCulture, treat and drain emergently
Suspected PJI accompanies sepsis, organ dysfunction or rapidly progressive local infection.
Start the sepsis pathway, obtain urgent blood cultures and inform orthopaedics, anaesthesia and microbiology immediately.
Give local parenteral protocol antibiotics after blood cultures and do not wait for planned aspiration in an unstable patient.
StablePreserve the organism and define evidence
Pain, loosening or drainage suggests PJI without current sepsis.
Key medicines
Empiric parenteral therapy for septic PJIAfter urgent blood cultures, give the current hospital's full adult sepsis and PJI protocol doses immediately; obtain deep samples at emergency drainage and narrow promptly to organism, susceptibilities, source-control operation and renal function.
Rifampicin-containing biofilm therapy when selectedUse only the infection specialist's organism-confirmed combination regimen after adequate debridement and when the wound is controlled; never use rifampicin alone, and prescribe the exact partner, dose, duration and monitoring in writing.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.