The Role of Positive Klebsiella Culture in Revision Hip and Knee Arthroplasty

Abstract

Gram-negative (GN) periprosthetic joint infections (PJIs) are being increasingly reported. However, the role of Klebsiella species in PJIs remains unclear. Therefore, we aimed to analyze the prevalence, clinical presentation, microbial spectrum, antibiogram, treatment strategies and outcomes of Klebsiella-associated PJIs. A total of 1925 culture-positive total joint revision arthroplasties (rTJA) were retrospectively reviewed at a single center. Patient data were extracted from our institutional arthroplasty and PJI database. We identified 20 Klebsiella-positive PJIs (hip/knee, 11/9), representing 1.0% of all culture-positive rTJAs. The cases were predominantly polymicrobial (80%) and chronic (50%). Notably, Klebsiella spp. was rarely detected as an initial infectious event but was predominantly identified in the context of revision or re-revision procedures, frequently in patients with prior or persistent PJIs. Klebsiella pneumoniae was the most frequent species, with 44% showing multi-drug resistance. The antimicrobial susceptibility of Klebsiella isolates showed high resistance to cephalosporines and penicillin, in contrast little to no resistance to meropenem, gentamicin and levofloxacin. The most common initial surgical intervention was a two-stage revision (65%). Infection control (Tier 1) was observed in 11%, while further intervention was needed in 56% (Tier 3). All patients who had already died were classified as Tier 4 (33%). Klebsiella spp. was detected in 10.0% of GN rTJAs and was mainly associated with complex revision settings rather than primary infections. It is often associated with chronic polymicrobial infections and high antimicrobial resistance. The outcomes were generally poor, highlighting the need for pathogen-specific treatment strategies and improved diagnostics.