Purpose: Periprosthetic joint infection (PJI) is a catastrophic complication after total joint arthroplasty (TJA). Treatment of PJI is challenging, especially when causative microorganism is not identified. The purpose of this systematic review was to guide diagnostic approach and treatment of culture-negative (CN) PJI. Methods: A systematic review was undertaken on clinical studies from MEDLINE, EMBASE, Cochrane Library, and Scopus databases. Basic science studies, letters, studies written in languages other than English, case reports, and review articles were excluded. Results: Proportion of CN PJI ranged from 5 to 42% of PJIs. Risk factors for culture negativity included prior use of antibiotic before culture test, inappropriate culture tools, insufficient culture period, and post-operative wound drainage. Specific diagnostic protocols including repeating sampling, longer incubation period, culture in blood culture bottles, sonication of implants, polymerase chain reaction in synovial fluid, and next-generation sequencing are recommended to identify undetected microorganisms. Vancomycin and cephalosporins are the most commonly used antibiotics. Two-stage revision arthroplasty showed success rate of 70–100%. Conclusions: A comprehensive review was performed to provide an up-to-date, evidence-based guide to the management of CN PJI.
- Systematic review