Treating periprosthetic joint infections as biofilms: key diagnosis and management strategies

• Periprosthetic joint infections (PJI) often show key features of biofilm infections.
• Biofilm infections evade culture-based diagnosis and resist standard antibiotics.
• 16S rRNA gene–based methods allow high-throughput, sensitive PJI detection.
• Antimicrobials work best as cocktails or combined with biofilm-targeting therapies.
• Biofilm diagnosis and management should be integrated into PJI clinical guidelines.

Considerable evidence suggests that microbial biofilms play an important role in periprosthetic joint infection (PJI) pathogenesis. Compared to free-floating planktonic bacteria, biofilm bacteria are more difficult to culture and possess additional immune-evasive and antibiotic resistance mechanisms, making infections harder to detect and eradicate. This article reviews cutting-edge advances in biofilm-associated infection diagnosis and treatment in the context of current PJI guidelines and highlights emerging technologies that may improve the efficacy and reduce costs associated with PJI. Promising PJI diagnostic tools include culture-independent methods based on sequence comparisons of the bacterial 16S ribosomal RNA gene, which offer higher throughput and greater sensitivity than culture-based methods. For therapy, novel methods based on disrupting biofilm-specific properties include quorum quenchers, bacteriophages, and ultrasound/electrotherapy. Since biofilm infections are not easily detected or treated by conventional approaches, molecular diagnostic techniques and next-generation antibiofilm treatments should be integrated into PJI clinical practice guidelines in the near future.