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Eriksson HK, Lazarinis S, Järhult JD, Hailer NP. Early Staphylococcal Periprosthetic Joint Infection (PJI) Treated with Debridement, Antibiotics, and Implant Retention (DAIR): Inferior Outcomes in Patients with Staphylococci Resistant to Rifampicin. Antibiotics (Basel) 2023; 12:1589. [PMID: 37998791 PMCID: PMC10668653 DOI: 10.3390/antibiotics12111589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/25/2023] Open
Abstract
It is unknown how rifampicin resistance in staphylococci causing a periprosthetic joint infection (PJI) affects outcomes after debridement, antibiotics, and implant retention (DAIR). We thus aimed to compare the risk of relapse in DAIR-treated early PJI caused by staphylococci with or without rifampicin resistance. In total, 81 patients affected by early PJI were included, and all patients were treated surgically with DAIR. This was repeated if needed. The endpoint of relapse-free survival was estimated using the Kaplan-Meier method, and Cox regression models were fitted to assess the risk of infection relapse for patients infected with rifampicin-resistant bacteria, adjusted for age, sex, type of joint, and type of index surgery. In patients with rifampicin-resistant staphylococci, relapse was seen in 80% after one DAIR procedure and in 70% after two DAIR procedures. In patients with rifampicin-sensitive bacteria, 51% had an infection relapse after one DAIR procedure and 33% had an infection relapse after two DAIR procedures. Patients with rifampicin-resistant staphylococcal PJI thus had an increased adjusted risk of infection relapse of 1.9 (95% CI: 1.1-3.6, p = 0.04) after one DAIR procedure compared to patients with rifampicin-sensitive bacteria and a 4.1-fold (95% CI: 1.2-14.1, p = 0.03) increase in risk of infection relapse after two DAIR procedures. Staphylococcal resistance to rifampicin is associated with inferior outcomes after DAIR. These findings suggest that DAIR may not be a useful strategy in early PJI caused by rifampicin-resistant staphylococci.
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Affiliation(s)
- Hannah K. Eriksson
- Department of Surgical Sciences, Section of Orthopaedics, Uppsala University, 751 83 Uppsala, Sweden; (S.L.); (N.P.H.)
| | - Stergios Lazarinis
- Department of Surgical Sciences, Section of Orthopaedics, Uppsala University, 751 83 Uppsala, Sweden; (S.L.); (N.P.H.)
| | - Josef D. Järhult
- Zoonosis Science Center, Department of Medical Sciences, Uppsala University, 751 83 Uppsala, Sweden;
| | - Nils P. Hailer
- Department of Surgical Sciences, Section of Orthopaedics, Uppsala University, 751 83 Uppsala, Sweden; (S.L.); (N.P.H.)
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2
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Wang C, Xu P, Li X, Zheng Y, Song Z. Research progress of stimulus-responsive antibacterial materials for bone infection. Front Bioeng Biotechnol 2022; 10:1069932. [PMID: 36636700 PMCID: PMC9831006 DOI: 10.3389/fbioe.2022.1069932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022] Open
Abstract
Infection is one of the most serious complications harmful to human health, which brings a huge burden to human health. Bone infection is one of the most common and serious complications of fracture and orthopaedic surgery. Antibacterial treatment is the premise of bone defect healing. Among all the antibacterial strategies, irritant antibacterial materials have unique advantages and the ability of targeted therapy. In this review, we focus on the research progress of irritating materials, the development of antibacterial materials and their advantages and disadvantages potential applications in bone infection.
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Affiliation(s)
| | | | | | - Yuhao Zheng
- *Correspondence: Zhiming Song, ; Yuhao Zheng,
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Berneking L, Haas M, Frielinghaus L, Berinson B, Lütgehetmann M, Christner M, Aepfelbacher M, Gerlach U, Seide K, Both A, Rohde H. Evaluation of a syndromic panel polymerase chain reaction (spPCR) assay for the diagnosis of device-associated bone and joint infections (BJI). Int J Infect Dis 2022; 116:283-288. [PMID: 35031396 DOI: 10.1016/j.ijid.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 01/05/2022] [Accepted: 01/05/2022] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Pathogen detection is crucial for diagnosis and targeted therapy in implant-associated bone and joint infections (BJI). Culture-based microbiology regularly fails to identify causative pathogens. This study evaluated the diagnostic accuracy and clinical usefulness of a syndromic panel polymerase chain reaction (spPCR) assay targeting common BJI pathogens in tissue specimens from patients with implant-associated BJI. METHODS Results obtained by spPCR assay and a 16S rDNA PCR were compared with results obtained from a standard of care (SOC) culture-based diagnostics, serving as a gold standard. In total, 126 specimens obtained from 73 patients were analyzed. RESULTS The spPCR assay correctly identified 33/40 culture-positive samples (82.5 %) and was positive in 9/86 (10.5 %) culture-negative samples, resulting in an overall sensitivity of 84.6 % (95% confidence interval [CI] 68.79-93.59%) and specificity of 89.35% (95% CI 80.6-94.81%). The spPCR was more sensitive compared with the 16S rDNA PCR (37.5%). The spPCR identified pathogens in 7/51 (13.7%) SOC-negative patients. Re-evaluation of spPCR results in clinical context suggested their clinical significance. CONCLUSION An spPCR assay targeting common pathogens causing implant-associated BJI may help to identify causative agents in culture-negative cases. As false-negative results are possible, spPCR assays appear as an add-on approach for pathogen detection in implant-associated BJI.
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Affiliation(s)
- Laura Berneking
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Michaela Haas
- Septische Unfallchirurgie und Orthopädie, BG Klinikum Hamburg, Hamburg, Germany
| | - Lisa Frielinghaus
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Berinson
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Marc Lütgehetmann
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Christner
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Aepfelbacher
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ulf Gerlach
- Septische Unfallchirurgie und Orthopädie, BG Klinikum Hamburg, Hamburg, Germany
| | - Klaus Seide
- Septische Unfallchirurgie und Orthopädie, BG Klinikum Hamburg, Hamburg, Germany
| | - Anna Both
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Holger Rohde
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
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Kuo YJ, Chen CH, Dash P, Lin YC, Hsu CW, Shih SJ, Chung RJ. Angiogenesis, Osseointegration, and Antibacterial Applications of Polyelectrolyte Multilayer Coatings Incorporated With Silver/Strontium Containing Mesoporous Bioactive Glass on 316L Stainless Steel. Front Bioeng Biotechnol 2022; 10:818137. [PMID: 35223788 PMCID: PMC8879691 DOI: 10.3389/fbioe.2022.818137] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/21/2022] [Indexed: 12/29/2022] Open
Abstract
The main causes for failure in implant surgery are prolonged exposure of implants or wound and tissue ischemia. Bacterial infection caused by the surrounding medical environment and equipment is also a major risk factor. The medical risk would be greatly reduced if we could develop an implant coating to guide tissue growth and promote antibacterial activity. Mesoporous bioactive glasses are mainly silicates with good osteoinductivity and have been used in medical dentistry and orthopedics for several decades. Strontium ions and silver ions could plausibly be incorporated into bioactive glass to achieve the required function. Strontium ions are trace elements in human bone that have been proposed to promote osseointegration and angiogenesis. Silver ions can cause bacterial apoptosis through surface charge imbalance after bonding to the cell membrane. In this study, functional polyelectrolyte multilayer (PEM) coatings were adhered to 316L stainless steel (SS) by spin coating. The multilayer film was composed of biocompatible and biodegradable collagen as a positively charged layer, γ-polyglutamic acid (γ-PGA) as a negatively charged layer. Chitosan was incorporated to the 11th positively charged layer as a stabilizing barrier. Spray pyrolysis prepared mesoporous bioactive glass incorporated with silver and strontium (AgSrMBG) was added to each negatively charged layer. The PEM/AgSrMBG coating was well hydrophilic with a contact angle of 37.09°, hardness of 0.29 ± 0.09 GPa, Young’s modulus of 5.35 ± 1.55 GPa, and roughness of 374.78 ± 22.27 nm, as observed through nano-indention and white light interferometry. The coating’s antibacterial activity was sustained for 1 month through the inhibition zone test, and was biocompatible with rat bone marrow mesenchymal stem cells (rBMSCs) and human umbilical vein endothelial cells (HUVECs), as observed in the MTT assay. There was more hydroxyapatite precipitation on the PEM/AgSrMBG surface after being soaked in simulated body fluid (SBF), as observed by scanning electron microscopy (SEM) and X-ray diffraction (XRD). In both in vitro and in vivo tests, the PEM/AgSrMBG coating promoted angiogenesis, osseointegration, and antibacterial activity due to the sustained release of silver and strontium ions.
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Affiliation(s)
- Yi-Jie Kuo
- Department of Orthopedic Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Orthopedic Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chia-Hsien Chen
- Department of Orthopedic Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Orthopedic Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
| | - Pranjyan Dash
- Department of Chemical Engineering and Biotechnology, National Taipei University of Technology (Taipei Tech), Taipei, Taiwan
| | - Yu-Chien Lin
- Department of Materials, Imperial College London, London, United Kingdom
| | - Chih-Wei Hsu
- Department of Chemical Engineering and Biotechnology, National Taipei University of Technology (Taipei Tech), Taipei, Taiwan
| | - Shao-Ju Shih
- Department of Materials Science and Engineering, National Taiwan University of Science and Technology, Taipei, Taiwan
| | - Ren-Jei Chung
- Department of Chemical Engineering and Biotechnology, National Taipei University of Technology (Taipei Tech), Taipei, Taiwan
- *Correspondence: Ren-Jei Chung,
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Factors associated with infection recurrence after two-stage exchange for periprosthetic hip infection. INTERNATIONAL ORTHOPAEDICS 2022; 46:953-961. [PMID: 35129644 DOI: 10.1007/s00264-022-05333-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Two-stage exchange is the treatment of choice for periprosthetic joint infection (PJI). Factors and outcomes associated with infection recurrence for hip PJI are limited. The primary aim of this study was to determine factors associated with infection recurrence after two-stage exchange. Secondary aims were survival, mobility, and the EuroQol five-dimension scale (EQ-5D-5L) health state. METHODS We retrospectively investigated patients with two-stage exchange for hip PJI at our institution from 2006 to 2017. Follow-up was conducted for a minimum of four years after the reimplantation. RESULTS We included 135 patients with 139 hip PJIs. The mean age of the patients was 69.6 years (range 32-88). The infection recurrence rate was 14.4% (n = 20) after a mean follow-up of 8.0 years (range 4.0-13.1). Four factors for recurrence were identified at the time of the first stage: previous orthopaedic diagnoses (p < 0.001), type of explanted prosthesis (p = 0.004), cultured microorganisms (p = 0.033), and sinus tract (p = 0.035). A longer surgical reimplantation time (p = 0.015) was the only one factor found at the second stage. The estimated Kaplan-Meier survival for the total sample was 9.0 years (95% confidence interval 8.3-9.8), without significant difference for those with infection recurrence compared to recurrence-free patients (log-rank 0.931). At the time of follow-up, 89 patients were alive. For these patients, Parker mobility score (p = 0.102), EuroQol five-dimensional scale (p = 0.099), and EQ Visual Analogue Scale (EQ-VAS) (p = 0.027) were inferior in those with infection recurrence, but significance was found only for VAS. CONCLUSION In this study with mid- to long-term follow-up, five factors for infection recurrence were identified. Recurrence did not affect survival, but health-related quality of life was inferior compared to recurrence-free patients. The results suggest that the period of the first stage including previous orthopaedic diagnoses requires more consideration in the future.
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Obesity, Comorbidities, and Prior Operations Additively Increase Failure in 2-Stage Revision Total Knee Arthroplasty for Prosthetic Joint Infection. J Arthroplasty 2022; 37:353-358. [PMID: 34619306 DOI: 10.1016/j.arth.2021.09.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/23/2021] [Accepted: 09/28/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Prosthetic joint infection (PJI) of the knee carries significant morbidity, mortality, and economic cost. We hypothesize that obese and poor medical hosts will have a significant and additive increase in failure rate undergoing 2-stage revision total knee arthroplasty for PJI. METHODS All 2-stage revision total knee arthroplasty procedures for PJI performed at one institution were identified between 2005 and 2020. In total, 144 patients were included and defined as success or failure based on published criteria regarding infection eradication, further intervention, or mortality. The American Society of Anesthesiologists score and the Charlson Comorbidity Index were utilized to assess host grade. Patient, surgical, and microbiologic variables were investigated with univariable and multivariable analysis to explore association with risk of failure. RESULTS In the cohort, 32.4% of patients failed with mean follow-up of 5.1 years. In multivariable analysis, the number of major operations requiring arthrotomy and implantation of new material between the primary and first stage, host grade, and elevated body mass index were the major contributors to failure. Combining these factors, with body mass index >30 and 2 or more major operations, the failure rate increased to 76.5% and 71.4% respectively for American Society of Anesthesiologists score 3 (P ≤ .001) and Charlson Comorbidity Index ≥2 (P ≤ .001). CONCLUSION In this cohort, multiple major operations between the primary and first stage, host grade, and obesity were the major contributors to failure. When combining these factors, patients had an additive increase in failure rate. Treatments such as amputation or less invasive options and suppression should be discussed and considered in these patients.
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7
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Wang Q, Vachon J, Prasad B, Pybus CA, Lapin N, Chopra R, Greenberg DE. Alternating magnetic fields and antibiotics eradicate biofilm on metal in a synergistic fashion. NPJ Biofilms Microbiomes 2021; 7:68. [PMID: 34385452 PMCID: PMC8360946 DOI: 10.1038/s41522-021-00239-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/16/2021] [Indexed: 12/13/2022] Open
Abstract
Hundreds of thousands of human implant procedures require surgical revision each year due to infection. Infections are difficult to treat with conventional antibiotics due to the formation of biofilm on the implant surface. We have developed a noninvasive method to eliminate biofilm on metal implants using heat generated by intermittent alternating magnetic fields (iAMF). Here, we demonstrate that heat and antibiotics are synergistic in biofilm elimination. For Pseudomonas aeruginosa biofilm, bacterial burden was reduced >3 log with iAMF and ciprofloxacin after 24 h compared with either treatment alone (p < 0.0001). This effect was not limited by pathogen or antibiotic as similar biofilm reductions were seen with iAMF and either linezolid or ceftriaxone in Staphylococcus aureus. iAMF and antibiotic efficacy was seen across various iAMF settings, including different iAMF target temperatures, dose durations, and dosing intervals. Initial mechanistic studies revealed membrane disruption as one factor important for AMF enhanced antibacterial activity in the biofilm setting. This study demonstrates the potential of utilizing a noninvasive approach to reduce biofilm off of metallic implants.
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Affiliation(s)
- Qi Wang
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Jonathan Vachon
- Medical School, UT Southwestern Medical Center, Dallas, TX, USA
| | - Bibin Prasad
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Christine A Pybus
- Department of Internal Medicine, Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Norman Lapin
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Rajiv Chopra
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
- Advanced Imaging Research Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - David E Greenberg
- Department of Internal Medicine, Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
- Department of Microbiology, UT Southwestern Medical Center, Dallas, TX, USA.
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Jensen LK. Implant-associated osteomyelitis: Development, characterisation, and application of a porcine model. APMIS 2021; 129 Suppl 141:1-44. [PMID: 34129250 DOI: 10.1111/apm.13125] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Louise Kruse Jensen
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
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Gaillard-Campbell D, Gross TP, Webb L. Antibiotic Delivery via Hickman Catheter for the Treatment of Prosthetic Joint Infection. Orthopedics 2021; 44:e395-e401. [PMID: 34039203 DOI: 10.3928/01477447-20210414-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Infection rates for total joint arthroplasty range from 1% to 2%, and infection carries significant risk. The traditional course of treatment is irrigation and debridement, but historically, success rates have been variable. The goals of this study were to evaluate the safety and efficacy of Hickman catheterization in the treatment of prosthetic joint infection and to assess its value as an alternative to irrigation and debridement. The authors retrospectively analyzed 26 Hickman catheterizations in the treatment of acute early, acute late, and chronic late infections of primary and revision hip and knee arthroplasty. Initial arthroplasty procedures were performed between 2006 and 2018, with all cases followed for a minimum of 1 year postoperatively. The authors evaluated surgical data, clinical outcomes, and success rates, and they compared their success rates with reported values for cases treated with irrigation and debridement. The authors' success rate was 100% for acute early hip infection, 100% for chronic knee infection, and 80.0% for chronic hip infection. They reported a 75.0% success rate in the treatment of acute late infection for hip arthroplasty and a rate of 62.5% for knee arthroplasty. Postoperative clinical outcomes were significantly improved for both hips and knees for all infection types. The success rates for the treatment of acute early prosthetic joint infection and chronic late prosthetic knee infection were superior to available reported rates on irrigation and debridement. The authors also reported the highest success rate for the treatment of acute late infection. The current data suggest that Hickman catheterization is a promising safe and effective alternative to irrigation and debridement for the treatment of prosthetic joint infection. [Orthopedics. 2021;44(3):e395-e401.].
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Tasse J, Dieppois G, Peyrane F, Tesse N. Improving the ability of antimicrobial susceptibility tests to predict clinical outcome accurately: Adding metabolic evasion to the equation. Drug Discov Today 2021; 26:2182-2189. [PMID: 34119667 DOI: 10.1016/j.drudis.2021.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/09/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023]
Abstract
Antimicrobial susceptibility tests (AST) are based on the minimal inhibitory concentration (MIC), the method used worldwide to guide antimicrobial therapy. Despite its relevance in correctly predicting clinical outcome for most acute infections, this approach is misleading for multiple clinical cases in which pathogens do not grow rapidly, uniformly or with physical protection. This behaviour, named 'metabolic evasion' (ME), enables bacteria to survive antimicrobials. ME can result from different, and sometimes combined, bacterial mechanisms such as biofilms, intracellular growth, persisters or dormancy. We discuss how ME can influence the MIC-based probability of target attainment. We identify clinical cases in which this approach is undermined by ME and propose a new approach that takes ME into account in order to improve patient management and the evaluation of innovative drugs.
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Affiliation(s)
- Jason Tasse
- BTF-E Group, BEAM Alliance, Le Dorian Bât B1 C/O Da Volterra, 172 Rue de Charonne, 75011 Paris, France; Biofilm Pharma, 307 Avenue Jean Jaurès, 69007 Lyon, France
| | - Guennaëlle Dieppois
- BTF-E Group, BEAM Alliance, Le Dorian Bât B1 C/O Da Volterra, 172 Rue de Charonne, 75011 Paris, France; Debiopharm, Chemin Messidor 5-7, Case postale 5911, 1002 Lausanne, Switzerland
| | - Frédéric Peyrane
- BTF-E Group, BEAM Alliance, Le Dorian Bât B1 C/O Da Volterra, 172 Rue de Charonne, 75011 Paris, France
| | - Nicolas Tesse
- BTF-E Group, BEAM Alliance, Le Dorian Bât B1 C/O Da Volterra, 172 Rue de Charonne, 75011 Paris, France; Septeos, 12 Avenue de la Grande Armée, 75017 Paris, France.
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Trends of Prosthetic Joint Infection Organisms and Recurrence for a Single High-Volume Arthroplasty Surgeon Over 20 Years. J Arthroplasty 2021; 36:1101-1108. [PMID: 33160807 DOI: 10.1016/j.arth.2020.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 09/11/2020] [Accepted: 10/04/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Prosthetic joint infection (PJI) is a morbid complication following total joint arthroplasty (TJA). PJI diagnosis and treatment has changed over time, and patient co-management with a high-volume musculoskeletal infectious disease (MSK ID) specialist has been implemented at our institution in the last decade. METHODS We retrospectively evaluated all consecutive TJA patients treated for PJI between 1995 and 2018 by a single high-volume revision TJA surgeon. Microbial identities, antibiotic resistance, prior PJI, and MSK ID consultation were investigated. RESULTS In total, 261 PJI patients (median age 66 years, interquartile range 57-75) were treated. One-year and 5-year reinfection rates were 15.8% (95% confidence interval [CI] 11.6-20.7) and 22.1% (95% CI 17.0-27.7), respectively. Microbial identities and antibiotic resistances did not change significantly over time. Despite seeing more prior PJI patients (53.3% vs 37.6%, P = .012), MSK ID-managed patients had similar infection rates as non-MSK ID-managed patients (hazard ratio [HR] 1.02, 95% CI 0.6-1.75, P = .93). Prior PJI was associated with higher reinfection risk (HR 2.39, 95% CI 1.39-4.12, P = .002) overall and in patients without MSK ID consultation, specifically (HR 2.78, 95% CI 1.37-5.65, P = .005). This risk was somewhat lower and did not reach significance in prior PJI patients with MSK ID consultation (HR 1.97, 95% CI 0.87-4.48, P = .106). CONCLUSION We noted minimal differences in microbial/antibiotic resistances for PJI over 20 years in a single institution, suggesting current standards of PJI treatment remain encouragingly valid in most cases. MSK ID involvement was not associated with lower reinfection risk overall; however, in patients with prior PJI, the risk of reinfection appeared to be somewhat lower with MSK ID involvement. LEVEL OF EVIDENCE Level IV-Case Series.
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12
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Van Belleghem JD, Manasherob R, Miȩdzybrodzki R, Rogóż P, Górski A, Suh GA, Bollyky PL, Amanatullah DF. The Rationale for Using Bacteriophage to Treat and Prevent Periprosthetic Joint Infections. Front Microbiol 2020; 11:591021. [PMID: 33408703 PMCID: PMC7779626 DOI: 10.3389/fmicb.2020.591021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/24/2020] [Indexed: 12/19/2022] Open
Abstract
Prosthetic joint infection (PJI) is a devastating complication after a joint replacement. PJI and its treatment have a high monetary cost, morbidity, and mortality. The lack of success treating PJI with conventional antibiotics alone is related to the presence of bacterial biofilm on medical implants. Consequently, surgical removal of the implant and prolonged intravenous antibiotics to eradicate the infection are necessary prior to re-implanting a new prosthetic joint. Growing clinical data shows that bacterial predators, called bacteriophages (phages), could be an alternative treatment strategy or prophylactic approach for PJI. Phages could further be exploited to degrade biofilms, making bacteria more susceptible to antibiotics and enabling potential combinatorial therapies. Emerging research suggests that phages may also directly interact with the innate immune response. Phage therapy may play an important, and currently understudied, role in the clearance of PJI, and has the potential to treat thousands of patients who would either have to undergo revision surgery to attempt to clear an infections, take antibiotics for a prolonged period to try and suppress the re-emerging infection, or potentially risk losing a limb.
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Affiliation(s)
- Jonas D. Van Belleghem
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Robert Manasherob
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, United States
| | - Ryszard Miȩdzybrodzki
- Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wrocław, Poland
| | - Paweł Rogóż
- Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wrocław, Poland
| | - Andrzej Górski
- Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wrocław, Poland
| | | | - Paul L. Bollyky
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Derek F. Amanatullah
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, United States
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Sahukhal GS, Tucci M, Benghuzzi H, Wilson G, Elasri MO. The role of the msaABCR operon in implant-associated chronic osteomyelitis in Staphylococcus aureus USA300 LAC. BMC Microbiol 2020; 20:324. [PMID: 33109085 PMCID: PMC7590495 DOI: 10.1186/s12866-020-01964-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 09/02/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The msaABCR operon regulates several staphylococcal phenotypes such as biofilm formation, capsule production, protease production, pigmentation, antibiotic resistance, and persister cells formation. The msaABCR operon is required for maintaining the cell wall integrity via affecting peptidoglycan cross-linking. The msaABCR operon also plays a role in oxidative stress defense mechanism, which is required to facilitate persistent and recurrent staphylococcal infections. Staphylococcus aureus is the most frequent cause of chronic implant-associated osteomyelitis (OM). The CA-MRSA USA300 strains are predominant in the United States and cause severe infections, including bone and joint infections. RESULTS The USA300 LAC strain caused significant bone damage, as evidenced by the presence of severe bone necrosis with multiple foci of sequestra and large numbers of multinucleated osteoclasts. Intraosseous survival and biofilm formation on the K-wires by USA300 LAC strains was pronounced. However, the msaABCR deletion mutant was attenuated. We observed minimal bone necrosis, with no evidence of intramedullary abscess and/or fibrosis, along reduced intraosseous bacterial population and significantly less biofilm formation on the K-wires by the msaABCR mutant. microCT analysis of infected bone showed significant bone loss and damage in the USA300 LAC and complemented strain, whereas the msaABCR mutant's effect was reduced. In addition, we observed increased osteoblasts response and new bone formation around the K-wires in the bone infected by the msaABCR mutant. Whole-cell proteomics analysis of msaABCR mutant cells showed significant downregulation of proteins, cell adhesion factors, and virulence factors that interact with osteoblasts and are associated with chronic OM caused by S. aureus. CONCLUSION This study showed that deletion of msaABCR operon in USA300 LAC strain lead to defective biofilm in K-wire implants, decreased intraosseous survival, and reduced cortical bone destruction. Thus, msaABCR plays a role in implant-associated chronic osteomyelitis by regulating extracellular proteases, cell adhesions factors and virulence factors. However additional studies are required to further define the contribution of msaABCR-regulated molecules in osteomyelitis pathogenesis.
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Affiliation(s)
- Gyan S Sahukhal
- Present Address: Center for Molecular and Cellular Biosciences, The University of Southern Mississippi, 118 College Drive # 5018, Hattiesburg, MS, 39406, USA.
| | - Michelle Tucci
- Department of Orthopaedics, University of Mississippi Medical Center, Jackson, MS, USA
| | - Hamed Benghuzzi
- Department of Orthopaedics, University of Mississippi Medical Center, Jackson, MS, USA
| | - Gerri Wilson
- Department of Orthopaedics, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mohamed O Elasri
- Present Address: Center for Molecular and Cellular Biosciences, The University of Southern Mississippi, 118 College Drive # 5018, Hattiesburg, MS, 39406, USA
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Aspirin administration might accelerate the subsidence of periprosthetic joint infection. Sci Rep 2020; 10:15967. [PMID: 32994449 PMCID: PMC7524723 DOI: 10.1038/s41598-020-72731-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 09/02/2020] [Indexed: 01/22/2023] Open
Abstract
Since the past decade, aspirin, a popular anti-inflammatory drug, has been increasingly studied for its potential antimicrobial and antibiofilm activity with promising results, but studies were limited to in vitro and in vivo investigations. Moreover, evidence concerning the beneficial effects of aspirin on the treatment of biofilm-related infections in real-world population is limited. Thus, this study aimed to investigate whether aspirin could promote infection control for patients with periprosthetic joint infections (PJIs). A single-center database was searched. Regular aspirin exposure was defined as a prescription of aspirin for > 6 months before diagnosis of PJIs and consecutive use during the PJI treatment course at a dose ≧ 100 mg/day. General data, treatment modalities, and recurrence status were collected from medical records by an independent orthopedic surgeon. From January 01, 2010, to February 17, 2019, 88 patients who met the PJI criteria were identified and included in this study. Of these patients, 12 were taking aspirin regularly during the infectious events. In the Cox proportional hazards model, multivariate analysis revealed that the aspirin group demonstrated significant benefit via superior resolution of PJIs (HR 2.200; 95% CI 1.018-4.757; p = 0.045). In this study, aspirin is beneficial for infection resolution when combined with the current standard of PJI treatment and conventional antibiotics in the management of PJIs.
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15
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Yen HT, Hsieh RW, Huang CY, Hsu TC, Yeh T, Chen YC, Chen WS, Lee CC. Short-course versus long-course antibiotics in prosthetic joint infections: a systematic review and meta-analysis of one randomized controlled trial plus nine observational studies. J Antimicrob Chemother 2020; 74:2507-2516. [PMID: 31050758 DOI: 10.1093/jac/dkz166] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 03/19/2019] [Accepted: 03/26/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Prosthetic joint infections (PJIs) often require long-course antibiotic therapy. However, recent studies argue against the current practice and raise concerns such as the development of antibiotic resistance, side effects of medications and medical costs. OBJECTIVES To review and compare the outcomes of short-course and long-course antibiotics in PJIs. METHODS We conducted a systemic review and meta-analysis using a predefined search term in PubMed and EMBASE databases. Studies that met the inclusion criteria from inception to June 2018 were included. The quality of the included studies was assessed. RESULTS A total of 10 articles and 856 patients were analysed, comprising 9 observational studies and 1 randomized controlled trial. Our meta-analysis showed no significant difference between short-course and long-course antibiotics (relative risk = 0.87, 95% CI = 0.62-1.22). Additionally, the older the studied group was, the more short-course antibiotics were favoured. CONCLUSIONS When treating PJI patients following debridement, antibiotics and implant retention, an 8 week course of antibiotic therapy for total hip arthroplasty and a 75 day course for total knee arthroplasty may be a safe approach. For two-stage exchange, a shorter duration of antibiotic treatment during implant-free periods is also generally safe with the usage of antibiotic-loaded cement spacers.
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Affiliation(s)
- Hung-Teng Yen
- School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ronan W Hsieh
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Chung-Yen Huang
- School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Tzu-Chun Hsu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Timothy Yeh
- Department of Molecular and Cellular Biology, University of California, Davis, CA, USA
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Shan Chen
- Department of Dermatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
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16
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Lüthje FL, Jensen LK, Jensen HE, Skovgaard K. The inflammatory response to bone infection - a review based on animal models and human patients. APMIS 2020; 128:275-286. [PMID: 31976582 DOI: 10.1111/apm.13027] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 01/14/2020] [Indexed: 12/17/2022]
Abstract
Bone infections are difficult to diagnose and treat, especially when a prosthetic joint replacement or implant is involved. Bone loss is a major complication of osteomyelitis, but the mechanism behind has mainly been investigated in cell cultures and has not been confirmed in human settings. Inflammation is important in initiating an appropriate immune response to invading pathogens. However, many of the signaling molecules used by the immune system can also modulate bone remodeling and contribute to bone resorption during osteomyelitis. Our current knowledge of the inflammatory response relies heavily on animal models as research based on human samples is scarce. Staphylococcus aureus is one of the most common causes of bone infections and is the pathogen of choice in animal models. The regulation of inflammatory genes during prosthetic joint infections and implant-associated osteomyelitis has only been studied in rodent models. It is important to consider the validity of an animal model when results are extrapolated to humans, and both bone composition and the immune system of pigs has been shown to be more similar to humans, than to rodents. Here in vivo studies on the inflammatory response to prosthetic joint infections and implant-associated osteomyelitis are reviewed.
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Affiliation(s)
- Freja Lea Lüthje
- Department of Veterinary and Animal Science, University of Copenhagen, Frederiksberg C, Denmark.,Department of Biotechnology and Biomedicine, Technical University of Denmark, Lyngby, Denmark
| | - Louise Kruse Jensen
- Department of Veterinary and Animal Science, University of Copenhagen, Frederiksberg C, Denmark
| | - Henrik Elvang Jensen
- Department of Veterinary and Animal Science, University of Copenhagen, Frederiksberg C, Denmark
| | - Kerstin Skovgaard
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Lyngby, Denmark
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Seebach E, Kubatzky KF. Chronic Implant-Related Bone Infections-Can Immune Modulation be a Therapeutic Strategy? Front Immunol 2019; 10:1724. [PMID: 31396229 PMCID: PMC6664079 DOI: 10.3389/fimmu.2019.01724] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 07/09/2019] [Indexed: 12/14/2022] Open
Abstract
Chronic implant-related bone infections are a major problem in orthopedic and trauma-related surgery with severe consequences for the affected patients. As antibiotic resistance increases in general and because most antibiotics have poor effectiveness against biofilm-embedded bacteria in particular, there is a need for alternative and innovative treatment approaches. Recently, the immune system has moved into focus as the key player in infection defense and bone homeostasis, and the targeted modulation of the host response is becoming an emerging field of interest. The aim of this review was to summarize the current knowledge of impaired endogenous defense mechanisms that are unable to prevent chronicity of bone infections associated with a prosthetic or osteosynthetic device. The presence of foreign material adversely affects the immune system by generating a local immune-compromised environment where spontaneous clearance of planktonic bacteria does not take place. Furthermore, the surface structure of the implant facilitates the transition of bacteria from the planktonic to the biofilm stage. Biofilm formation on the implant surface is closely linked to the development of a chronic infection, and a misled adaption of the immune system makes it impossible to effectively eliminate biofilm infections. The interaction between the immune system and bone cells, especially osteoclasts, is extensively studied in the field of osteoimmunology and this crosstalk further aggravates the course of bone infection by shifting bone homeostasis in favor of bone resorption. T cells play a major role in various chronic diseases and in this review a special focus was therefore set on what is known about an ineffective T cell response. Myeloid-derived suppressor cells (MDSCs), anti-inflammatory macrophages, regulatory T cells (Tregs) as well as osteoclasts all suppress immune defense mechanisms and negatively regulate T cell-mediated immunity. Thus, these cells are considered to be potential targets for immune therapy. The success of immune checkpoint inhibition in cancer treatment encourages the transfer of such immunological approaches into treatment strategies of other chronic diseases. Here, we discuss whether immune modulation can be a therapeutic tool for the treatment of chronic implant-related bone infections.
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Affiliation(s)
- Elisabeth Seebach
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Heidelberg, Germany
| | - Katharina F Kubatzky
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Heidelberg, Germany
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18
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Zhu M, Rahardja R, Munro J, Coleman B, Young SW. Wound closure and follow-up after total knee arthroplasty - Do they affect the rate of antibiotic prescription? Knee 2019; 26:700-707. [PMID: 30904322 DOI: 10.1016/j.knee.2019.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 01/21/2019] [Accepted: 01/27/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND This study aimed to evaluate risk factors for oral antibiotic prescription in the first six weeks after primary TKA, particularly whether the wound closure method (staples or sutures) and two-week follow-up clinician (surgeon or general practitioner (GP)) altered antibiotic use. METHODS Four thousand eight hundred forty-six TKAs from January 2013 to December 2016 at three tertiary hospitals in Auckland, New Zealand were analysed by manual review of patient electronic records and a national prescription database. Surgeon preference dictates the method of wound closure and whether wound review is followed up by the operating surgeon or by the patient's GP. Univariate and multivariate analysis was carried out to identify significant patient and surgical risk factors for oral antibiotic prescribing. RESULTS Oral antibiotics were prescribed in 24% of patients following primary TKA. Twenty-six percent of patients closed with staples were prescribed oral antibiotics versus 19% with sutures (adjusted OR = 1.4, p < 0.004). Excluding re-presentations and readmissions, GPs prescribed oral antibiotics in 22% of patients compared to seven percent of patients seen by surgeons (adjusted OR = 2.8, p < 0.001). Other risk factors for antibiotic prescription included increasing age, BMI and ASA score. CONCLUSION Oral antibiotic prescribing rates are higher if the wound was closed with staples and if a GP performed the two-week follow-up. Improved communication between surgeons and GPs are required to ensure adequate follow-up following TKA and appropriate oral antibiotic use.
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Affiliation(s)
- Mark Zhu
- University of Auckland, Auckland, New Zealand; Department of Orthopaedic Surgery, Auckland Hospital, Auckland, New Zealand.
| | | | - Jacob Munro
- Department of Orthopaedic Surgery, Auckland Hospital, Auckland, New Zealand
| | - Brendan Coleman
- Department of Orthopaedic Surgery, Middlemore Hospital, Auckland, New Zealand
| | - Simon W Young
- University of Auckland, Auckland, New Zealand; Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
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19
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Benito N, Mur I, Ribera A, Soriano A, Rodríguez-Pardo D, Sorlí L, Cobo J, Fernández-Sampedro M, Del Toro MD, Guío L, Praena J, Bahamonde A, Riera M, Esteban J, Baraia-Etxaburu JM, Martínez-Alvarez J, Jover-Sáenz A, Dueñas C, Ramos A, Sobrino B, Euba G, Morata L, Pigrau C, Horcajada JP, Coll P, Crusi X, Ariza J. The Different Microbial Etiology of Prosthetic Joint Infections according to Route of Acquisition and Time after Prosthesis Implantation, Including the Role of Multidrug-Resistant Organisms. J Clin Med 2019; 8:jcm8050673. [PMID: 31086080 PMCID: PMC6572185 DOI: 10.3390/jcm8050673] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/06/2019] [Accepted: 05/09/2019] [Indexed: 02/05/2023] Open
Abstract
The aim of our study was to characterize the etiology of prosthetic joint infections (PJIs)-including multidrug-resistant organisms (MDRO)-by category of infection. A multicenter study of 2544 patients with PJIs was performed. We analyzed the causative microorganisms according to the Tsukayama's scheme (early postoperative, late chronic, and acute hematogenous infections (EPI, LCI, AHI) and "positive intraoperative cultures" (PIC)). Non-hematogenous PJIs were also evaluated according to time since surgery: <1 month, 2-3 months, 4-12 months, >12 months. AHIs were mostly caused by Staphylococcus aureus (39.2%) and streptococci (30.2%). EPIs were characterized by a preponderance of virulent microorganisms (S. aureus, Gram-negative bacilli (GNB), enterococci), MDROs (24%) and polymicrobial infections (27.4%). Conversely, coagulase-negative staphylococci (CoNS) and Cutibacterium species were predominant in LCIs (54.5% and 6.1%, respectively) and PICs (57.1% and 15.1%). The percentage of MDROs isolated in EPIs was more than three times the percentage isolated in LCIs (7.8%) and more than twice the proportion found in AHI (10.9%). There was a significant decreasing linear trend over the four time intervals post-surgery for virulent microorganisms, MDROs, and polymicrobial infections, and a rising trend for CoNS, streptococci and Cutibacterium spp. The observed differences have important implications for the empirical antimicrobial treatment of PJIs.
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Affiliation(s)
- Natividad Benito
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau - Institut d'Investigació Biomèdica Sant Pau, 08025 Barcelona, Spain.
- Department of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain.
| | - Isabel Mur
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau - Institut d'Investigació Biomèdica Sant Pau, 08025 Barcelona, Spain.
- Department of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain.
| | - Alba Ribera
- Department of Infectious Diseases, Hospital Universitari Bellvitge, 08097 Barcelona, Spain.
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clínic Universitari, 08036 Barcelona, Spain.
| | - Dolors Rodríguez-Pardo
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain.
| | - Luisa Sorlí
- Department of Infectious Diseases, Parc de Salut Mar, 08003 Barcelona, Spain.
| | - Javier Cobo
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal ⁻ IRYCIS, 28034 Madrid, Spain.
| | | | - María Dolores Del Toro
- Department of Infectious Diseases, Clinical Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain.
| | - Laura Guío
- Department of Infectious Diseases, Hospital Universitario Cruces, 48903 Bilbao, Spain.
| | - Julia Praena
- Department of Infectious Diseases, Clinical Microbiology and Preventive Medicine, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain.
| | - Alberto Bahamonde
- Department of Internal Medicine-Infectious Diseases, Hospital Universitario del Bierzo, 24404 León, Spain.
| | - Melchor Riera
- Infectious Diseases Unit, Department of Internal Medicine, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain.
| | - Jaime Esteban
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, 28040 Madrid, Spain.
| | | | - Jesús Martínez-Alvarez
- Department of Orthopedic and Traumatology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain.
| | - Alfredo Jover-Sáenz
- Unit of Nosocomial Infection, Hospital Universitari Arnau de Vilanova, 25198 Lleida, Spain.
| | - Carlos Dueñas
- Department of Internal Medicine, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain.
| | - Antonio Ramos
- Infectious Diseases Unit, Department of Internal Medicine, Hospital Universitario Puerta de Hierro, 28222 Madrid, Spain.
| | - Beatriz Sobrino
- Department of Infectious Diseases, Hospital Regional Universitario Málaga, 29010 Málaga, Spain.
| | - Gorane Euba
- Department of Infectious Diseases, Hospital Universitari Bellvitge, 08097 Barcelona, Spain.
| | - Laura Morata
- Department of Infectious Diseases, Hospital Clínic Universitari, 08036 Barcelona, Spain.
| | - Carles Pigrau
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain.
| | - Juan P Horcajada
- Department of Infectious Diseases, Parc de Salut Mar, 08003 Barcelona, Spain.
| | - Pere Coll
- Department of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain.
- Department of Clinical Microbiology, Hospital de la Santa Creu i Sant Pau - Institut d'Investigació Biomèdica Sant Pau, 08025 Barcelona, Spain.
| | - Xavier Crusi
- Department of Orthopedic and Traumatology, Hospital de la Santa Creu i Sant Pau - Institut d'Investigació Biomèdica Sant Pau, 08025 Barcelona, Spain.
| | - Javier Ariza
- Department of Infectious Diseases, Hospital Universitari Bellvitge, 08097 Barcelona, Spain.
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- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau - Institut d'Investigació Biomèdica Sant Pau, 08025 Barcelona, Spain.
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20
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Trombetta RP, Ninomiya MJ, El-Atawneh IM, Knapp EK, de Mesy Bentley KL, Dunman PM, Schwarz EM, Kates SL, Awad HA. Calcium Phosphate Spacers for the Local Delivery of Sitafloxacin and Rifampin to Treat Orthopedic Infections: Efficacy and Proof of Concept in a Mouse Model of Single-Stage Revision of Device-Associated Osteomyelitis. Pharmaceutics 2019; 11:E94. [PMID: 30813284 PMCID: PMC6410209 DOI: 10.3390/pharmaceutics11020094] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/12/2019] [Accepted: 02/17/2019] [Indexed: 12/15/2022] Open
Abstract
Osteomyelitis is a chronic bone infection that is often treated with adjuvant antibiotic-impregnated poly(methyl methacrylate) (PMMA) cement spacers in multi-staged revisions. However, failure rates remain substantial due to recurrence of infection, which is attributed to the poor performance of the PMMA cement as a drug release device. Hence, the objective of this study was to design and evaluate a bioresorbable calcium phosphate scaffold (CaPS) for sustained antimicrobial drug release and investigate its efficacy in a murine model of femoral implant-associated osteomyelitis. Incorporating rifampin and sitafloxacin, which are effective against bacterial phenotypes responsible for bacterial persistence, into 3D-printed CaPS coated with poly(lactic co-glycolic) acid, achieved controlled release for up to two weeks. Implantation into the murine infection model resulted in decreased bacterial colonization rates at 3- and 10-weeks post-revision for the 3D printed CaPS in comparison to gentamicin-laden PMMA. Furthermore, a significant increase in bone formation was observed for 3D printed CaPS incorporated with rifampin at 3 and 10 weeks. The results of this study demonstrate that osteoconductive 3D printed CaPS incorporated with antimicrobials demonstrate more efficacious bacterial colonization outcomes and bone growth in a single-stage revision in comparison to gentamicin-laden PMMA requiring a two-stage revision.
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Affiliation(s)
- Ryan P Trombetta
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14642, USA.
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY 14642, USA.
| | - Mark J Ninomiya
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY 14642, USA.
- Department of Microbiology and Immunology, University of Rochester, Rochester, NY 14642, USA.
| | - Ihab M El-Atawneh
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14642, USA.
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY 14642, USA.
| | - Emma K Knapp
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY 14642, USA.
- Department of Orthopedics, University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Karen L de Mesy Bentley
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY 14642, USA.
- Department of Pathology & Laboratory Medicine, University of Rochester, Rochester, NY 14642, USA.
- Department of Orthopedics, University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Paul M Dunman
- Department of Microbiology and Immunology, University of Rochester, Rochester, NY 14642, USA.
| | - Edward M Schwarz
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14642, USA.
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY 14642, USA.
- Department of Pathology & Laboratory Medicine, University of Rochester, Rochester, NY 14642, USA.
- Department of Orthopedics, University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Stephen L Kates
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY 14642, USA.
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA 0153, USA.
| | - Hani A Awad
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14642, USA.
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY 14642, USA.
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Bargon R, Bruenke J, Carli A, Fabritius M, Goel R, Goswami K, Graf P, Groff H, Grupp T, Malchau H, Mohaddes M, Novaes de Santana C, Phillips KS, Rohde H, Rolfson O, Rondon A, Schaer T, Sculco P, Svensson K. General Assembly, Research Caveats: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S245-S253.e1. [PMID: 30348560 DOI: 10.1016/j.arth.2018.09.076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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22
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Kheir MM, Tan TL, George J, Higuera CA, Maltenfort MG, Parvizi J. Development and Evaluation of a Prognostic Calculator for the Surgical Treatment of Periprosthetic Joint Infection. J Arthroplasty 2018; 33:2986-2992.e1. [PMID: 29885971 DOI: 10.1016/j.arth.2018.04.034] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Preoperative identification of patients at risk of failing surgical treatment for periprosthetic joint infection (PJI) is imperative to allow medical optimization and targeted prevention. The purpose of this study was to create a preoperative prognostic calculator for PJI treatment by assessing a patient's individual risk for treatment failure based on many preoperative variables. METHODS A retrospective review was performed of 1438 PJIs, treated at 2 institutions from 2000 to 2014. Minimum follow-up was 1 year. A total of 63 risk factors, including patient characteristics, microbiology data, and surgical variables were evaluated using logistic regression, in which coefficients were scaled to produce weighted scores. RESULTS The 10 significant risk factors for PJI treatment failure were in descending order of relative weight: irrigation and debridement (30 points), history of myocardial infarction (15 points), revision surgery (11 points), presence of sinus tract (10 points), resistant organisms (9 points), ever smoker (6 points), prior surgery (2.86 points per prior operation), synovial white blood cell count (8.3 × natural log of cell count), body mass index (0.66 per increment), and erythrocyte sedimentation rate (depends on both smoking and 2 stage, as these are higher order interaction factors). The area under the curve for this risk model was 0.6904 (95% confidence interval: 0.6476-0.7331). CONCLUSION In this large cohort study, we were able to identify risk factors and their relative weight for predicting PJI treatment failure. Some of the identified factors are indeed modifiable and should be addressed before treating a patient for PJI.
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Affiliation(s)
- Michael M Kheir
- Department of Orthpaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Timothy L Tan
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jaiben George
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Javad Parvizi
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
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Fagotti L, Tatka J, Salles MJC, Queiroz MC. Risk Factors and Treatment Options for Failure of a Two-Stage Exchange. Curr Rev Musculoskelet Med 2018; 11:420-427. [PMID: 29934884 PMCID: PMC6105486 DOI: 10.1007/s12178-018-9504-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Although a two-stage exchange revision is reported to have a high success rate, this strategy may fail as a treatment for prosthetic joint infection (PJI). When it does, resection arthroplasty, arthrodesis, amputation, and chronic antibiotic suppression may play a role. The purpose of this review is to determine which are the main risk factors for a two-stage exchange failure and to analyze the indications and results of resection arthroplasty, arthrodesis, amputation, and antibiotic chronic suppression for PJI. RECENT FINDINGS Recent literature demonstrates that the main risk factors for a two-stage exchange failure are as follows: hemodialysis, obesity, multiple previous procedures, diabetes mellitus, corticosteroid therapy, hypoalbuminemia, immunosuppression, rheumatological conditions, coagulation disorders, and infection due to multidrug-resistant (MDR) bacteria or fungal species. Regarding microorganisms, besides Staphylococcus aureus, Streptococcus spp., Enterobacteriaceae species such as Klebsiella pneumoniae and Enterobacter sp., Pseudomonas aeruginosa, or Acinetobacter baumannii, and fungus including Candida sp. are also considered risk factors for a two-stage exchange failure. Resection arthroplasty, arthrodesis, and amputation have a limited role. Chronic suppression is an option for high-risk patients or unfeasible reconstruction. In summary, we report the main risk factors for a two-stage exchange failure and alternative procedures when it occurs. Future research on patient-specific risk factors for a two-stage exchange may aid surgical decision-making and optimization of outcomes.
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Affiliation(s)
| | - Jakub Tatka
- Steadman Philippon Research Institute, Vail, CO, USA
| | - Mauro Jose Costa Salles
- Division of Infectious Diseases, Department of Internal Medicine, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Marcelo C Queiroz
- Department of Orthopaedic Surgery, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil.
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24
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Kasina P, Enocson A, Lindgren V, Lapidus LJ. Patient claims in prosthetic hip infections: a comparison of nationwide incidence in Sweden and patient insurance data. Acta Orthop 2018; 89:394-398. [PMID: 29808747 PMCID: PMC6066767 DOI: 10.1080/17453674.2018.1477708] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Patients in Sweden are insured against avoidable patient injuries. Prosthetic joint infections (PJIs) resulting from intraoperative contamination are regarded as compensable by the Swedish public insurance system. According to the Patient Injury Act, healthcare personnel must inform patients about any injury resulting from treatment and the possibility of filing a claim. To analyze any under-reporting of claims and their outcome, we investigated patients' claims of PJI in a nationwide setting Patients and methods - The national cohort of PJI after primary total hip replacement, initially operated between 2005 and 2008, was established through cross-matching of registers and review of individual medical records. We analyzed 441 PJIs and the number of filed patients' claims, with regards to incidence, outcome, and any national, sex-linked or socioeconomic differences. Results - We identified 329/441 (75%) patients with PJIs as non-claimants. 96% of the filed claims were accepted. 64 (57%) of claimants sustained permanent disability. 2 factors were found to statistically significantly reduce the odds of filing claims: patient's age above 73 years and fracture as indication for surgery. There were no significant national, sex-linked, or socioeconomic differences. Interpretation - The incidence of patients' claims of PJI is low but claims are usually accepted when filed. Healthcare personnel should increase their knowledge of the Patient Injury Act to inform patients about possibilities of eligible compensation.
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Affiliation(s)
- Piotr Kasina
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm;; ,Correspondence:
| | - Anders Enocson
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm;; ,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Viktor Lindgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Lasse J Lapidus
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm;;
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25
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Bue M, Hanberg P, Koch J, Jensen LK, Lundorff M, Aalbaek B, Jensen HE, Søballe K, Tøttrup M. Single-dose bone pharmacokinetics of vancomycin in a porcine implant-associated osteomyelitis model. J Orthop Res 2018; 36:1093-1098. [PMID: 29058823 DOI: 10.1002/jor.23776] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 10/13/2017] [Indexed: 02/04/2023]
Abstract
The increasing incidence of orthopaedic methicillin-resistant Staphylococcus aureus (MRSA) infections represents a significant therapeutic challenge. Being effective against MRSA, the role of vancomycin may become more important in the orthopaedic setting in the years to come. Nonetheless, vancomycin bone and soft tissue penetration during infection remains unclear. In eight pigs, implant-associated osteomyelitis was induced on day 0, using a Staphylococcus aureus strain. Following administration of 1,000 mg of vancomycin on day 5, vancomycin concentrations were obtained with microdialysis for 8 h in the implant bone cavity, in cancellous bone adjacent to the implant cavity, in subcutaneous adipose tissue (SCT) adjacent to the implant cavity, and in healthy cancellous bone and healthy SCT in the contralateral leg. Venous blood samples were also obtained. The extent of infection and inflammation was evaluated by post-mortem computed tomography scans, C-reactive protein serum levels and cultures of blood and swabs. In relation to all the implant cavities, bone destruction was found. Ranging from 0.20 to 0.74, tissue penetration, expressed as the ratio of the area under the concentration-time curve from 0 to the last measured value, was incomplete for all compartments except for healthy SCT. The lowest penetration was found in the implant cavity. In conclusion, Staphylococcus aureus implant-associated osteomyelitis was found to reduce vancomycin bone penetration, especially in the implant cavity. These findings suggest that it may be unsafe to rely solely on vancomycin therapy when treating acute osteomyelitis. Particularly when metaphyseal cavities are present, surgical debridement seems necessary. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1093-1098, 2018.
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Affiliation(s)
- Mats Bue
- Department of Orthopaedic Surgery, Horsens Regional Hospital, Sundvej 30, Horsens, 8700, Denmark.,Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Pelle Hanberg
- Department of Orthopaedic Surgery, Horsens Regional Hospital, Sundvej 30, Horsens, 8700, Denmark.,Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Janne Koch
- Department of Experimental medicine, University of Copenhagen, Denmark
| | | | - Martin Lundorff
- Department of Orthopaedic Surgery, Horsens Regional Hospital, Sundvej 30, Horsens, 8700, Denmark
| | - Bent Aalbaek
- Department of Veterinary Disease Biology, University of Copenhagen, Denmark
| | | | - Kjeld Søballe
- Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Mikkel Tøttrup
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopaedic Surgery, Randers Regional Hospital, Randers, Denmark
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26
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Jensen LK, Koch J, Henriksen NL, Bue M, Tøttrup M, Hanberg P, Søballe K, Jensen HE. Suppurative Inflammation and Local Tissue Destruction Reduce the Penetration of Cefuroxime to Infected Bone Implant Cavities. J Comp Pathol 2017; 157:308-316. [PMID: 29169629 DOI: 10.1016/j.jcpa.2017.10.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 09/27/2017] [Accepted: 10/04/2017] [Indexed: 11/18/2022]
Abstract
Treatment of post-traumatic and implant-associated osteomyelitis (IAO) includes surgical debridement, removal of implants and long-term antibiotic therapy. The success of antibiotic therapy relies not only on activity towards the infecting pathogen, but also on sufficient penetration of the target site. The aim of the present study was to characterize the local pathological changes associated with reduced penetration of cefuroxime to infected bone implant cavities. Previously, reduced penetration of systemically administrated cefuroxime was demonstrated in the implant cavity of 10 pigs with Staphylococcus aureus IAO present for 5 days. In the present study, a comprehensive histopathological characterization of the peri-implant bone tissue was performed and correlated with the reduced penetration of cefuroxime. In two pigs, the levels of oxygen, pyruvate and lactate was estimated in the implant cavity. A peri-implant pathological bone area (PIBA) developed with a width of 1.2 up to 3.8 mm. PIBAs included: (1) suppuration, resulting in destruction of the implant cavity contour, and (2) a non-vascular zone of primarily necrotic bone tissue. A strong negative correlation was seen between PIBA width and cefuroxime area under the concentration time curves (AUC[0-last]) and peak concentration of cefuroxime (Cmax). All metabolic measurements demonstrated hypoxia. In conclusion, subacute suppurative bone inflammation with local tissue destruction can result in decreased penetration of antibiotics and insufficient oxygen supply.
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Affiliation(s)
- L Kruse Jensen
- Department of Veterinary and Animal Science, Ridebanevej 3, 1870 Frederiksberg C, University of Copenhagen, Denmark.
| | - J Koch
- Department of Veterinary and Animal Science, Ridebanevej 3, 1870 Frederiksberg C, University of Copenhagen, Denmark
| | - N Lind Henriksen
- Department of Veterinary and Animal Science, Ridebanevej 3, 1870 Frederiksberg C, University of Copenhagen, Denmark
| | - Mats Bue
- Orthopaedic Research Unit, Building 1A, Nørrebrogade 44, 8000 Aarhus, Aarhus University Hospital, Denmark; Department of Orthopaedic Surgery, Sundvej 30, 8700 Horsens, Horsens Regional Hospital, Denmark
| | - M Tøttrup
- Orthopaedic Research Unit, Building 1A, Nørrebrogade 44, 8000 Aarhus, Aarhus University Hospital, Denmark; Department of Orthopaedic Surgery, Skovlyvej 15, 8930 Randers NØ, Randers Regional Hospital, Denmark
| | - P Hanberg
- Orthopaedic Research Unit, Building 1A, Nørrebrogade 44, 8000 Aarhus, Aarhus University Hospital, Denmark
| | - K Søballe
- Orthopaedic Research Unit, Building 1A, Nørrebrogade 44, 8000 Aarhus, Aarhus University Hospital, Denmark
| | - H Elvang Jensen
- Department of Veterinary and Animal Science, Ridebanevej 3, 1870 Frederiksberg C, University of Copenhagen, Denmark
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27
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Bouaziz A, Uçkay I, Lustig S, Boibieux A, Lew D, Hoffmeyer P, Neyret P, Chidiac C, Ferry T. Non-compliance with IDSA guidelines for patients presenting with methicillin-susceptible Staphylococcus aureus prosthetic joint infection is a risk factor for treatment failure. Med Mal Infect 2017; 48:207-211. [PMID: 29122410 DOI: 10.1016/j.medmal.2017.09.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 11/09/2016] [Accepted: 09/26/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The long-term impact of treatment strategies proposed by the IDSA guidelines for patients presenting with methicillin-susceptible S. aureus (MSSA) prosthetic joint infection (PJI) is not well-known. PATIENTS AND METHODS Retrospective (2000-2010) cohort study including patients presenting with MSSA hip or knee PJI. A univariate Cox analysis was performed to determine if the non-compliance with IDSA surgical guidelines was a risk factor for treatment failure. RESULTS Eighty-nine patients with a mean follow-up of 2.8 years were included. Non-compliance with IDSA surgical guidelines was associated with treatment failure (hazard ratio 2.157; 95% CI [1.022-4.7]). The American Society of Anesthesiologists score, inadequate antimicrobial therapy, and a rifampicin-based regimen did not significantly influence patient outcome. CONCLUSION Based on the IDSA guidelines, if a patient presenting with MSSA PJI is not eligible for implant retention, complete implant removal is needed to limit treatment failure.
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Affiliation(s)
- A Bouaziz
- Service de maladies infectieuses et tropicales, hôpital de la Croix-Rousse, hospices civils de Lyon, 93, Grande rue de la Croix-Rousse, 69004 Lyon, France
| | - I Uçkay
- Hôpitaux universitaires de Genève, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland
| | - S Lustig
- Service de chirurgie orthopédique, centre Albert-Trillat, hôpital de la Croix-Rousse, hospices civils de Lyon, 69004 Lyon, France; Université Claude-Bernard Lyon 1, 69100 Lyon, France; Centre de référence des IOA complexes de Lyon, Lyon, France
| | - A Boibieux
- Service de maladies infectieuses et tropicales, hôpital de la Croix-Rousse, hospices civils de Lyon, 93, Grande rue de la Croix-Rousse, 69004 Lyon, France
| | - D Lew
- Hôpitaux universitaires de Genève, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland
| | - P Hoffmeyer
- Hôpitaux universitaires de Genève, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland
| | - P Neyret
- Service de chirurgie orthopédique, centre Albert-Trillat, hôpital de la Croix-Rousse, hospices civils de Lyon, 69004 Lyon, France; Université Claude-Bernard Lyon 1, 69100 Lyon, France
| | - C Chidiac
- Service de maladies infectieuses et tropicales, hôpital de la Croix-Rousse, hospices civils de Lyon, 93, Grande rue de la Croix-Rousse, 69004 Lyon, France; Université Claude-Bernard Lyon 1, 69100 Lyon, France; Centre de référence des IOA complexes de Lyon, Lyon, France; Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, centre international de recherche en infectiologie (CIRI), 69007 Lyon, France
| | - T Ferry
- Service de maladies infectieuses et tropicales, hôpital de la Croix-Rousse, hospices civils de Lyon, 93, Grande rue de la Croix-Rousse, 69004 Lyon, France; Université Claude-Bernard Lyon 1, 69100 Lyon, France; Centre de référence des IOA complexes de Lyon, Lyon, France; Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, centre international de recherche en infectiologie (CIRI), 69007 Lyon, France.
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28
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Jensen LK, Koch J, Dich-Jorgensen K, Aalbaek B, Petersen A, Fuursted K, Bjarnsholt T, Kragh KN, Tøtterup M, Bue M, Hanberg P, Søballe K, Heegaard PMH, Jensen HE. Novel porcine model of implant-associated osteomyelitis: A comprehensive analysis of local, regional, and systemic response. J Orthop Res 2017; 35:2211-2221. [PMID: 27958656 DOI: 10.1002/jor.23505] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 12/05/2016] [Indexed: 02/04/2023]
Abstract
UNLABELLED Pigs are favorable experimental animals for infectious diseases in humans. However, implant-associated osteomyelitis (IAO) models in pigs have only been evaluated using high-inoculum infection (>108 CFU) models in 1975 and 1993. Therefore, the aim of this paper was to present a new low inoculum porcine model of human IAO based on 42 experimental pigs. The model was created by drilling an implant cavity in the tibial bone followed by insertion of a small steel implant and simultaneous inoculation of Staphylococcus aureus bacteria (n = 32) or saline (n = 10). The infected pigs were either inoculated with 104 CFU (n = 26) or 102 and 103 CFU (n = 6). All animals were euthanized 5 days after insertion of implants. Pigs receiving the high-inoculum infections showed a significantly higher volume of bone lesion, number of neutrophils around the implant, concentrations of acute phase proteins in serum, and enlargement of regional lymph nodes. A positive correlation was present between a high number of surrounding neutrophils and high values of all other parameters. Furthermore, a threshold of 40 neutrophils per 10 high power fields for the histopathological diagnosis of high grade IAO was defined. IN CONCLUSION This paper describes a novel low-inoculum S. aureus porcine model of IAO which was demonstrated to be reliable, reproducible and discriminative to human IAO, and represents a requested and valuable tool in orthopedic research. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2211-2221, 2017.
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Affiliation(s)
- Louise Kruse Jensen
- Department of Veterinary Disease Biology, University of Copenhagen, Ridebanevej 3, 1870, Frederiksberg C, Denmark
| | - Janne Koch
- Department of Experimental Medicine, University of Copenhagen, Blegdamsvej 2, 2200, Copenhagen N, Denmark
| | - Kirstine Dich-Jorgensen
- Department of Veterinary Disease Biology, University of Copenhagen, Ridebanevej 3, 1870, Frederiksberg C, Denmark
| | - Bent Aalbaek
- Department of Veterinary Disease Biology, University of Copenhagen, Ridebanevej 3, 1870, Frederiksberg C, Denmark
| | - Andreas Petersen
- Statens Serum Institut, Artillerivej 5, 2300, Copenhagen S, Denmark
| | - Kurt Fuursted
- Statens Serum Institut, Artillerivej 5, 2300, Copenhagen S, Denmark
| | - Thomas Bjarnsholt
- Costerton Biofilm Center, Institute of Immunology and Microbiology, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen N, Denmark.,Department of Clinical Microbiology, Copenhagen University Hospital, Juliane Maries Vej 22, 2100, Copenhagen Ø, Denmark
| | - Kasper Nørskov Kragh
- Costerton Biofilm Center, Institute of Immunology and Microbiology, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen N, Denmark
| | - Mikkel Tøtterup
- Orthopedic Research Unit, Aarhus University Hospital, Building 1A, Nørrebrogade 44, 8000, Aarhus, Denmark.,Department of Orthopedic Surgery, Randers Regional Hospital, Skovlyvej 15, 8930, Randers NØ, Denmark
| | - Mats Bue
- Orthopedic Research Unit, Aarhus University Hospital, Building 1A, Nørrebrogade 44, 8000, Aarhus, Denmark.,Department of Orthopedic Surgery, Horsens Regional Hospital, Sundvej 30, 8700, Horsens, Denmark
| | - Pelle Hanberg
- Orthopedic Research Unit, Aarhus University Hospital, Building 1A, Nørrebrogade 44, 8000, Aarhus, Denmark
| | - Kjeld Søballe
- Orthopedic Research Unit, Aarhus University Hospital, Building 1A, Nørrebrogade 44, 8000, Aarhus, Denmark
| | - Peter M H Heegaard
- Innate Immunology Group, National Veterinary Institute, Technical University of Denmark, Bülowsvej 27, 1870, Frederiksberg C, Denmark
| | - Henrik Elvang Jensen
- Department of Veterinary Disease Biology, University of Copenhagen, Ridebanevej 3, 1870, Frederiksberg C, Denmark
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29
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Factors Associated with Choice and Success of One- Versus Two-Stage Revision Arthroplasty for Infected Hip and Knee Prostheses. HSS J 2017; 13:224-231. [PMID: 28983214 PMCID: PMC5617816 DOI: 10.1007/s11420-017-9550-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 02/24/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prosthetic joint infections (PJI) of hip and knee arthroplasties are becoming increasingly common with an aging population and an increasing demand for these procedures. Despite attempts at standardization, medical and surgical approaches vary widely among practitioners. QUESTIONS/PURPOSES We first sought to determine if there were specific factors associated with choice of one- versus two-stage revision. Then we investigated whether the type of revision approach influenced clinical treatment success. Finally, among two-stage revisions, we assessed if an antibiotic holiday prior to the second procedure affected clinical treatment success. METHODS We retrospectively reviewed patients who had revision surgery for infection of a hip or knee arthroplasty between January 1, 2000, and December 31, 2013, at the Sunnybrook Health Sciences Centre and the Holland Orthopedic and Arthritic Centre. PJI cases were identified using the Ontario Joint Replacement Registry. Infection was defined by gross intraoperative evidence of infection, positive intraoperative culture(s), and/or sinus tract prior to operation. The primary outcome was treatment failure at 1 year after revision surgery based on requirement for further surgery, ongoing infection, and/or continuous suppressive antibiotics. RESULTS Of 110 eligible patients identified, 35 patients had a one-stage and 75 patients had a two-stage revision. Choice of a one-stage approach was most influenced by particular surgeon preference and was more likely for hip revision versus knee revision (OR 3.39 (95%CI 1.85-6.23). There was no statistical difference in clinical treatment success rate between one-stage (33/35; 94.2% success) and two-stage revision (63/75; 84%; p = 0.13). Enterococcus spp. (21 versus 3%; p = 0.027) and Peptostreptococcus spp. (14 versus 1%; p = 0.042) were more common among clinical treatment failures than successes, with a trend towards the same for Staphylococcus aureus (29 versus 9%; p = 0.06). Additionally, treatment success was not influenced by whether the patient had an antibiotic holiday with a two-stage revision. CONCLUSION Our findings confirm the uncertainty of surgical strategy for treatment of PJI in hip and knee arthroplasty. Superiority of one- versus two-stage revision and the value of antibiotic-free periods prior to definitive revision remain unclear. Large prospective studies or randomized controlled trials are needed to inform best practice for treatment of these complex clinical problems.
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30
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Jensen LK, Koch J, Aalbaek B, Moodley A, Bjarnsholt T, Kragh KN, Petersen A, Jensen HE. Early implant-associated osteomyelitis results in a peri-implanted bacterial reservoir. APMIS 2016; 125:38-45. [PMID: 27704604 PMCID: PMC5298028 DOI: 10.1111/apm.12597] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 07/31/2016] [Indexed: 01/18/2023]
Abstract
Implant-associated osteomyelitis (IAO) is a common complication in orthopedic surgery. The aim of this study was to elucidate how deep IAO can go into the peri-implanted bone tissue within a week. The study was performed in a porcine model of IAO. A small steel implant and either 104 CFU/kg body weight of Staphylococcus aureus or saline was inserted into the right tibial bone of 12 pigs. The animals were consecutively killed on day 2, 4 and 6 following implantation. Bone tissue around the implant was histologically evaluated. Identification of S. aureus was performed immunohistochemically on tissue section and with scanning electron microscopy and peptide nucleic acid in situ hybridization on implants. The distance of the peri-implanted pathological bone area (PIBA), measured perpendicular to the implant, was significantly larger in infected animals compared to controls (p = 0.0014). The largest differences were seen after 4 and 6 days of inoculation, where PIBA measurements of up to 6 mm were observed. Positive S. aureus bacteria were identified on implants and from 25 μm to 6 mm into PIBA. This is important knowledge for optimizing outcomes of surgical debridement in osteomyelitis.
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Affiliation(s)
- Louise Kruse Jensen
- Department of Veterinary Disease Biology, University of Copenhagen, Frederiksberg, Denmark
| | - Janne Koch
- Department of Experimental Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Bent Aalbaek
- Department of Veterinary Disease Biology, University of Copenhagen, Frederiksberg, Denmark
| | - Arshnee Moodley
- Department of Veterinary Disease Biology, University of Copenhagen, Frederiksberg, Denmark
| | - Thomas Bjarnsholt
- Costerton Biofilm Center, Institute of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kasper Nørskov Kragh
- Costerton Biofilm Center, Institute of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Henrik Elvang Jensen
- Department of Veterinary Disease Biology, University of Copenhagen, Frederiksberg, Denmark
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31
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Benito N, Franco M, Ribera A, Soriano A, Rodriguez-Pardo D, Sorlí L, Fresco G, Fernández-Sampedro M, Dolores Del Toro M, Guío L, Sánchez-Rivas E, Bahamonde A, Riera M, Esteban J, Baraia-Etxaburu JM, Martínez-Alvarez J, Jover-Sáenz A, Dueñas C, Ramos A, Sobrino B, Euba G, Morata L, Pigrau C, Coll P, Mur I, Ariza J. Time trends in the aetiology of prosthetic joint infections: a multicentre cohort study. Clin Microbiol Infect 2016; 22:732.e1-8. [PMID: 27181408 DOI: 10.1016/j.cmi.2016.05.004] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 04/24/2016] [Accepted: 05/03/2016] [Indexed: 02/05/2023]
Abstract
It is important to know the spectrum of the microbial aetiology of prosthetic joint infections (PJIs) to guide empiric treatment and establish antimicrobial prophylaxis in joint replacements. There are no available data based on large contemporary patient cohorts. We sought to characterize the causative pathogens of PJIs and to evaluate trends in the microbial aetiology. We hypothesized that the frequency of antimicrobial-resistant organisms in PJIs has increased in the recent years. We performed a cohort study in 19 hospitals in Spain, from 2003 to 2012. For each 2-year period (2003-2004 to 2011-2012), the incidence of microorganisms causing PJIs and multidrug-resistant bacteria was assessed. Temporal trends over the study period were evaluated. We included 2524 consecutive adult patients with a diagnosis of PJI. A microbiological diagnosis was obtained for 2288 cases (90.6%). Staphylococci were the most common cause of infection (1492, 65.2%). However, a statistically significant rising linear trend was observed for the proportion of infections caused by Gram-negative bacilli, mainly due to the increase in the last 2-year period (25% in 2003-2004, 33.3% in 2011-2012; p 0.024 for trend). No particular species contributed disproportionally to this overall increase. The percentage of multidrug-resistant bacteria PJIs increased from 9.3% in 2003-2004 to 15.8% in 2011-2012 (p 0.008), mainly because of the significant rise in multidrug-resistant Gram-negative bacilli (from 5.3% in 2003-2004 to 8.2% in 2011-2012; p 0.032). The observed trends have important implications for the management of PJIs and prophylaxis in joint replacements.
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Affiliation(s)
- N Benito
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau-Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Spain; Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain.
| | - M Franco
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau-Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Spain
| | - A Ribera
- Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain; Department of Infectious Diseases, Hospital Universitari Bellvitge, Barcelona, Spain
| | - A Soriano
- Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain; Department of Infectious Diseases, Hospital Clínic Universitari, Barcelona, Spain
| | - D Rodriguez-Pardo
- Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain; Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - L Sorlí
- Department of Infectious Diseases, Hospital del Mar, Barcelona, Spain
| | - G Fresco
- Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain; Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - M Fernández-Sampedro
- Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain; Department of Infectious Diseases, Hospital Universitario Valdecilla, Santander, Spain
| | - M Dolores Del Toro
- Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain; Department of Infectious Diseases, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - L Guío
- Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain; Department of Infectious Diseases, Hospital Universitario Cruces, Bilbao, Spain
| | - E Sánchez-Rivas
- Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain; Department of Infectious Diseases, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - A Bahamonde
- Department of Internal Medicine-Infectious Diseases, Hospital el Bierzo, León, Spain
| | - M Riera
- Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain; Infectious Diseases Unit, Department of Infectious Diseases, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - J Esteban
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, Madrid, Spain
| | | | - J Martínez-Alvarez
- Department of Internal Medicine, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - A Jover-Sáenz
- Unit of Nosocomial Infection, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - C Dueñas
- Department of Internal Medicine, Hospital Universitario de Burgos, Burgos, Spain
| | - A Ramos
- Infectious Diseases Unit, Department of Internal Medicine, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - B Sobrino
- Department of Infectious Diseases, Hospital Regional Universitario Málaga, Málaga, Spain
| | - G Euba
- Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain; Department of Infectious Diseases, Hospital Universitari Bellvitge, Barcelona, Spain
| | - L Morata
- Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain; Department of Infectious Diseases, Hospital Clínic Universitari, Barcelona, Spain
| | - C Pigrau
- Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain; Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - P Coll
- Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain; Department of Clinical Microbiology, Hospital de la Santa Creu i Sant Pau-Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain
| | - I Mur
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau-Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain
| | - J Ariza
- Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), Instituto de Salud Carlos III, Madrid, Spain; Department of Infectious Diseases, Hospital Universitari Bellvitge, Barcelona, Spain
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Tornero E, Morata L, Martínez-Pastor JC, Angulo S, Combalia A, Bori G, García-Ramiro S, Bosch J, Mensa J, Soriano A. Importance of selection and duration of antibiotic regimen in prosthetic joint infections treated with debridement and implant retention. J Antimicrob Chemother 2016; 71:1395-401. [DOI: 10.1093/jac/dkv481] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 12/15/2015] [Indexed: 12/26/2022] Open
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Yoon YC, Lakhotia D, Oh JK, Moon JG, Prashant K, Shon WY. Is two-stage reimplantation effective for virulent pathogenic infection in a periprosthetic hip? A retrospective analysis. World J Orthop 2015; 6:712-718. [PMID: 26495248 PMCID: PMC4610913 DOI: 10.5312/wjo.v6.i9.712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 07/10/2015] [Accepted: 08/14/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effectiveness of two-stage reimplantation using antibiotic-loaded bone cement (ALBC) and the risk factors associated with failure to control periprosthetic joint infection (PJI).
METHODS: We retrospectively reviewed 38 consecutive hips managed using two-stage reimplantation with ALBC. The mean follow-up period was 5.4 years (range: 2.5-9 years).
RESULTS: The causative pathogens were isolated from 29 patients (76%), 26 of whom were infected with highly virulent organisms. Sixteen patients (42%) underwent at least two first-stage debridements. An increased debridement frequency correlated significantly with high comorbidity (P < 0.001), a lower preoperative Harris hip score (HHS; P < 0.001), antimicrobial resistance, and gram-negative and polymicrobial infection (P = 0.002). Of the 35 patients who underwent two-stage reimplantation, 34 showed no signs of recurrence of infection. The mean HHS improved from 46 ± 12.64 to 78 ± 10.55 points, with 7 (20%), 12 (34%), 11 (32%) and 5 (14%) patients receiving excellent, good, fair and poor ratings, respectively.
CONCLUSION: The current study demonstrated that two-stage reimplantation could successfully treat PJI after hip arthroplasty. However, the ability of ALBC to eradicate infection was limited because frequent debridement was required in high-risk patients (i.e., patients who are either in poor general health due to associated comorbidities or harbor infections due to highly virulent, difficult-to-treat organisms). Level of evidence: Level IV.
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Santos-Ferreira I, Bettencourt A, Almeida AJ. Nanoparticulate platforms for targeting bone infections: meeting a major therapeutic challenge. Nanomedicine (Lond) 2015; 10:3131-45. [PMID: 26446355 DOI: 10.2217/nnm.15.134] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Bone infections are devastating complications in orthopedics due to biofilm formation. Treatment requires high antibiotic doses, which may lead to systemic toxicity thus limiting the drug therapeutic effectiveness. In this context, nanoparticles are well-known controlled release drug carriers that are able to modulate release rate, versatile in terms of administration routes and may be used as local delivery systems. Regarding bone infections, although nanoparticles are a promising strategy for overcoming biofilm tolerance, there are clearly technical, safety, regulatory and clinical challenges that need to be overcome before such nanomedicines may be translated into clinical use. In this paper, we present a critical overview on the high expectations against the real potential of the nanotechnological approaches to bone infection treatment.
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Affiliation(s)
- Inês Santos-Ferreira
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Alameda da Universidade, 1649-004 Lisboa, Portugal
| | - Ana Bettencourt
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Alameda da Universidade, 1649-004 Lisboa, Portugal
| | - António J Almeida
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Alameda da Universidade, 1649-004 Lisboa, Portugal
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Patel H, Khoury H, Girgenti D, Welner S, Yu H. Burden of Surgical Site Infections Associated with Arthroplasty and the Contribution of Staphylococcus aureus. Surg Infect (Larchmt) 2015; 17:78-88. [PMID: 26407172 DOI: 10.1089/sur.2014.246] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patients undergoing arthroplasty are at considerable risk of experiencing post-operative complications, including surgical site infections (SSIs). In addition to potential economic consequences, SSIs can have a negative impact on patient outcomes and may potentially be life-threatening. Staphylococcus aureus has been consistently shown as the leading cause of SSIs associated with orthopedic surgery, with an important contribution from methicillin-resistant S. aureus (MRSA). This study evaluated the global burden of SSIs among patients undergoing orthopedic surgical procedures, and specifically those undergoing knee and hip arthroplasties. METHODS An extensive search of PubMed and recent conference proceedings was conducted. English articles published between 2003 and 2013 pertaining to SSI epidemiology, patient outcomes, and healthcare resource utilization and costs were reviewed. RESULTS Overall, 81 studies were included, mainly from North America and Europe. Median SSI and S. aureus SSI rates, calculated as percentage of all arthroplasty procedures, were 1.7% (range: 0.25%-4.4%; 15 studies) and 0.6% (range: 0.1%-23%), respectively. Median SSI rates were 1.3% (range: 0.05%-19%; 22 studies) after knee arthroplasty, and 2.1% (range: 0.05%-28%; 24 studies) after hip arthroplasty. S. aureus SSI rates ranged from 0.2%-2.4% and 0.18%-3.8% for patients undergoing knee and hip arthroplasty, respectively. The percentage of S. aureus SSIs because of MRSA varied widely within each patient category. SSI-related mortality data (14 studies) showed that in-hospital mortality rates were low (1.2%-2.5%), but increased with time after index arthroplasty procedure (up to 56% over 1 y). Studies assessing healthcare resource utilization (n = 21) revealed that developing post-orthopedic SSIs resulted in a two- to three-fold increase in length of hospital stay (LOS) compared with non-infected patients (median LOS: 18.9 d vs. 6 d for non-SSI patients). Patients with SSIs because of methicillin-resistant staphylococci incurred greater mean LOS compared with SSIs because of methicillin-sensitive organisms. Readmission rates reported in 11 studies indicate a greater likelihood in the presence of SSIs; comparison across studies was not feasible because of differences in data reporting. Consistent with increased healthcare resource utilization (LOS and readmission) associated with SSIs, cost studies (n = 23) revealed that the presence of SSIs was associated with up to three-fold cost increase compared with the absence of SSI across all orthopedic patient categories assessed. CONCLUSIONS SSIs are associated with increased morbidity, mortality rates, healthcare resource utilization, and costs. Despite the relatively low SSI incidence following orthopedic surgery and specifically arthroplasty, preventive methods, specifically those targeting S. aureus, would serve to minimize costs and improve patient outcomes.
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Affiliation(s)
| | | | | | | | - Holly Yu
- 3 Pfizer Inc. , Collegeville, Pennsylvania
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Antony SJ, Westbrook RS, Jackson JS, Heydemann JS, Nelson JL. Efficacy of Single-stage Revision with Aggressive Debridement Using Intra-articular Antibiotics in the Treatment of Infected Joint Prosthesis. Infect Dis (Lond) 2015; 8:17-23. [PMID: 26279625 PMCID: PMC4524167 DOI: 10.4137/idrt.s26824] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/21/2015] [Accepted: 06/22/2015] [Indexed: 12/15/2022] Open
Abstract
Prosthetic joint infections (PJI) of the hip and knee are uncommon, but result in significant morbidity and mortality when they do occur. Current management consists of a combination of either single- or two-stage exchange of the prosthesis and/or exchange of polymer components with intravenous (IV) antibiotics (4–6 weeks) and intraoperative debridement of the joint prior to reimplantation. However, failure rate, morbidity, and expense associated with current management are high, especially if the infection involves resistant pathogens and/or osteomyelitis. Also, the current use of systemic antibiotics does not allow for high local concentrations of the drug and biofilm penetration of the infected prosthesis. To overcome these difficulties, we examined the outcomes of aggressive operative debridement of the infected prosthesis. This was achieved through the use of a single-stage revision and administration of high concentrations of local intra-articular antibiotics via Hickman catheters. We present 57 patients with PJI who were treated with intra-articular antibiotics and single-stage revisions. Minimal systemic toxicity was observed along with a 100% microbiologic cure rate and 89% without relapse at 11-month follow-up despite isolation of multidrug resistant pathogens. This is the largest study to date using this method in the treatment of PJI.
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Affiliation(s)
- Suresh J Antony
- Texas Tech University School of Medicine, and Center for Infectious Diseases and Travel Medicine, El Paso, Texas, USA
| | | | | | | | - Jenny L Nelson
- Sierra Providence Memorial Hospitals, El Paso, Texas, USA
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Roger PM, Tabutin J, Blanc V, Léotard S, Brofferio P, Léculé F, Redréau B, Bernard E. Prosthetic joint infection: A pluridisciplinary multi-center audit bridging quality of care and outcome. Med Mal Infect 2015; 45:229-36. [DOI: 10.1016/j.medmal.2015.04.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 03/05/2015] [Accepted: 04/26/2015] [Indexed: 11/27/2022]
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KLIC-score for predicting early failure in prosthetic joint infections treated with debridement, implant retention and antibiotics. Clin Microbiol Infect 2015; 21:786.e9-786.e17. [PMID: 25959106 DOI: 10.1016/j.cmi.2015.04.012] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 04/13/2015] [Accepted: 04/14/2015] [Indexed: 01/22/2023]
Abstract
Debridement, irrigation and antibiotic treatment form the current approach in early prosthetic joint infection (PJI). Our aim was to design a score to predict patients with a higher risk of failure. From 1999 to 2014 early PJIs were prospectively collected and retrospectively reviewed. The primary end-point was early failure defined as: 1) the need for unscheduled surgery, 2) death-related infection within the first 60 days after debridement or 3) the need for suppressive antibiotic treatment. A score was built-up according to the logistic regression coefficients of variables available before debridement. A total of 222 patients met the inclusion criteria. The most frequently isolated microorganisms were coagulase-negative staphylococci (95 cases, 42.8%) and Staphylococcus aureus (81 cases, 36.5%). Treatment of 52 (23.4%) cases failed. Independent predictors of failure were: chronic renal failure (OR 5.92, 95% CI 1.47-23.85), liver cirrhosis (OR 4.46, 95% CI 1.15-17.24), revision surgery (OR 4.34, 95% CI 1.34-14.04) or femoral neck fracture (OR 4.39, 95% CI1.16-16.62) compared with primary arthroplasty, C reactive protein >11.5 mg/dL (OR 12.308, 95% CI 4.56-33.19), cemented prosthesis (OR 8.71, 95% CI 1.95-38.97) and when all intraoperative cultures were positive (OR 6.30, 95% CI 1.84-21.53). A score for predicting the risk of failure was designed using preoperative factors (KLIC-score: Kidney, Liver, Index surgery, Cemented prosthesis and C-reactive protein value) and it ranged between 0 and 9.5 points. Patients with scores of ≤2, >2-3.5, 4-5, >5-6.5 and ≥7 had failure rates of 4.5%, 19.4%, 55%, 71.4% and 100%, respectively. The KLIC-score was highly predictive of early failure after debridement. In the future, it would be necessary to validate our score using cohorts from other institutions.
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Pharmacokinetic variability of clindamycin and influence of rifampicin on clindamycin concentration in patients with bone and joint infections. Infection 2015; 43:473-81. [DOI: 10.1007/s15010-015-0773-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 03/24/2015] [Indexed: 10/23/2022]
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Marschall J, Lewis JWS, Warren DK, Babcock HM, Barrack RL, Fraser VJ. Baseline hypovitaminosis D is not associated with poor clinical outcomes in osteoarticular infections. Int J Infect Dis 2014; 26:98-102. [PMID: 25025238 PMCID: PMC4233280 DOI: 10.1016/j.ijid.2014.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 04/09/2014] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Although vitamin D is recognized as an important factor in bone health, its role in osteoarticular infections is unclear. We hypothesized that low vitamin D (25-hydroxycholecalciferol) levels are associated with a lower likelihood of treatment success in osteoarticular infections. METHODS This was a retrospective cohort study of patients with orthopedic infections who had a 25-hydroxycholecalciferol level drawn when their infection was diagnosed. Outcomes were determined at early (3-6 months) and late (≥ 6 months) follow-up after completing intravenous antibiotics. RESULTS We included 223 patients seen during an 11-month period with osteoarticular infections and baseline 25-hydroxycholecalciferol levels. During the initial inpatient management of the infection, hypovitaminosis D was identified and treated. The mean 25-hydroxycholecalciferol level was 23 ± 14 ng/ml; 167 (75%) patients had levels <30 ng/ml. Overall, infection treatment success was 91% (159/174) at early follow-up and 88% (145/164) at late follow-up. 25-Hydroxycholecalciferol baseline levels were similar in those with and without successful clinical outcomes, both at early (25 ± 15 vs. 21 ± 9 ng/ml; p=0.3) and late follow-up (25 ± 15 vs. 23 ± 16 ng/ml; p=0.6). CONCLUSIONS To our knowledge this is the first report on hypovitaminosis D and its impact on outcomes of osteoarticular infections. Hypovitaminosis D was frequent in this cohort. With vitamin D repletion, there was no difference in treatment success whether patients had baseline hypovitaminosis or not.
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Affiliation(s)
- J Marschall
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 S. Euclid, St. Louis, MO 63110, USA; Department of Infectious Diseases, Bern University Hospital and University of Bern, Bern, Switzerland.
| | - J W S Lewis
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 S. Euclid, St. Louis, MO 63110, USA
| | - D K Warren
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 S. Euclid, St. Louis, MO 63110, USA
| | - H M Babcock
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 S. Euclid, St. Louis, MO 63110, USA
| | - R L Barrack
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - V J Fraser
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 S. Euclid, St. Louis, MO 63110, USA
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Abstract
Prosthetic joint infection (PJI) is a tremendous burden for individual patients as well as the global health care industry. While a small minority of joint arthroplasties will become infected, appropriate recognition and management are critical to preserve or restore adequate function and prevent excess morbidity. In this review, we describe the reported risk factors for and clinical manifestations of PJI. We discuss the pathogenesis of PJI and the numerous microorganisms that can cause this devastating infection. The recently proposed consensus definitions of PJI and approaches to accurate diagnosis are reviewed in detail. An overview of the treatment and prevention of this challenging condition is provided.
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Affiliation(s)
- Aaron J. Tande
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Robin Patel
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Bertazzoni Minelli E, Benini A, Samaila E, Bondi M, Magnan B. Antimicrobial activity of gentamicin and vancomycin combination in joint fluids after antibiotic-loaded cement spacer implantation in two-stage revision surgery. J Chemother 2014; 27:17-24. [PMID: 24621165 DOI: 10.1179/1973947813y.0000000157] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Gentamicin (G) and vancomycin (V) concentrations in joints fluids obtained from patients during the first 24 hours after implantation of antibiotic-loaded polymethylmethacrylate (PMMA) spacers in two-stage revision for infected arthroplasty, and the inhibitory activity of joint fluids against different multiresistant clinical isolates were studied. A total of 12 patients undergoing two-stage revision surgery with implantation of industrial G spacers added with different amounts of V was studied. Serum and joint fluid samples were collected 1, 4, and 24 hours after spacer implantation. Antibiotics concentrations and joint bactericidal titer (JBT) of combination were determined against multiresistant staphylococcal strains. The local release of G and V from PMMA cement seemed prompt and effective. Serum levels were below the limit of detection. The same joint fluid showed different activity according to the susceptibility of the pathogens tested. Gentamicin and V were released from spacers at bactericidal concentrations exerting a strong inhibition against methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative staphylococci (CoNS) strains.
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Antimicrobial-related severe adverse events during treatment of bone and joint infection due to methicillin-susceptible Staphylococcus aureus. Antimicrob Agents Chemother 2013; 58:746-55. [PMID: 24247130 DOI: 10.1128/aac.02032-13] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Prolonged antimicrobial therapy is recommended for methicillin-susceptible Staphylococcus aureus (MSSA) bone and joint infections (BJI), but its safety profile and risk factors for severe adverse events (SAE) in clinical practice are unknown. We addressed these issues in a retrospective cohort study (2001 to 2011) analyzing antimicrobial-related SAE (defined according to the Common Terminology Criteria for Adverse Events) in 200 patients (male, 62%; median age, 60.8 years [interquartile range {IQR}, 45.5 to 74.2 years]) with MSSA BJI admitted to a reference regional center with acute (66%) or chronic arthritis (7.5%), osteomyelitis (9.5%), spondylodiscitis (16%), or orthopedic device-related infections (67%). These patients received antistaphylococcal therapy for a median of 26.6 weeks (IQR, 16.8 to 37.8 weeks). Thirty-eight SAE occurred in 30 patients (15%), with a median time delay of 34 days (IQR, 14.75 to 60.5 days), including 10 patients with hematologic reactions, 9 with cutaneomucosal reactions, 6 with acute renal injuries, 4 with hypokalemia, and 4 with cholestatic hepatitis. The most frequently implicated antimicrobials were antistaphylococcal penicillins (ASP) (13 SAE/145 patients), fluoroquinolones (12 SAE/187 patients), glycopeptides (9 SAE/101 patients), and rifampin (7 SAE/107 patients). Kaplan-Meier curves and stepwise binary logistic regression analyses were used to determine the risk factors for the occurrence of antimicrobial-related SAE. Age (odds ratio [OR], 1.479 for 10-year increase; 95% confidence interval [CI], 1.116 to 1.960; P = 0.006) appeared to be the only independent risk factor for SAE. In patients receiving ASP or rifampin, daily dose (OR, 1.028; 95% CI, 1.006 to 1.051; P = 0.014) and obesity (OR, 8.991; 95% CI, 1.453 to 55.627; P = 0.018) were associated with the occurrence of SAE. The high rate of SAE and their determinants highlighted the importance of the management and follow-up of BJI, with particular attention to be paid to older persons, especially for ASP dosage, and to rifampin dose adjustment in obese patients.
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Release of gentamicin and vancomycin from preformed spacers in infected total hip arthroplasties: measurement of concentrations and inhibitory activity in patients' drainage fluids and serum. ScientificWorldJournal 2013; 2013:752184. [PMID: 24174916 PMCID: PMC3794627 DOI: 10.1155/2013/752184] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 08/06/2013] [Indexed: 01/20/2023] Open
Abstract
Gentamicin (G) and vancomycin (V) concentrations in drainage fluids obtained from patients during the first 24 hours after implantation of antibiotic-loaded polymethylmethacrylate (PMMA) spacers in two-stage revision of infected total hip arthroplasty were studied. The inhibitory activity of drainage fluids against different multiresistant clinical isolates was investigated as well. Seven hips were treated by implantation of industrial G-loaded spacers. Vancomycin was added by manually mixing with PMMA bone cement. Serum and drainage fluid samples were collected 1, 4, and 24 hours after spacer implantation. Antibiotics concentrations and drains bactericidal titer of combination were determined against multiresistant staphylococcal strains. The release of G and V from PMMA cement at the site of infection was prompt and effective. Serum levels were below the limit of detection. The local release kinetics of G and V from PMMA cement was similar, exerting a pronounced, combined inhibitory effect in the implant site. The inhibitory activity of drainage fluids showed substantial intersubject variability related to antibiotic concentrations and differed according to the pathogens tested. Gentamicin and vancomycin were released from temporary hip spacers at bactericidal concentrations, and their use in combination exerted strong inhibition against methicillin-resistant S. aureus and Coagulase Negative Staphylococci strains.
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Bouaziz A, Uçkay I, Lustig S, Boibieux A, Laurent F, Lew D, Hoffmeyer P, Neyret P, Chidiac C, Ferry T. Microbiological markers suggesting high inoculum size at time of surgery are risk factors for relapse in patients with Staphylococcus aureus prosthetic joint infection. J Infect 2012; 65:582-4. [DOI: 10.1016/j.jinf.2012.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 09/09/2012] [Indexed: 10/27/2022]
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Maaloum Y, Meybeck A, Olive D, Boussekey N, Delannoy PY, Chiche A, Georges H, Beltrand E, Senneville E, d'Escrivan T, Leroy O. Clinical spectrum and outcome of critically ill patients suffering from prosthetic joint infections. Infection 2012; 41:493-501. [PMID: 23097026 DOI: 10.1007/s15010-012-0357-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 10/11/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE To report the clinical characteristics and prognosis of prosthetic joint infections (PJIs) in Intensive care units (ICUs). METHODS Forty-one patients consecutively admitted to ICUs for PJIs between January 2004 and June 2011 were included in a retrospective case series. RESULTS A majority of patients (73 %) had severe underlying disease. Acute infection affected 26 patients (63 %). Blood cultures were positive in 16 patients (39 %). Staphylococcus species were the most commonly implicated causative organisms (n = 36, 88 %). The surgical strategy was two-stage replacement in 25 cases (61 %). The surgical procedure leading to ICU admission was mainly prosthesis removal with spacer implantation (n = 13, 32 %). Initial antibiotherapy was a broad-spectrum beta-lactam antibiotic combined with a glycopeptide, linezolid, or daptomycin in 26 cases (63 %). Mortality in the ICU was 20 %. In nonsurvivors, diabetes, acute infection, and American Society of Anesthesiologists (ASA) score >3 were more frequent. The distribution of surgical strategies and procedures was not statistically different in survivors and nonsurvivors. The proportion of patients treated with antibiotherapy adjusted according to previous microbiological findings was higher in nonsurvivors (50 vs. 12 %, p = 0.02). CONCLUSIONS In our case series of critically ill patients suffering from PJI, factors associated with a poor outcome were diabetes mellitus, ASA score >3, and acute infection. Surgical strategies and surgical procedures had no significant impact on the ICU mortality. Adjustment of initial antibiotherapy according to previous microbiological findings should be made with caution.
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Affiliation(s)
- Y Maaloum
- Service de Réanimation et Maladies Infectieuses, Hôpital Dron, 135 avenue du Président Coty, 59200, Tourcoing, France
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Comparison of conventional culture with SeptiFast real-time PCR for microbial pathogen detection in clinical specimens other than blood. J Med Microbiol 2011; 60:1774-1778. [DOI: 10.1099/jmm.0.034280-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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