Skip to main content
SpringerLink
Log in

Diagnosing Periprosthetic Infection: False-positive Intraoperative Gram Stains

  • Symposium: Periprosthetic Joint Infection
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Intraoperative Gram stains have a reported low sensitivity but high specificity when used to help diagnose periprosthetic infections. In early 2008, we recognized an unexpectedly high frequency of apparent false-positive Gram stains from revision arthroplasties.

Questions/purposes

The purpose of this report is to describe the cause of these false-positive test results.

Methods

We calculated the sensitivity and specificity of all intraoperative Gram stains submitted from revision arthroplasty cases during a 3-month interval using microbiologic cultures of the same samples as the gold standard. Methods of specimen harvesting, handling, transport, distribution, specimen processing including tissue grinding/macerating, Gram staining, and interpretation were studied. After a test modification, results of specimens were prospectively collected for a second 3-month interval, and the sensitivity and specificity of intraoperative Gram stains were calculated.

Results

The retrospective review of 269 Gram stains submitted from revision arthroplasties indicated historic sensitivity and specificity values of 23% and 92%, respectively. Systematic analysis of all steps of the procedure identified Gram-stained but nonviable bacteria in commercial broth reagents used as diluents for maceration of periprosthetic membranes before Gram staining and culture. Polymerase chain reaction and sequencing showed mixed bacterial DNA. Evaluation of 390 specimens after initiating standardized Millipore filtering of diluent fluid revealed a reduced number of positive Gram stains, yielding 9% sensitivity and 99% specificity.

Conclusions

Clusters of false-positive Gram stains have been reported in other clinical conditions. They are apparently rare related to diagnosing periprosthetic infections but have severe consequences if used to guide treatment. Even occasional false-positive Gram stains should prompt review of laboratory methods. Our observations implicate dead bacteria in microbiologic reagents as potential sources of false-positive Gram stains.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1A–B
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Atkins BL, Athanasou N, Deeks JJ, Crook DWM, Simpson H, Peto TEA, McLardy-Smith P, Berendt AR. Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty. J Clin Microbiol. 1998;36:2932–2939.

    PubMed  CAS  Google Scholar 

  2. Banit DM, Kaufer H, Hartford JM. Intraoperative frozen section analysis in revision total joint arthroplasty. Clin Orthop Relat Res. 2002;401:230–238.

    Article  PubMed  Google Scholar 

  3. Barrack RL, Jennings RW, Wolfe MW, Bertot AJ. The value of preoperative aspiration before total knee revision. Clin Orthop Relat Res. 1997;345:8–16.

    Article  PubMed  Google Scholar 

  4. Bauer TW, Parvizi J, Kobayashi N, Krebs V. Diagnosis of periprosthetic infection. J Bone Joint Surg Am. 2006;88:869–882.

    Article  PubMed  Google Scholar 

  5. Blot F, Raynard B, Chachaty E, Tancrede C, Antoun S, Nitenberg G. Value of Gram stain examination of lower respiratory tract secretions for early diagnosis of nosocomial pneumonia. Am J Respir Crit Care Med. 2000;160:1731–1737.

    Google Scholar 

  6. Chimento GF, Finger S, Barrack RL. Gram stain detection of infection during revision arthroplasty. J Bone Joint Surg Br. 1996;78:838–839.

    PubMed  CAS  Google Scholar 

  7. Della Valle C, Scher DM, Kim YH, Oxley CM, Desai P, Zuckerman JD, DeCesare PE. The role of intraoperative Gram stain in revision total joint arthroplasty. J Arthroplasty. 1999;14:500–504.

    Article  PubMed  CAS  Google Scholar 

  8. Ericsson CD, Carmichael M, Pickering LK, Mussett R, Kohl S. Erroneous diagnosis of meningitis due to false-positive Gram stains. South Med J. 1978;71:1524–1525.

    PubMed  CAS  Google Scholar 

  9. Ghanem E, Ketonis C, Restrepo C, Joshi A, Barrack R, Parvizi J. Periprosthetic infection: where do we stand with regard to Gram stain? Acta Orthop. 2009;80:37–40.

    Article  PubMed  Google Scholar 

  10. Hoke CH, Batt JM, Mirrett S, Cox RL, Reller B. False-positive Gram-stained smears. JAMA. 1979;241:478–479.

    Article  PubMed  Google Scholar 

  11. Keighley MRB, McLeish AR, Bishop HM, Burdon DW, Quoraishi AH, Oates GD, Dorricott NJ, Alexander-Williams J. Identification of the presence and type of biliary microflora by immediate Gram stains. Surgery. 1977;81:469–472.

    PubMed  CAS  Google Scholar 

  12. Ko PS, Ip D, Chow KP, Cheung F, Lee OB, Lam JJ. The role of intraoperative frozen section in decision making in revision hip and knee arthroplasty in a local community hospital. J Arthroplasty. 2005;20:189–195.

    Article  PubMed  Google Scholar 

  13. Kobayashi N, Procop GW, Krebs V, Kobayashi H, Bauer TW. Molecular identification of bacteria from aseptically loose implants. Clin Orthop Relat Res. 2008;466:1716–1725.

    Article  PubMed  Google Scholar 

  14. Kraemer WJ, Saplys R, Waddell JP, Morton J. Bone scan, gallium scan and hip aspiration in the diagnosis of infected total hip arthroplasty. J Arthroplasty. 1993;8:611–615.

    Article  PubMed  CAS  Google Scholar 

  15. Morgan PM, Sharkey P, Ghanem E, Parvizi J, Clohisy JC, Burnett RSJ, Barrack RL. The value of intraoperative Gram stain in revision total knee arthroplasty. J Bone Joint Surg Am. 2009;91:2124–2129.

    Article  PubMed  Google Scholar 

  16. Muscher DM, Schell RF. False-positive Gram stains of cerebrospinal fluid. Ann Intern Med. 1973;79:603–604.

    Google Scholar 

  17. Parvizi J, Ghanem E, Menashe S, Barack BL, Bauer TW. Periprosthetic infection: what are the diagnostic challenges? J Bone Joint Surg Am. 2006;88:138–147.

    Article  PubMed  Google Scholar 

  18. Southern PM Jr, Colvin DD. Pseudomeningitis again. Association with cytocentrifuge funnel and Gram-stain reagent contamination. Arch Pathol Lab Med. 1996;120:456–458.

    PubMed  Google Scholar 

  19. Spangehl MJ, Masterson E, Masri BA, O’Connell JX, Duncan CP. The role of intraoperative Gram stain in the diagnosis of infection during total hip arthroplasty. J Arthroplasty. 1999;14:952–956.

    Article  PubMed  CAS  Google Scholar 

  20. Willcox JR, Adler MW, Belsey EM. Observer variation in the interpretation of Gram-stained urethral smears: implications for the diagnosis of non-specific urethritis. Br J Vener Dis. 1981;57:134–136.

    PubMed  CAS  Google Scholar 

Download references

Acknowledgments

We thank Geraldine Hall, PhD, and Gary Procop, MD, MS, for their guidance during the course of this study and formulation of the manuscript.

Author information

Author notes

  1. Margret Oethinger MD, PhD

    Present address: Department of Pathology, Providence Portland Medical Center, Portland, OR, USA

Authors and Affiliations

  1. Department of Clinical Pathology, The Cleveland Clinic, Cleveland, OH, USA

    Margret Oethinger MD, PhD, Debra K. Warner MT(ASCP) & Susan A. Schindler MT(ASCP)

  2. Department of Anatomic Pathology, The Cleveland Clinic, Cleveland, OH, USA

    Hideo Kobayashi MD, PhD & Thomas W. Bauer MD, PhD

  3. Department of Pathology–L25, The Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA

    Thomas W. Bauer MD, PhD

Authors
  1. Margret Oethinger MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Debra K. Warner MT(ASCP)
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Susan A. Schindler MT(ASCP)
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hideo Kobayashi MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Thomas W. Bauer MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Thomas W. Bauer MD, PhD.

Additional information

Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

About this article

Cite this article

Oethinger, M., Warner, D.K., Schindler, S.A. et al. Diagnosing Periprosthetic Infection: False-positive Intraoperative Gram Stains. Clin Orthop Relat Res 469, 954–960 (2011). https://doi.org/10.1007/s11999-010-1589-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-010-1589-9

Keywords

Search

Navigation