Does Pre- and Intra-operative Culture Negativity Affect the Outcome of Debridement, Antibiotics, and Implant Retention in Acute Periprosthetic Joint Infection: A Single Center Retrospective Cohort Study

Background: Debridement, antibiotics, and implant retention (DAIR) are standard treatments for acute hip and knee periprosthetic joint infection (PJI).However, culture-negative (CN) cases complicate diagnosis and management, and their impact on DAIR outcomes remains unclear.This study evaluated whether pre-and intraoperative culture negativity influences clinical outcomes following DAIR. Methods:We retrospectively reviewed patients who underwent DAIR for acute hip or knee PJI between January 2008 and December 2022 at a single institution.Diagnosis was confirmed using the 2018 Musculoskeletal Infection Society criteria.To minimize misclassification, CN cases were defined exclusively from 2016 to 2022, when a standardized intra-operative protocol obtaining 18 specimens was implemented.Outcomes of CN cases were compared with culture-positive (CP) cases treated between 2008 and 2022.A total of 672 patients were included (504 CP, 168 CN).Baseline demographics were comparable, although renal failure was more prevalent in the CN group (23.2 versus 14.1%, P < 0.01). Results:The CN cases demonstrated lower serum C-reactive protein and synovial white blood cell counts, and experienced longer delays from admission to surgery (6.3 versus 3.0 days, P < 0.01).Conversion to two-stage exchange arthroplasty was more frequent in the CN group (63.7 versus 46.4%, P < 0.01).Complications, mortality, and recurrence of PJI were similar between groups. Conclusions:The CN acute PJI is associated with delayed intervention, greater medical complexity, and increased progression to staged revision.These findings appear to reflect challenges in timely diagnosis and clinical decision-making rather than intrinsically more aggressive infection biology.Infection control following definitive surgical management remained comparable between groups at final follow-up.Future efforts should focus on earlier recognition, minimizing unnecessary preoperative antibiotics, and adherence to standardized culture protocols to reduce diagnostic delay and treatment escalation.