Probiotics in the Prevention of Recurrent Prosthetic Joint Infection of the Hip and Knee

The Role of Peri-operative Adjunctive Probiotics in the Prevention of Recurrent Prosthetic Joint Infection of the Hip and Knee

Prosthetic joint infection (PJI) is one of the most devastating complications following total joint arthroplasty (TJA) of the hip and knee. Standard of care (SOC) treatment includes surgery and antimicrobials. Morbidity and mortality remain high despite contemporary treatments. The human body is colonized by billions of organisms, collectively, the microbiome, which is central to healthy immune function. Microbiome disruption, dysbiosis, can impair the immune response to infection.

Despite recent evidence that suggests dysbiosis may be implicated in PJI, the role of probiotics in the treatment of PJI is unknown. Perioperative probiotics have been demonstrated to be safe and effective for infection prevention in abdominal surgery. The investigators hypothesize that perioperative probiotics will reduce re-infection in patients treated for PJI. A multi-centered, randomized controlled trial (RCT) at two academic, tertiary care centers will be conducted to determine the impact of probiotics on recurrent infection following treatment for PJI. Controls will receive SOC; study patients will receive a probiotic, started shortly after the initiation of and for the duration of their antibiotic therapy + 7 days, in addition to SOC. Primary outcome is re-operation for recurrent infection within 1 year.

Study Overview

• Status: Enrolling by invitation
• Conditions: Dysbiosis; Prosthetic-joint Infection
• Intervention / Treatment: Drug: Probiotic; Other: Standard of care

Detailed Description

The primary and secondary aims for this RCT are:

Primary Aim 1.1 To determine the impact of administration of probiotics administered for 6 weeks after the index surgical treatment for PJI on reinfection rates (deep infection) within 1 year following revision TJA for PJI in each of the treatment arms (probiotics and standard of care).

Secondary Aims 2.1 To evaluate the incidence of superficial infections including wound drainage, cellulitis, or infections superficial to the deep fascia within 1 year following revision TJA for PJI in each of the treatment arms (probiotics and standard of care).

2.2 To evaluate the safety of use of probiotics in this population and to monitor the incidence of adverse events in patients administered probiotics versus standard of care in patients undergoing treatment for PJI.

2.3 To evaluate the 1-year mortality rate in patients undergoing revision TJA for PJI in each of treatment arms (probiotics and standard of care).

2.4 To evaluate the rate of wound healing and dehiscence in patients undergoing revision TJA for PJI in each of treatment arms (probiotics and standard of care).

2.5 To evaluate the need for chronic antibiotic suppression for the treatment of PJI at final follow-up of one year following revision TJA for PJI in each of the treatment arms (probiotics and standard of care).

2.6 To evaluate the rate of infection with Clostridium difficile within 90 days of finishing antibiotic therapy in each of the treatment arms (probiotics and standard of care). The risk of developing C. difficile infection is present for 90 days following cessation of antibiotic treatment.

• Study Type: Interventional
• Enrollment (Estimated): 152
• Phase: Phase 4

Contacts and Locations

Study Locations

• United States
  • Massachusetts
    • Boston, Massachusetts, United States, 02118
      • Boston Medical Center, Orthopedic Surgery
  • New York
    • New York, New York, United States, 10016
      • New York University Langone Orthopedics

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

All patients scheduled to undergo revision total knee arthroplasty (TKA) or total hip arthroplasty (THA) for infection at the participating institutions will be screened for eligibility in this prospective trial.

Inclusion Criteria:

• Diagnosis of PJI based upon Musculoskeletal Infection Society (MSIS) criteria
• Planned treatment with surgical debridement, antibiotics, implant retention (DAIR), single- and two-stage revision TJA for PJI with an anticipated plan for eventual discontinuation of oral/IV antibiotics.
• Patients with prior PJI in the same joint that has recurred.
• Patients who understand the benefits and risks associated with taking a probiotic and are willing and able to provide informed consent.

Exclusion Criteria:

• Fungal PJI.
• Inflammatory bowel disease, diverticulitis, history of intestinal surgery, or gastrointestinal
• issue where there is concern for gut integrity.
• History of pancreatitis at any point in time.
• History of intolerance to probiotics.
• Immunocompromised patients.
• Revision TJA for aseptic reasons

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Treatment- Probiotics and standard of care; Participants randomized into this are will receive Culturelle probiotic and standard of care.	Drug: Probiotic; Culturelle probiotic, one capsule daily to start following SOC surgical treatment for PJI during the initial 6 weeks of SOC antibiotic treatment.; Other Names: Culturelle; Other: Standard of care; Standard of care (SOC) treatment includes surgery and antimicrobials.
Active Comparator: Controls- Standard of care; Participants randomized into this are will receive standard of care.	Other: Standard of care; Standard of care (SOC) treatment includes surgery and antimicrobials.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Recurrent Prosthetic Joint Infection (PJI)	The number of participants who develop PJI after PJI surgery will be abstracted from electronic medical records.	1 year, 2 years after PJI surgery
Surgical Site Infection (SSI)	The number of participants who develop SSI within 12 months of PJI surgery will be abstracted from electronic medical records.	3 months, 6 months, 12 months post PJI surgery

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Medical complications	This outcome will be assessed from information in the electronic medical records and reported as Yes or No.	3 months, 6 months, 12 months post PJI surgery
Surgical complications	This outcome will be assessed from information in the electronic medical records and reported as Yes or No.	3 months, 6 months, 12 months post PJI surgery
Sepsis	The number of participants who have a diagnosis of sepsis related to PJI surgery will be abstracted from electronic medical records.	3 months, 6 months, 12 months post PJI surgery
Re-operation for recurrent infection	The number of participants who have a re-operation for recurrent infection within 12 months of the PJI surgery will be abstracted from the electronic medical records.	3 months, 6 months, 12 months post PJI surgery
Revision surgery	The number of participants who have revision surgery within 12 months of PJI surgery will be abstracted from electronic medical records.	3 months, 6 months, 12 months post PJI surgery
Complications related to the use of probiotics	This outcome will be assessed from information in the electronic medical records and reported as Yes or No.	3 months, 6 months, 12 months post PJI surgery
Mortality	The number of participants who die within 12 months of the PJI surgery will be abstracted from the electronic medical records.	12 months post PJI surgery
Patient reported health outcomes	The Patient-Reported Outcomes Measurement Information System (PROMIS)-10 score ranges from 0 to 20 points, with 0 representing the most severe impairment and 20 representing the best possible health. Low scores may indicate poorer self-reported health and a greater risk of future healthcare utilization.	3 months, 6 months, 12 months post PJI surgery
Patient reported hip disability	The Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR) will be used to assess hip disability. It is patient reported and contains 6 items from the original HOOS survey. Items are coded from 0 to 4, none to extreme respectively. HOOS, JR is scored by summing the raw response (range 0-24) and then converting it to an interval score using a table where the interval score ranges from 0 to 100 where 0 represents total hip disability and 100 represents perfect hip health.	3 months, 6 months, 12 months post PJI surgery
Patient reported knee disability	Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS, JR) will be used to assess knee disability. It is patient reported and contains 7 items from the original KOOS survey. Items are coded from 0 to 4, none to extreme respectively. KOOS, JR is scored by summing the raw response (range 0-28) and then converting it to an interval score using a table.. The interval score ranges from 0 to 100 where 0 represents total knee disability and 100 represents perfect knee health.	3 months, 6 months, 12 months post PJI surgery

Collaborators and Investigators

• Sponsor: Boston Medical Center
• Collaborators: American Association of Hip and Knee Surgeons
• Investigators: Principal Investigator: Ayesha Abdeen, MD, Boston Medical Center

Study record dates

Study Major Dates

• Study Start (Actual): August 15, 2025
• Primary Completion (Estimated): June 1, 2027
• Study Completion (Estimated): June 1, 2027

Study Registration Dates

• First Submitted: October 8, 2024
• First Submitted That Met QC Criteria: October 8, 2024
• First Posted (Actual): October 15, 2024

Study Record Updates

• Last Update Posted (Estimated): August 29, 2025
• Last Update Submitted That Met QC Criteria: August 24, 2025
• Last Verified: August 1, 2025

More Information

Terms related to this study

• Keywords: Probiotics; Patient Reported Outcome Measures (PROMs); DAIR; Hip total joint arthroplasty (TJA); Knee TJA; Recurrent reinfection; Surgical site infection (SSI)
• Additional Relevant MeSH Terms: Postoperative Complications; Pathologic Processes; Disease Attributes; Infections; Wound Infection; Recurrence; Pathological Conditions, Signs and Symptoms; Reinfection; Dysbiosis; Surgical Wound Infection; Health Services Administration; Health Care Quality, Access, and Evaluation; Quality of Health Care; Dietary Supplements; Food; Diet, Food, and Nutrition; Physiological Phenomena; Food and Beverages; Quality Indicators, Health Care; Probiotics; Standard of Care
• Other Study ID Numbers: H-44452

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: Yes
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No