• Prosthetic joint infections (PJI) can be difficult to diagnose.

• Studies have shown that we are missing many infections, possibly due to poor diagnostic workup and the presence of culture-negative infection.

• PJI diagnosis requires a methodical approach and a standardised set of criteria.

• Multiple PJI definitions have been published with improved accuracy in recent years.

• The new European Bone and Joint Infection Society definition offers some advantages in clinical practice. It identifies more clinically important infections and accurately defines those with the highest risk of treatment failure. It reduces the number of patients with uncertain diagnoses.

• Classification of PJIs may offer a better understanding of treatment outcomes and risk factors for failure.

• Fracture-related infection (FRI) is common and often diagnosed late.

• Accurate diagnosis is the beginning of effective treatment.

• Diagnosis can be difficult, particularly when there are no outward signs of infection.

• The new FRI definition, together with clear protocols for nuclear imaging, microbiological culture and histological analysis, should allow much better study design and a clearer understanding of infected fractures.

• In recent years, there has been a new focus on defining FRI and avoiding non-specific, poorly targeted treatment. Previous studies on FRI have often failed to define infection precisely and so are of limited value. This review highlights the essential principles of making the diagnosis and how clinical signs, serum tests, imaging, microbiology, molecular biology and histology all contribute to the diagnostic pathway.

Cite this article: EFORT Open Rev 2020;5:614-619. DOI: 10.1302/2058-5241.5.190072

• The global burden of fracture-related infection (FRI) is likely to be found in countries with limited healthcare resources and strategies are needed to ensure the best available practice is context appropriate. This study has two main aims: (i) to assess the applicability of recently published expert guidance from the FRI consensus groups on the diagnosis and management of FRI to low- and middle-income countries (LMICs); (ii) to summarise the available evidence on FRI, with consideration for strategies applicable to low resource settings.

• Data related to the International Consensus Meeting Orthopaedic Trauma Work Group and the International Fracture Related Infection Consensus Group FRI guidelines were collected including panel membership, country of origin, language of publication, open access status and impact factor of the journal of publication. The recommendations and guidelines were then summarised with specific consideration for relevance and applicability to LMICs. Barriers to implementation were explored within a group of LMIC residents and experienced workers.

• The authorship, evidence base and reach of the FRI consensus guidelines lack representation from low resource settings. The majority of authors (78.5–100%) are based in high-income countries and there are no low-income country collaborators listed in any of the papers. All papers are in English.

• The FRI consensus guidelines give a clear set of principles for the optimum management of FRI. Many of these – including the approach to diagnosis, multidisciplinary team working and some elements of surgical management – are achievable in low resource settings. Current evidence suggests that it is important that a core set of principles is prioritised but robust evidence for this is lacking. There are major organisational and infrastructure obstacles in LMICs that will make any standardisation of FRI diagnosis or management challenging. The detail of how FRI consensus principles should be applied in low resource settings requires further work.

• The important work presented in the current FRI consensus guidelines is relevant to low resource settings. However, leadership, collaboration, creativity and innovation will be needed to implement these strategies for communities who need it the most.