Clinicians evaluating a suspected infection around an artificial hip or knee should consider mycobacteria when cultures are negative, the infection is indolent, conventional antibacterial treatment has failed, the patient is immunosuppressed, or there has been relevant tuberculosis exposure, according to a review published on 21 August 2026. The review covers infections caused by the Mycobacterium tuberculosis complex and by nontuberculous mycobacteria.
This is not a report from a new patient cohort. The authors synthesized previously published clinical studies, systematic reviews, consensus documents and relevant case series. The review did not involve human participants or animal subjects. It asks what current evidence indicates about how these infections are recognized, diagnosed and managed, including surgery, antimicrobial therapy and outcomes.
When routine tests do not settle the question
The authors' conclusion starts with recognition. They say early recognition and accurate microbiological diagnosis are essential. They also call for multidisciplinary collaboration and individualized medical-surgical treatment. In practical terms, the review recommends identifying the organism as accurately as possible and combining surgery with prolonged, species-directed multidrug therapy.
Diagnosis, the review says, requires appropriate specimens to be sent for prolonged mycobacterial culture. It also lists histopathology, meaning tissue examination, molecular testing when available, and antimicrobial susceptibility testing. The review presents these as parts of the diagnostic approach.
The recommendation to consider mycobacteria is tied to a specific set of clinical situations. These include a culture-negative or indolent prosthetic-joint infection, failure of conventional antibacterial therapy, immunosuppression, or relevant tuberculosis exposure.
Treatment depends on the organism
The review does not describe one treatment recipe for every infection. It says regimens and treatment duration differ substantially between Mycobacterium tuberculosis complex and nontuberculous mycobacteria. Against that background, the authors recommend species-directed multidrug therapy alongside surgery and emphasize an individualized medical-surgical approach.
Surgery is not presented as settled. Two-stage revision is the most frequently reported reconstructive strategy when reimplantation is feasible, but comparative evidence does not establish a universally superior operation. The review's conclusion therefore leaves treatment decisions tied to the circumstances of the individual infection.
Debridement with implant retention has a narrower place in the review. It may be considered only for carefully selected early infections, including selected infections caused by rapidly growing mycobacteria. The recommendation does not establish implant retention as a general strategy for every prosthetic-joint infection.
What the evidence can support
The evidence base limits how firmly these recommendations can be generalized. The authors say current recommendations derive mainly from retrospective studies and case series. The review does not establish a universal surgical rule or a single treatment regimen for every infection; instead, it brings together available evidence across the two broad organism groups and emphasizes individualized care.
Several questions remain open. The authors call for multicenter studies using standardized definitions for diagnosis, treatment, functional results and outcomes. They present this as a needed next step for strengthening the evidence on these infections.
Taken together, the review's message is to suspect mycobacterial infection in the clinical situations it identifies, obtain specimens for the testing needed to diagnose it, and coordinate medical and surgical management around the organism and the individual case. The authors conclude that early recognition, accurate microbiological diagnosis, multidisciplinary collaboration and individualized treatment are essential.
Disclosures
The authors report that no funds, grants or other support were received during manuscript preparation. They declare no competing interests, and say no datasets were generated or analyzed during the study.
Paper data and sources
Original title: Mycobacterial periprosthetic joint infection of the hip and knee: current concepts in diagnosis and management.
Authors: Carolina Coelho Cunha, Ghazal Pourbozorg, Atthakorn Jarusriwanna et al.
Journal/Repository: European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology
Status: Peer-reviewed
First online: 2026-08-21
DOI: 10.1007/s10096-026-05633-y
Original paper · Full text