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Rico Nieto A, Loeches Yagüe B, Quiles Melero I, Talavera Buedo G, Pizones J, Fernández-Baillo Sacristana N. [Translated article] Descriptive study of spinal instrumentation-related infections in a tertiary hospital. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:T201-T208. [PMID: 38232934 DOI: 10.1016/j.recot.2024.01.007] [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: 03/14/2023] [Accepted: 08/11/2023] [Indexed: 01/19/2024] Open
Abstract
INTRODUCTION Spinal instrumentation-related infections (SIRI) are one of the main causes of post-surgical complication and comorbidity. Our objective was to describe the clinical and microbiological characteristics, treatment and prognosis of these infections. MATERIAL AND METHODS We conducted a retrospective study in our institution (2011-2018) including adult patients undergoing spinal instrumentation who met the diagnostic criteria for confirmed infection. Superficial surgical wound and deep intraoperative samples were processed for microbiological culture. The medical and orthopaedic team was always the same. RESULTS Forty-one cases were diagnosed of which 39 patients (95.1%) presented early infection (<3 months after initial surgery) with symptoms in the first two weeks, mean CRP at diagnosis was 133mg/dl and 23% associated bacteremia. The remaining two patients (4.8%) were chronic infections (symptoms >3 months after surgery). The treatment of choice in early infections was the Debridement, Antibiotics and Implant Retention (DAIR) strategy without removal of the bone graft, which successfully resolved 84.2% of the infections. The main aetiology was gram-positive (Staphylococcus aureus: 31.7%), followed by gram-negative and polymicrobial flora. Antibiotics were optimised according to cultures with a mean duration of 12 weeks. CONCLUSIONS In early infections, early diagnosis and DAIR strategy (with bone graft retention) demonstrated a healing rate higher than 80%.
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Affiliation(s)
- A Rico Nieto
- Unidad de Infecciosas y Microbiología Clínica, Hospital Universitario La Paz, Madrid, Spain.
| | - B Loeches Yagüe
- Unidad de Infecciosas y Microbiología Clínica, Hospital Universitario La Paz, Madrid, Spain
| | - I Quiles Melero
- Servicio de Microbiología y Parasitología, Hospital Universitario La Paz, Madrid, Spain
| | - G Talavera Buedo
- Unidad de Raquis, Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario La Paz, Madrid, Spain
| | - J Pizones
- Unidad de Raquis, Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario La Paz, Madrid, Spain
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Rico Nieto A, Loeches Yagüe B, Quiles Melero I, Talavera Buedo G, Pizones J, Fernández-Baillo Sacristana N. Descriptive study of spinal instrumentation-related infections in a tertiary hospital. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:201-208. [PMID: 37690513 DOI: 10.1016/j.recot.2023.08.019] [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: 03/14/2023] [Revised: 07/21/2023] [Accepted: 08/11/2023] [Indexed: 09/12/2023] Open
Abstract
INTRODUCTION Spinal instrumentation-related infections (SIRI) are one of the main causes of post-surgical complication and comorbidity. Our objective was to describe the clinical and microbiological characteristics, treatment and prognosis of these infections. MATERIAL AND METHODS We conducted a retrospective study in our institution (2011-2018) including adult patients undergoing spinal instrumentation who met the diagnostic criteria for confirmed infection. Superficial surgical wound and deep intraoperative samples were processed for microbiological culture. The medical and orthopaedic team was always the same. RESULTS Forty-one cases were diagnosed of which 39 patients (95.1%) presented early infection (<3 months after initial surgery) with symptoms in the first two weeks, mean CRP at diagnosis was 133mg/dl and 23% associated bacteremia. The remaining two patients (4.8%) were chronic infections (symptoms >3 months after surgery). The treatment of choice in early infections was the Debridement, Antibiotics and Implant Retention (DAIR) strategy without removal of the bone graft, which successfully resolved 84.2% of the infections. The main etiology was gram-positive (Staphylococcus aureus: 31.7%), followed by gram-negative and polymicrobial flora. Antibiotics were optimized according to cultures with a mean duration of 12 weeks. CONCLUSIONS In early infections, early diagnosis and DAIR strategy (with bone graft retention) demonstrated a healing rate higher than 80%.
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Affiliation(s)
- A Rico Nieto
- Unidad de Infecciosas y Microbiología Clínica, Hospital Universitario La Paz, Madrid, España.
| | - B Loeches Yagüe
- Unidad de Infecciosas y Microbiología Clínica, Hospital Universitario La Paz, Madrid, España
| | - I Quiles Melero
- Servicio de Microbiología y Parasitología, Hospital Universitario La Paz, Madrid, España
| | - G Talavera Buedo
- Unidad de Raquis, Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario La Paz, Madrid, España
| | - J Pizones
- Unidad de Raquis, Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario La Paz, Madrid, España
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Mirghaderi P, Gholamshahi H, Jahromi A, Iranmehr A, Dabbagh-Ohadi MA, Eshraghi N. Unexpected positive culture (UPC) in adults revision spine surgery: a systematic review and meta-analysis of incidence, risk factors, and management. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024:10.1007/s00586-024-08229-2. [PMID: 38573385 DOI: 10.1007/s00586-024-08229-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 03/07/2024] [Accepted: 03/12/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Without clear signs of infection, spinal implant failure is attributed to mechanical overloads and aseptic loosening. However, how low-grade infections contribute to seemingly aseptic implant failure is unclear. PURPOSE The systematic review examined unexpected positive cultures (UPCs) in revision spine surgery regarding prevalence, isolated pathogens, risk factors, and strategies to reduce infection among asymptomatic patients undergoing revision spine surgery. METHODS We followed the PRISMA guidelines and searched four main databases (PubMed, EMBASE, SCOPUS, Web of Science) comprehensively until January 2023 for articles reporting UPC after presumed aseptic adult revision spine surgery. The UPC rates were pooled, and risk factors were compared with the culture-negative control group and represented as odds ratio (OR) or mean difference (MD). RESULTS Fifteen studies of 1057 individuals were included in two groups: culture-positive or UPCs (n = 317) and culture-negative or control (n = 740). The overall UPC prevalence was 33.2% (317/1057, range: 0 to 53%, 95% CI = 30.2%-36.4%), and Cutibacterium acnes (43.0%, 95% CI = 37.4%-48.8%), Coagulase-negative Staphylococci (CoNS), (39.5%, 95% CI = 33.2%-46.2%), and Staphylococcus species in general (49.5%, 95%CI = 43.7%-55.4%) were reported the most common isolated microbes. 16.1% of the UPCs were polymicrobial. Risk factors associated with UPC rates were female sex (OR = 2.62, 95%CI = 1.76-3.90, P < 0.001), screw loosening (OR = 4.43, 95%CI = 1.31-15.02, P = 0.02), number of operated levels (MD = 0.77, 95%CI = 0.33-1.22, P = 0.0007), and shorter time since index surgery (MD = - 8.57 months, 95%CI = - 14.76, -2.39, P = 0.02). CONCLUSIONS One-third of patients undergoing spine revision surgery revealed UPC in this study. Each UPC pathogen interpretation and antibiotic use decision should be interpreted case by case. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Peyman Mirghaderi
- Surgical Research Society (SRS), Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Hediye Gholamshahi
- Surgical Research Society (SRS), Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Jahromi
- Surgical Research Society (SRS), Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Arad Iranmehr
- Neurosurgery Department, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Amin Dabbagh-Ohadi
- Surgical Research Society (SRS), Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Nasim Eshraghi
- Surgical Research Society (SRS), Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Vali-e-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Azad MA, Patel R. Practical Guidance for Clinical Microbiology Laboratories: Microbiologic diagnosis of implant-associated infections. Clin Microbiol Rev 2024:e0010423. [PMID: 38506553 DOI: 10.1128/cmr.00104-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
SUMMARYImplant-associated infections (IAIs) pose serious threats to patients and can be associated with significant morbidity and mortality. These infections may be difficult to diagnose due, in part, to biofilm formation on device surfaces, and because even when microbes are found, their clinical significance may be unclear. Despite recent advances in laboratory testing, IAIs remain a diagnostic challenge. From a therapeutic standpoint, many IAIs currently require device removal and prolonged courses of antimicrobial therapy to effect a cure. Therefore, making an accurate diagnosis, defining both the presence of infection and the involved microorganisms, is paramount. The sensitivity of standard microbial culture for IAI diagnosis varies depending on the type of IAI, the specimen analyzed, and the culture technique(s) used. Although IAI-specific culture-based diagnostics have been described, the challenge of culture-negative IAIs remains. Given this, molecular assays, including both nucleic acid amplification tests and next-generation sequencing-based assays, have been used. In this review, an overview of these challenging infections is presented, as well as an approach to their diagnosis from a microbiologic perspective.
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Affiliation(s)
- Marisa Ann Azad
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robin Patel
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of 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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García-Pérez D, García-Posadas G, San-Juan R, Brañas P, Panero-Pérez I, Delgado-Fernández J, Paredes I. A prospective study to identify preoperative serum parameters for spinal implant infection detected by sonication fluid culture. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1818-1829. [PMID: 36897428 DOI: 10.1007/s00586-023-07628-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/03/2023] [Accepted: 02/23/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE Low-virulent microorganisms identified on pedicle screws by sonication fluid culture (SFC) are an important cause of implant loosening. While sonication of explanted material improves the detection rate, the risk of contamination exists and no standardized diagnostic criteria for chronic low-grade spinal implant-related infection (CLGSII) are stablished. Besides, the role of serum C-reactive protein (CRP) and procalcitonin (PCT) in CLGSII has not been adequately investigated. METHODS Blood samples were collected prior to implant removal. To increase sensitivity, the explanted screws were sonicated and processed separately. Patients exhibiting at least one positive SFC were classified in the infection group (loose criteria). To increase specificity, the strict criteria only considered multiple positive SFC (≥ 3 implants and/or ≥ 50% of explanted devices) as meaningful for CLGSII. Factors which might promote implant infection were also recorded. RESULTS Thirty-six patients and 200 screws were included. Among them, 18 (50%) patients had any positive SFCs (loose criteria), whereas 11 (31%) patients fulfilled the strict criteria for CLGSII. Higher serum protein level was the most accurate marker for the preoperative detection of CLGSSI, exhibiting an area under the curve of 0.702 (loose criteria) and 0.819 (strict criteria) for the diagnosis of CLGSII. CRP only exhibited a modest accuracy, whereas PCT was not a reliable biomarker. Patient history (spinal trauma, ICU hospitalization and/or previous wound-related complications) increased the likelihood of CLGSII. CONCLUSION Markers of systemic inflammation (serum protein level) and patient history should be employed to stratify preoperative risk of CLGSII and decide the best treatment strategy.
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Affiliation(s)
- Daniel García-Pérez
- Department of Neurosurgery, University Hospital, 12 de Octubre, Avda de Córdoba S/N, 28041, Madrid, Spain.
- Department of Neurosurgery, Complejo Universitario Hospital Albacete, Calle Hermanos Falcó 37, 02008, Albacete, Spain.
| | - Guillermo García-Posadas
- Department of Neurosurgery, University Hospital, 12 de Octubre, Avda de Córdoba S/N, 28041, Madrid, Spain
| | - Rafael San-Juan
- Unit of Infectious Diseases, University Hospital, 12 de Octubre, Avda de Córdoba S/N, 28041, Madrid, Spain
| | - Patricia Brañas
- Department of Clinical Microbiology, University Hospital, 12 de Octubre, Avda de Córdoba S/N, 28041, Madrid, Spain
| | - Irene Panero-Pérez
- Department of Neurosurgery, University Hospital, 12 de Octubre, Avda de Córdoba S/N, 28041, Madrid, Spain
| | - Juan Delgado-Fernández
- Department of Neurosurgery, University Hospital, 12 de Octubre, Avda de Córdoba S/N, 28041, Madrid, Spain
| | - Igor Paredes
- Department of Neurosurgery, University Hospital, 12 de Octubre, Avda de Córdoba S/N, 28041, Madrid, Spain
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Aldahamsheh O, Burger LD, Evaniew N, Swamy G, Jacobs WB, Thomas KC, Nicholls F. Unexpected intraoperative positive culture (UIPC) in presumed aseptic revision spine surgery: a systematic review and meta-analysis. Spine J 2023; 23:492-503. [PMID: 36336255 DOI: 10.1016/j.spinee.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/16/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND CONTEXT Unexpected intraoperative positive culture (UIPC) has recently become increasingly common in revision spine surgery, being implicated as an etiological factor in revision spine surgery indications such as implant failure or pseudoarthrosis. PURPOSE Utilizing the available literature, this study aimed to investigate the prevalence of UIPC, and its clinical importance in patients following presumed aseptic revision spine surgery. STUDY DESIGN Meta-analysis and systematic review. METHODS Multiple databases and reference articles were searched until May 2022. The primary outcome was the pooled rate of UIPC, and the secondary outcomes were the microbiological profile of UIPC, the risk factors of UIPC, and the clinical fate of UIPC. RESULTS Twelve studies were eligible for meta-analysis, with a total of 1,108 patients. The pooled rate of UIPC was 24.3% (95% CI=15.8%-35.5%) in adult patients, and 43.2% (95% CI=32.9%-54.2%) in pediatric patients. The UIPC rate was higher when both conventional wound culture and sonication were used together compared to sonication alone or conventional wound culture alone. The rates were 28.9%, 23.6%, and 15.5 %, respectively. In adult and pediatric patients, the most commonly cultured organism was Cutibacterium acnes (42.5% vs 57.7%), followed by coagulase-negative Staphylococcus (39.9% vs 30.5%). Male patients had a higher rate of UIPC (OR= 2.6, 95% CI=1.84-3.72, p<.001), as did patients with a longer fusion construct (MD=0.76, 95% CI=0.27-1.25, p<.001). CONCLUSIONS The pooled rate of UIPC in aseptic spine revision surgery was 24.3% and 43.2% in adult and pediatric patients respectively. The most common organisms were C. acnes and coagulase-negative Staphylococcus. The impact of UIPC on patients` clinical outcomes is not fully understood. We are not able to recommend routine culture in revision spine surgery, however, adding sonication may aid in the diagnosis of UIPC. There is not enough evidence to recommend specific treatment strategies at this time, and further studies are warranted.
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Affiliation(s)
- Osama Aldahamsheh
- Division of Orthopedic Surgery-Spine Program, Department of Surgery, University of Calgary, 1403 - 29 St, NW Calgary, Alberta, Canada.
| | - Lukas D Burger
- Division of Orthopedic Surgery-Spine Program, Department of Surgery, University of Calgary, 1403 - 29 St, NW Calgary, Alberta, Canada
| | - Nathan Evaniew
- Division of Orthopedic Surgery-Spine Program, Department of Surgery, University of Calgary, 1403 - 29 St, NW Calgary, Alberta, Canada
| | - Ganesh Swamy
- Division of Orthopedic Surgery-Spine Program, Department of Surgery, University of Calgary, 1403 - 29 St, NW Calgary, Alberta, Canada
| | - W Bradley Jacobs
- Division of Orthopedic Surgery-Spine Program, Department of Surgery, University of Calgary, 1403 - 29 St, NW Calgary, Alberta, Canada
| | - Kenneth C Thomas
- Division of Orthopedic Surgery-Spine Program, Department of Surgery, University of Calgary, 1403 - 29 St, NW Calgary, Alberta, Canada
| | - Fred Nicholls
- Division of Orthopedic Surgery-Spine Program, Department of Surgery, University of Calgary, 1403 - 29 St, NW Calgary, Alberta, Canada
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Peng G, Liu Q, Guan Z, Liu M, Sun X, Zhu X, Chen J, Feng W, Li J, Zeng J, Zhong Z, Zeng Y. Diagnostic accuracy of sonication fluid cultures from prosthetic components in periprosthetic joint infection: an updated diagnostic meta-analysis. J Orthop Surg Res 2023; 18:175. [PMID: 36890571 PMCID: PMC9996915 DOI: 10.1186/s13018-023-03662-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/27/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is the most serious complication following total joint arthroplasty (TJA) and has a significant impact on patients and the national healthcare system. To date, the diagnosis of PJI is still confronted with dilemmas. The present study investigated the validity of sonication fluid culture (SFC) for removing implants in the diagnosis of PJI after joint replacement. METHODS From database establishment to December 2020, relevant literature was retrieved from the PubMed, Web of Science, Embase and Cochrane Library databases. Two reviewers independently performed quality assessment and data extraction to calculate the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), area under the curve (AUC) and diagnostic odds ratio (DOR) to evaluate the diagnostic value of overall SFC for PJI. RESULTS A total of 38 eligible studies including 6302 patients were selected in this study. The pooled sensitivity, specificity, PLR, NLR, and DOR of SFC for PJI diagnosis were 0.77 (95% confidence interval [CI], 0.76-0.79), 0.96 (95% CI, 0.95-0.96), 18.68 (95% CI, 11.92-29.28), 0.24 (95% CI, 0.21-0.29), and 85.65 (95% CI, 56.46-129.94), respectively, while the AUC was 0.92. CONCLUSION This meta-analysis showed that SFC was of great value in PJI diagnosis, and the evidence of SFC on PJI was more favorable but not yet strong. Therefore, improvement of the diagnostic accuracy of SFC is still necessary, and the diagnosis of PJI continues to warrant a multiplex approach before and during a revision procedure.
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Affiliation(s)
- Guanrong Peng
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, People's Republic of China.,Yudu People's Hospital, Huancheng North Road 2#, District Yudu, Ganzhou, 342300, Jiangxi, People's Republic of China
| | - Qiang Liu
- Peking University People's Hospital, Arthritis Clinic and Research Center, Beijing, People's Republic of China
| | - Zhenhua Guan
- Yudu People's Hospital, Huancheng North Road 2#, District Yudu, Ganzhou, 342300, Jiangxi, People's Republic of China
| | - Min Liu
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, People's Republic of China
| | - Xiaobo Sun
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, People's Republic of China
| | - Xingyang Zhu
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, People's Republic of China
| | - Jinlun Chen
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Wenjun Feng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Jie Li
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Jianchun Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Zhangrong Zhong
- Yudu People's Hospital, Huancheng North Road 2#, District Yudu, Ganzhou, 342300, Jiangxi, People's Republic of China.
| | - Yirong Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, People's Republic of China.
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Spindler P, Braun F, Truckenmüller P, Wasilewski D, Faust K, Schneider GH, Trampuz A, Conen A, Kühn AA, Vajkoczy P, Prinz V. Surgical Site Infections Associated With Implanted Pulse Generators for Deep Brain Stimulation: Meta-Analysis and Systematic Review. Neuromodulation 2023; 26:280-291. [PMID: 35970765 DOI: 10.1016/j.neurom.2022.03.014] [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: 12/13/2021] [Revised: 02/18/2022] [Accepted: 03/14/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The aim of this study was to identify and systematically analyze relevant literature on surgical site infections (SSIs) associated with implantable pulse generator (IPG) procedures for deep brain stimulation (DBS). MATERIALS AND METHODS In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review and meta-analyses of 58 studies that reported SSI rates of 11,289 patients and 15,956 IPG procedures. A meta-analysis of proportions was performed to estimate the pooled proportion of SSIs across DBS procedures in general and to estimate the proportion of SSIs that occur at the IPG pocket. Moreover, a meta-analysis of odds ratio (OR) was conducted on those studies that reported their results of applying topical vancomycin powder during closure of the IPG wound. Results are presented as rates and OR with 95% CIs. RESULTS The pooled proportion of SSIs was 4.9% (95% CI, 4.1%-6.1%) among all DBS procedures. The dominant SSI localization was the IPG pocket in 61.2% (95% CI, 53.4%-68.5%). A trend toward a beneficial effect of vancomycin powder over standard wound closure was found with an OR of 0.46 (95% CI, 0.21-1.02). Most studies (79.1%) that reported their treatment strategy in case of SSI had a strict protocol of removal of the IPG, followed by antimicrobial treatment and reimplantation of the IPG once the SSI had been eradicated. CONCLUSIONS The IPG pocket was identified as the main site of SSI after DBS procedures. Most studies recommend complete IPG removal, antimicrobial treatment, and reimplantation of an IPG once the SSI has been eradicated. Future studies are needed to clarify the role of alternative approaches (eg, topical vancomycin powder) in the prevention of SSI associated with IPG.
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Affiliation(s)
- Philipp Spindler
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Franziska Braun
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Peter Truckenmüller
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - David Wasilewski
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Katharina Faust
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Gerd-Helge Schneider
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Anna Conen
- Clinic for Infectious Diseases and Infection Prevention, Department of Infectious Diseases and Hospital Hygiene, Kantonsspital Aarau, Aarau, Switzerland
| | - Andrea A Kühn
- Department of Neurology, Movement Disorder Section, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Vincent Prinz
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Department of Neurosurgery, University Hospital, Goethe University, Frankfurt am Main, Germany.
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Choi SW, Lee JC, Lee WS, Hwang JY, Baek MJ, Choi YS, Jang HD, Shin BJ. Clinical differences between delayed and acute onset postoperative spinal infection. Medicine (Baltimore) 2022; 101:e29366. [PMID: 35713438 PMCID: PMC9276148 DOI: 10.1097/md.0000000000029366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 04/11/2022] [Indexed: 11/25/2022] Open
Abstract
Spine surgeons often encounter cases of delayed postoperative spinal infection (PSI). Delayed-onset PSI is a common clinical problem. However, since many studies have investigated acute PSIs, reports of delayed PSI are rare. The purpose of this study was to compare the clinical features, treatment course, and prognosis of delayed PSI with acute PSI.Ninety-six patients diagnosed with postoperative spinal infection were enrolled in this study. Patients were classified into 2 groups: acute onset (AO) within 90 days (n = 73) and delayed onset (DO) after 90 days (n = 23). The baseline data, clinical manifestations, specific treatments, and treatment outcomes were compared between the 2 groups.The history of diabetes mellitus (DM) and metallic instrumentation at index surgery were more DO than the AO group. The causative organisms did not differ between the 2 groups. Redness or heat sensation around the surgical wound was more frequent in the AO group (47.9%) than in the DO group (21.7%) (P = .02). The mean C-reactive protein levels during infection diagnosis was 8.9 mg/dL in the AO and 4.0 mg/dL in the DO group (P = .02). All patients in the DO group had deep-layer infection. In the DO group, revision surgery and additional instrumentation were required, and the duration of parenteral antibiotic use and total antibiotic use was significantly longer than that in the AO group. Screw loosening, disc space collapse, and instability were higher in the DO group (65.2%) than in the AO group (41.1%) (P = .04). However, the length of hospital stay did not differ between the groups.Delayed-onset PSI requires more extensive and longer treatment than acute-onset surgical site infection. Clinicians should try to detect the surgical site infection as early as possible.
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Affiliation(s)
- Sung-Woo Choi
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae Chul Lee
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Won Seok Lee
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jin Yeong Hwang
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Min Jung Baek
- Department of Obstetrics and Gynecology, Bundang CHA Hospital, Seongnam, Korea
| | - Yoon Seo Choi
- Early Childhood Education, Ewha Woman's University, Korea
| | - Hae-Dong Jang
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Byung-Joon Shin
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
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10
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Ponraj DS, Lange J, Falstie-Jensen T, Jørgensen NP, Ravn C, Poehlein A, Brüggemann H. Amplicon-Based Next-Generation Sequencing as a Diagnostic Tool for the Detection of Phylotypes of Cutibacterium acnes in Orthopedic Implant-Associated Infections. Front Microbiol 2022; 13:866893. [PMID: 35464945 PMCID: PMC9022064 DOI: 10.3389/fmicb.2022.866893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/21/2022] [Indexed: 01/04/2023] Open
Abstract
The diagnosis of orthopedic implant-associated infections (OIAIs) caused by the slow-growing anaerobic bacterium Cutibacterium acnes is challenging. The mild clinical presentations of this low-virulent bacterium along with its ubiquitous presence on human skin and human-dominated environments often make it difficult to differentiate true infection from contamination. Previous studies have applied C. acnes phylotyping as a potential avenue to distinguish contamination from infection; several studies reported a prevalence of phylotypes IB [corresponding to type H in the single-locus sequence typing (SLST) scheme] and II (SLST type K) in OIAIs, while a few others found phylotype IA1 (more specifically SLST type A) to be abundant. However, phylotype determination has mainly been done in a culture-dependent manner on randomly selected C. acnes isolates. Here, we used a culture-independent amplicon-based next-generation sequencing (aNGS) approach to determine the presence and relative abundances of C. acnes phylotypes in clinical OIAI specimens. As amplicon, the SLST target was used, a genomic fragment that is present in all C. acnes strains known to date. The aNGS approach was applied to 30 sonication fluid (SF) samples obtained from implants removed during revision surgeries, including 17 C. acnes culture-positive and 13 culture-negative SF specimens. In 53% of the culture-positive samples, SLST types were identified: relative abundances were highest for K-type C. acnes, followed by H- and D-type C. acnes. Other types, including A- and C-type C. acnes that are more prevalent on human skin, had low relative abundances. The aNGS results were compared with, and confirmed by a culture-dependent approach, which included the isolation, whole genome sequencing (WGS) and phylotyping of 36 strains of C. acnes obtained from these SF samples. Besides serving as a powerful adjunct to identify C. acnes phylotypes, the aNGS approach could also distinguish mono- from heterotypic infections, i.e., infections caused by more than one phylotype of C. acnes: in eight out of nine culture-positive SF samples multiple C. acnes types were detected. We propose that the aNGS approach, along with the patient’s clinical information, tissue and SF cultures and WGS, could help differentiate C. acnes contamination from true infection.
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Affiliation(s)
| | - Jeppe Lange
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Orthopedic Surgery, Horsens Regional Hospital, Horsens, Denmark
| | | | | | - Christen Ravn
- Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopedic Surgery, Lillebaelt Hospital, Kolding, Denmark
| | - Anja Poehlein
- Department of Genomic and Applied Microbiology, Institute of Microbiology and Genetics, University of Göttingen, Göttingen, Germany
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11
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Wang Y, Che M, Zheng Z, Liu J, Ji X, Sun Y, Xin J, Gong W, Na S, Jin Y, Wang S, Zhang S. Animal Models for Postoperative Implant‐Related Spinal Infection. Orthop Surg 2022; 14:1049-1058. [PMID: 35466555 PMCID: PMC9163983 DOI: 10.1111/os.13238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 01/13/2022] [Accepted: 01/19/2022] [Indexed: 12/04/2022] Open
Abstract
Postoperative infections following implant‐related spinal surgery are severe and disastrous complications for both orthopaedic surgeons and patients worldwide. They can cause neurological damage, disability, and death. To better understand the mechanism of these destructive complications and intervene in the process, further research is needed. Therefore, there is an urgent need for efficient, accurate, and easily available animal models to study the pathogenesis of spinal infections and develop new and effective anti‐bacterial methods. In this paper, we provide a general review of the commonly used animal models of postoperative implant‐related spinal infections, describe their advantages and disadvantages, and highlight the significance of correctly choosing the model according to the infection aspect under investigation. These models are valuable tools contributing to the better understanding of postoperative spinal infections and will continue to facilitate the invention of novel preventative and treatment strategies for patients with postoperative spinal infections. However, although they are valid and reproducible in some respects, the current animal models present certain limitations. Future ideal spinal infection animal models may assess the bacterial load of the same animal in real‐time in vivo, and better mimic the human anatomy as well as surgical techniques. Strains other than Staphylococcus aureus account for a large proportion of postoperative spinal infections, and thus, the establishment of models to evaluate other types of microbial infections is expected in the future. Furthermore, novel transgenic models established on advancements in genome editing are also likely to be developed in the future.
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Affiliation(s)
- Yongjie Wang
- Department of Spinal Surgery the First Hospital of Jilin University Changchun China
- Jilin Engineering Research Center for Spine and Spinal Cord Injury Changchun China
| | - Mingxue Che
- Department of Spinal Surgery the First Hospital of Jilin University Changchun China
- Jilin Engineering Research Center for Spine and Spinal Cord Injury Changchun China
| | - Zhi Zheng
- Department of Spinal Surgery the First Hospital of Jilin University Changchun China
- Jilin Engineering Research Center for Spine and Spinal Cord Injury Changchun China
| | - Jun Liu
- Institute of Military Veterinary Science the Academy of Military Medical Science of PLA Changchun China
| | - Xue Ji
- Institute of Military Veterinary Science the Academy of Military Medical Science of PLA Changchun China
| | - Yang Sun
- Institute of Military Veterinary Science the Academy of Military Medical Science of PLA Changchun China
| | - Jingguo Xin
- Department of Spinal Surgery the First Hospital of Jilin University Changchun China
- Jilin Engineering Research Center for Spine and Spinal Cord Injury Changchun China
| | - Weiquan Gong
- Department of Spinal Surgery the First Hospital of Jilin University Changchun China
- Jilin Engineering Research Center for Spine and Spinal Cord Injury Changchun China
| | - Shibo Na
- Department of Spinal Surgery the First Hospital of Jilin University Changchun China
- Jilin Engineering Research Center for Spine and Spinal Cord Injury Changchun China
| | - Yuanzhe Jin
- Department of Spinal Surgery the First Hospital of Jilin University Changchun China
- Jilin Engineering Research Center for Spine and Spinal Cord Injury Changchun China
| | - Shuo Wang
- Department of Ophthalmology the Second Hospital of Jilin University Changchun China
| | - Shaokun Zhang
- Department of Spinal Surgery the First Hospital of Jilin University Changchun China
- Jilin Engineering Research Center for Spine and Spinal Cord Injury Changchun China
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12
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A Porcine Model for the Development and Testing of Preoperative Skin Preparations. Microorganisms 2022; 10:microorganisms10050837. [PMID: 35630283 PMCID: PMC9146673 DOI: 10.3390/microorganisms10050837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 04/11/2022] [Accepted: 04/14/2022] [Indexed: 11/17/2022] Open
Abstract
Clinical preoperative skin preparations (PSPs) do not eradicate skin flora dwelling in the deepest dermal regions. Survivors constitute a persistent infection risk. In search of solutions, we created a porcine model intended for PSP developmental testing. This model employed microbiological techniques sensitive to the deep-dwelling microbial flora as these microorganisms are frequently overlooked when using institutionally-entrenched testing methodologies. Clinical gold-standard PSPs were assessed. Ten Yorkshire pigs were divided into two groups: prepared with either povidone iodine (PVP-I) or chlorhexidine gluconate (CHG) PSP. Bioburdens were calculated on square, 4 cm by 4 cm, full-thickness skin samples homogenized in neutralizing media. Endogenous bioburden of porcine skin (3.3 log10 CFU/cm2) was consistent with natural flora numbers in dry human skin. On-label PSP scrub kits with PVP-I (n = 39) or CHG (n = 40) failed the 2–3 log10-reduction criteria established for PSPs by the Food and Drug Administration (FDA), resulting in a 1.46 log10 and 0.58 log10 reduction, respectively. Porcine dermal microbiota mirrored that of humans, displaying abundant staphylococcal species. Likewise, histological sections showed similarity in hair follicle depths and sebaceous glands (3.2 ± 0.7 mm). These shared characteristics and the considerable fraction of bacteria which survived clinical PSPs make this model useful for developmental work.
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13
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14
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Coenye T, Spittaels KJ, Achermann Y. The role of biofilm formation in the pathogenesis and antimicrobial susceptibility of Cutibacterium acnes. Biofilm 2021; 4:100063. [PMID: 34950868 PMCID: PMC8671523 DOI: 10.1016/j.bioflm.2021.100063] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 12/20/2022] Open
Abstract
Cutibacterium acnes (previously known as Propionibacterium acnes) is frequently found on lipid-rich parts of the human skin. While C. acnes is most known for its role in the development and progression of the skin disease acne, it is also involved in many other types of infections, often involving implanted medical devices. C. acnes readily forms biofilms in vitro and there is growing evidence that biofilm formation by this Gram-positive, facultative anaerobic micro-organism plays an important role in vivo and is also involved in treatment failure. In this brief review we present an overview on what is known about C. acnes biofilms (including their role in pathogenesis and reduced susceptibility to antibiotics), discuss model systems that can be used to study these biofilms in vitro and in vivo and give an overview of interspecies interactions occurring in polymicrobial communities containing C. acnes.
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Affiliation(s)
- Tom Coenye
- Laboratory of Pharmaceutical Microbiology, Ghent University, Gent, Belgium
| | - Karl-Jan Spittaels
- Laboratory of Pharmaceutical Microbiology, Ghent University, Gent, Belgium
| | - Yvonne Achermann
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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15
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Oliva A, Miele MC, Al Ismail D, Di Timoteo F, De Angelis M, Rosa L, Cutone A, Venditti M, Mascellino MT, Valenti P, Mastroianni CM. Challenges in the Microbiological Diagnosis of Implant-Associated Infections: A Summary of the Current Knowledge. Front Microbiol 2021; 12:750460. [PMID: 34777301 PMCID: PMC8586543 DOI: 10.3389/fmicb.2021.750460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/04/2021] [Indexed: 12/14/2022] Open
Abstract
Implant-associated infections are characterized by microbial biofilm formation on implant surface, which renders the microbiological diagnosis challenging and requires, in the majority of cases, a complete device removal along with a prolonged antimicrobial therapy. Traditional cultures have shown unsatisfactory sensitivity and a significant advance in the field has been represented by both the application of the sonication technique for the detachment of live bacteria from biofilm and the implementation of metabolic and molecular assays. However, despite the recent progresses in the microbiological diagnosis have considerably reduced the rate of culture-negative infections, still their reported incidence is not negligible. Overall, several culture- and non-culture based methods have been developed for diagnosis optimization, which mostly relies on pre-operative and intra-operative (i.e., removed implants and surrounding tissues) samples. This review outlines the principal culture- and non-culture based methods for the diagnosis of the causative agents of implant-associated infections and gives an overview on their application in the clinical practice. Furthermore, advantages and disadvantages of each method are described.
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Affiliation(s)
- Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Maria Claudia Miele
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Dania Al Ismail
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Federica Di Timoteo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Massimiliano De Angelis
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Luigi Rosa
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Antimo Cutone
- Department of Biosciences and Territory, University of Molise, Pesche, Italy
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Maria Teresa Mascellino
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Piera Valenti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
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16
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Ponraj DS, Falstie-Jensen T, Jørgensen NP, Ravn C, Brüggemann H, Lange J. Diagnosis of orthopaedic-implant-associated infections caused by slow-growing Gram-positive anaerobic bacteria - a clinical perspective. J Bone Jt Infect 2021; 6:367-378. [PMID: 34660180 PMCID: PMC8515996 DOI: 10.5194/jbji-6-367-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/13/2021] [Indexed: 12/21/2022] Open
Abstract
Slow-growing Gram-positive anaerobic bacteria (SGAB) such as
Cutibacterium acnes are increasingly recognized as causative agents of implant-associated infections (IAIs) in orthopaedic surgeries. SGAB IAIs are difficult to diagnose because of their non-specific clinical and laboratory findings as well as the fastidious growth conditions required by these bacteria. A high degree of clinical suspicion and awareness of the various available diagnostic methods is therefore important. This review gives an overview of the current knowledge regarding SGAB IAI, providing details about clinical features and available diagnostic methodologies. In recent years, new methods for the diagnosis of IAI were developed, but there is limited knowledge about their usefulness in SGAB IAI. Further studies are required to determine the ideal diagnostic methodology to identify these infections so that they are not overlooked and mistakenly classified as aseptic failure.
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Affiliation(s)
| | - Thomas Falstie-Jensen
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, 8200, Denmark
| | | | - Christen Ravn
- Department of Orthopaedic Surgery, Lillebaelt Hospital, Kolding, 6000, Denmark
| | | | - Jeppe Lange
- Department of Clinical Medicine, Aarhus University, Aarhus, 8000, Denmark.,Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, 8700, Denmark
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17
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Fatima N, Bjarnsholt T, Bay L. Dynamics of skin microbiota in shoulder surgery infections. APMIS 2021; 129:665-674. [PMID: 34587324 DOI: 10.1111/apm.13185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/25/2021] [Indexed: 01/10/2023]
Abstract
Post-surgical infections arise due to various contributing factors. Most important is the presence of potential pathogenic microorganisms in the skin complemented by the patient´s health status. Cutibacterium acnes is commonly present in the pilosebaceous glands and hair follicle funnels in human skin. After surgical intervention, these highly prevalent, slow-growing bacteria can be found in the deeper tissues and in proximity of implants. C. acnes is frequently implicated in post-surgical infections, often resulting in the need for revision surgery. This review summarizes the current understanding of microbial dynamics in shoulder surgical infections. In particular, we shed light on the contribution of C. acnes to post-surgical shoulder infections as well as their colonization and immune-modulatory potential. Despite being persistently found in post-surgical tissues, C. acnes is often underestimated as a causative organism due to its slow growth and the inefficient detection methods. We discuss the role of the skin environment constituted by microbial composition and host cellular status in influencing C. acnes recolonization potential. Future mapping of the individual skin microbiome in shoulder surgery patients using advanced molecular methods would be a useful approach for determining the risk of post-operative infections.
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Affiliation(s)
- Naireen Fatima
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Bjarnsholt
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
| | - Lene Bay
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
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18
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Spindler P, Faust K, Finger T, Schneider GH, Bayerl S, Trampuz A, Kühn AA, Vajkoczy P, Prinz V. High Frequency of Low-Virulent Microorganisms Detected by Sonication of Implanted Pulse Generators: So What? Stereotact Funct Neurosurg 2021; 100:8-13. [PMID: 34488223 DOI: 10.1159/000517472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/10/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Deep brain stimulation (DBS) has become a well-established treatment modality for a variety of conditions over the last decades. Multiple surgeries are an essential part in the postoperative course of DBS patients if nonrechargeable implanted pulse generators (IPGs) are applied. So far, the rate of subclinical infections in this field is unknown. In this prospective cohort study, we used sonication to evaluate possible microbial colonization of IPGs from replacement surgery. METHODS All consecutive patients undergoing IPG replacement between May 1, 2019 and November 15, 2020 were evaluated. The removed hardware was investigated using sonication to detect biofilm-associated bacteria. Demographic and clinical data were analyzed. RESULTS A total of 71 patients with a mean (±SD) of 64.5 ± 15.3 years were evaluated. In 23 of these (i.e., 32.4%) patients, a positive sonication culture was found. In total, 25 microorganisms were detected. The most common isolated microorganisms were Cutibacterium acnes (formerly known as Propionibacterium acnes) (68%) and coagulase-negative Staphylococci (28%). Within the follow-up period (5.2 ± 4.3 months), none of the patients developed a clinical manifest infection. DISCUSSIONS/CONCLUSIONS Bacterial colonization of IPGs without clinical signs of infection is common but does not lead to manifest infection. Further larger studies are warranted to clarify the impact of low-virulent pathogens in clinically asymptomatic patients.
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Affiliation(s)
- Philipp Spindler
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Katharina Faust
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Tobias Finger
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Gerd-Helge Schneider
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Simon Bayerl
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Andrej Trampuz
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Andrea A Kühn
- Department of Neurology, Movement Disorder and Neuromodulation Unit, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Vincent Prinz
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
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19
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[Infections of the spine : Pyogenic spondylodiscitis and implant-associated vertebral osteomyelitis]. Unfallchirurg 2021; 124:489-504. [PMID: 33970304 DOI: 10.1007/s00113-021-01002-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
Pyogenic (unspecific) spondylodiscitis and implant-associated vertebral osteomyelitis (IAVO) are important diseases with the risk of neurological and septic complications. An early diagnosis is essential in which magnetic resonance imaging (MRI), histopathology and microbiological identification of the pathogen play key roles. The goals of conservative treatment in uncomplicated spondylodiscitis are antibiotic infection control and pain management. In the case of sepsis, neurological deficits, segmental instability or epidural abscesses surgical treatment of the infection with stabilization of the spine should be considered. In IAVO the formation of a mature biofilm represents the transition from acute to chronic infection. Acute infections can be treated by extensive debridement in combination with biofilm-active antibiotic treatment while retaining the implant. In chronic infections implant removal or exchange in combination with several weeks of antibiotic treatment is often necessary.
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20
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Wang K, Li W, Liu H, Yang Y, Lv L. Progress in Prevention, Diagnosis, and Treatment of Periprosthetic Joint Infection. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2021; 2021:3023047. [PMID: 33542741 PMCID: PMC7840269 DOI: 10.1155/2021/3023047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 01/02/2021] [Accepted: 01/11/2021] [Indexed: 12/24/2022]
Abstract
Periprosthetic joint infection (PJI) after joint replacement surgery is a severe complication associated with high morbidity and increased treatment costs. More than 25% of joint implant failures are attributed to PJI. PJI diagnosis and treatment methods have substantially improved in recent years. However, the prevalence of PJI remains high, primarily due to the increased prevalences of obesity, diabetes, and other underlying conditions. Moreover, increasing elderly prefers to total joint replacement surgery. However, due to frailty and comorbidities, most are at increased risk of infectious arthritis and artificial joint infection (PJI). Therefore, PJI management for the elderly requires multilevel and multiangle intervention. In this review, we summarize the risk factors and diagnostic methods currently available for PJI and discuss the current PJI prevention and treatment interventions, especially the management in older adults.
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Affiliation(s)
- Kai Wang
- International Medicine Center, Tianjin Hospital, 406 Jiefang South Road, Hexi District, Tianjin 300211, China
| | - Wei Li
- College of Light Industry Science and Engineering, Tianjin University of Science and Technology, Tianjin 30045, China
| | - Huayu Liu
- College of Light Industry Science and Engineering, Tianjin University of Science and Technology, Tianjin 30045, China
| | - Yang Yang
- International Medicine Center, Tianjin Hospital, 406 Jiefang South Road, Hexi District, Tianjin 300211, China
| | - Lingyun Lv
- Department of Otorhinolaryngology-Head and Neck Surgery, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian 223300, China
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21
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Cieslinski J, Ribeiro VST, Kraft L, Suss PH, Rosa E, Morello LG, Pillonetto M, Tuon FF. Direct detection of microorganisms in sonicated orthopedic devices after in vitro biofilm production and different processing conditions. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:1113-1120. [PMID: 33394140 DOI: 10.1007/s00590-020-02856-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 12/16/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The gold standard for microbial detection in prosthetic joint infections is the multiple culture of the peri-prosthetic tissue. The fluid cultures after sonication can improve the recovery of the microorganisms. OBJECTIVE The aim of this study was to evaluate the sonication technique with a plastic bag and the effect of refrigeration on microorganism detection with conventional culturing, MALDI-TOF MS and qPCR assay on an orthopedic screw model. METHODS We produced biofilms of Staphylococcus aureus, Pseudomonas aeruginosa, and Candida albicans on orthopedic screws, which were stored under different conditions and temperatures before sonication. After sonication, the mass spectrometry by MALDI-TOF, qPCR and culture protocols was performed using the sonicated fluid, for detecting the microorganisms involved in the biofilm. RESULTS The bacterial bioburden decreased by approximately one log after the refrigeration period, in the screws containing P. aeruginosa and S. aureus biofilms. All the microorganisms involved in the screw biofilms were detected with MALDI-TOF and qPCR. Significant reductions in CFU counts occurred only in groups stored in the plastic bag, indicating that changes in temperature and humidity may favor cell death. However, this variation is not important for this model as it did not affect the detection owing to the high counts obtained. CONCLUSION Microbial identification by MALDI-TOF in sonicated fluid is feasible. With qPCR, there were no differences between the detection in the screws processed immediately or after refrigeration. It is necessary to consider whether or not the refrigeration period would affect microbial recovery in an explanted prosthesis.
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Affiliation(s)
- Juliette Cieslinski
- Laboratory of Emerging Infectious Diseases (LEID), School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
| | - Victoria Stadler Tasca Ribeiro
- Laboratory of Emerging Infectious Diseases (LEID), School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
| | - Letícia Kraft
- Laboratory of Emerging Infectious Diseases (LEID), School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
| | - Paula Hansen Suss
- Laboratory of Emerging Infectious Diseases (LEID), School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
| | - Edvaldo Rosa
- Xenobiotics Research Unit, School of Life Sciences, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
| | - Luis Gustavo Morello
- Paraná Institute of Molecular Biology, Curitiba, Brazil.,Laboratory for Applied Science and Technology in Health, Carlos Chagas Institute, Oswaldo Cruz Foundation (Fiocruz), Curitiba, PR, Brazil
| | - Marcelo Pillonetto
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
| | - Felipe Francisco Tuon
- Laboratory of Emerging Infectious Diseases (LEID), School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil. .,Escola de Medicina-Pontifícia Universidade Católica do Paraná, R. Imaculada Conceição, 1155 - Prado Velho, Curitiba, PR, 80215-901, Brazil.
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22
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Prinz V, Vajkoczy P. Surgical revision strategies for postoperative spinal implant infections (PSII). JOURNAL OF SPINE SURGERY (HONG KONG) 2020; 6:777-784. [PMID: 33447683 PMCID: PMC7797799 DOI: 10.21037/jss-20-514] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Over the last years the number of spine surgeries with instrumentation has grown to an indispensable column in the treatment for different pathologies of the spine. A further increase in the incidence of instrumented spinal surgery is expected throughout the next years. Although the implementation and development of new techniques offer faster and more minimal invasive procedures, shortening surgery time, reducing soft tissue injury and revision due to hardware misplacement, the incidence of postoperative spinal implant infections (PSII) remains high. PSII related complications and revision procedures pose an enormous socioeconomic burden. Therefore, standardized strategies and protocols for treatment of PSII are urgently needed. While in former times hardware exchange or hardware removal was common practise in the field of spine surgery this approach has changed over the last years. Although the evidence from clinical studies in the field of PSII is of limited evidence, critical variables for revision strategies of PSII have been identified. Further, to quickly advance in the field of PSII it is certainly important to extrapolate and learn using data regarding the management from other fields of prosthetic joint infections. This should include clinical as well as experimental work in particular in the context of the biofilm, sonication as well as microbiological concepts. Over the last years, at our institution standardized procedures for diagnostic, surgical as well as antimicrobial treatment have been developed, based on the latest recommendations in peer-reviewed literature and our own data. Here we give an overview about surgical revision strategies for PSII and discuss the key points of our standardized protocol.
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Affiliation(s)
- Vincent Prinz
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
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23
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Zippelius T, Bürger J, Schömig F, Putzier M, Matziolis G, Strube P. Clinical presentation and diagnosis of acute postoperative spinal implant infection (PSII). JOURNAL OF SPINE SURGERY 2020; 6:765-771. [PMID: 33447681 DOI: 10.21037/jss-20-587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute postoperative infections after surgical interventions on the spinal column are associated with prolonged treatment duration, poor patient outcomes, and a high socioeconomic burden. In the field of joint replacement, guidelines have been established with recommendations for the diagnosis and treatment of such complications, but in spinal surgery there are no definitions permitting distinction between early and late infections and no specific instructions for their management. Various factors increase the risk of acute postoperative infection, including blood transfusions, leakage of cerebrospinal fluid, urinary tract infection, injury of the dura mater, an American Society of Anesthesiologists (ASA) score >2, obesity, diabetes mellitus, and surgical revision. We suggest defining all infections occurring within the first 4 weeks after spinal surgery as early infections. The symptoms are pain at rest, on motion, and/or pressure pain, abnormal warmth, local erythema, circumscribed swelling of the wound, and newly occurring secretion. Together with laboratory parameters such as C-reactive protein (CRP) and leukocytes, a central role is played by imaging in the form of magnetic resonance imaging (MRI), although diagnosis can be hampered by the presence of postoperative fluid collections such as edema or hematoma or by artifacts from an implant. Once an infection has been confirmed, immediate wound revision with debridement and rinsing (sodium hypochlorite) is essential. Intraoperatively it may prove advantageous to use jet lavage and administer vancomycin. We recommend leaving the implant in place in cases of acute postoperative infection. Patients who are not conditional for surgery can first receive antibiotic suppression treatment before surgery at a later date. In such cases initial computed tomography (CT)-guided aspiration or drain insertion can take place.
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Affiliation(s)
- Timo Zippelius
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, Eisenberg, Germany
| | - Justus Bürger
- Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Friederike Schömig
- Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Michael Putzier
- Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Georg Matziolis
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, Eisenberg, Germany
| | - Patrick Strube
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, Eisenberg, Germany
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24
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Karczewski D, Pumberger M, Müller M, Andronic O, Perka C, Winkler T. Implications for diagnosis and treatment of peri-spinal implant infections from experiences in periprosthetic joint infections-a literature comparison and review. JOURNAL OF SPINE SURGERY 2020; 6:800-813. [PMID: 33447686 DOI: 10.21037/jss-20-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Both, periprosthetic joint infection (PJI) and peri-spinal implant infection (PSII) are serious complications occurring in arthroplasty and spine instrumentation with absolute numbers expected to rise in the next years. The currently existing literature data describing the characteristics of PSII are limited when compared to PJI studies. However, both PJI and PSII exhibit similarities concerning pathogenesis, symptoms, diagnosis, treatment and prognosis. This literature review aims at comparing PJI and PSII and to develop implications for diagnosis and treatment of PSII from existing studies about PJI. The review was performed on the basis of a structured PubMed, Cochrane Library, and Medline analysis and existing guidelines, with 99 references being included. The results indicate that specific terms like re-infection should be defined in the context of PSII based on existing definitions of PJI, that in vitro biofilm studies and studies analyzing different prosthesis surfaces in arthroplasty could be used for PSII, and that histopathology as an additional standard tool in PSII diagnosis might be helpful. In addition, the development of a standardized algorithm-based treatment system with antibiotic protocols, including long term suppression, for PSII similar to the ones existing for PJI is necessary.
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Affiliation(s)
- Daniel Karczewski
- Center for Musculoskeletal Surgery, Charité - Universitaetsmedizin Berlin, Berlin, Germany.,Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Michael Müller
- Center for Musculoskeletal Surgery, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Octavian Andronic
- Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Carsten Perka
- Center for Musculoskeletal Surgery, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Tobias Winkler
- Center for Musculoskeletal Surgery, Charité - Universitaetsmedizin Berlin, Berlin, Germany.,Julius Wolff Institute, Charité - Universit tsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies, Charité - Universit tsmedizin Berlin, Berlin, Germany
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25
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Schömig F, Putzier M. Clinical presentation and diagnosis of delayed postoperative spinal implant infection. JOURNAL OF SPINE SURGERY 2020; 6:772-776. [PMID: 33447682 DOI: 10.21037/jss-20-499] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Friederike Schömig
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Berlin, Germany
| | - Michael Putzier
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Berlin, Germany
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26
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Palmowski Y, Bürger J, Kienzle A, Trampuz A. Antibiotic treatment of postoperative spinal implant infections. JOURNAL OF SPINE SURGERY 2020; 6:785-792. [PMID: 33447684 DOI: 10.21037/jss-20-456] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Postoperative spinal implant infection (PSII) is a serious complication after spinal surgery. It is associated with increased morbidity and mortality for affected patients as well as significant costs for the healthcare system. Due to the formation of biofilm on foreign material, both diagnosis and treatment of PSII can pose a considerable challenge. Modern treatment protocols allow efficient eradication and good clinical outcomes in the majority of patients. In this article, we review the current antibiotic treatment concepts for PSII including the correct choice of antibiotics and their combination. In cases of late-onset PSII where the implants can be removed, two weeks of intravenous (IV) antibiotics followed by 4 weeks of oral antibiotics seem appropriate. If the implant needs to be retained, a 2-week IV antibiotic treatment should be followed by 10 weeks of oral antibiotic therapy with biofilm activity or, in case of problematic pathogens, a long-term suppression therapy. Initial empiric antibiotic therapy should cover staphylococci, streptococci, enterococci and Gram-negative bacilli as the most common pathogens. Antibiotic adjustments according to the type of pathogen and its antimicrobial susceptibility are essential for successful eradication of infection.
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Affiliation(s)
- Yannick Palmowski
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Justus Bürger
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Arne Kienzle
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany.,Laboratory of Adaptive and Regenerative Biology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrej Trampuz
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
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27
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Bürger J, Palmowski Y, Pumberger M. Comprehensive treatment algorithm of postoperative spinal implant infection. JOURNAL OF SPINE SURGERY 2020; 6:793-799. [PMID: 33447685 DOI: 10.21037/jss-20-497] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Postoperative spinal implant infection (PSII) is a commonly found and serious complication after instrumented spinal surgery. Whereas early-onset PSII usually can be diagnosed by clinical symptoms, the diagnosis of late-onset PSII can be often made only by examination of intraoperatively collected samples. The treatment of PSII consists of surgical and antibiotic therapy schemes. In case of early PSII, the retention of spinal implants is a feasible option, whereas late PSII is usually treated by one-staged exchange of the spinal implants. Radical debridement of surrounding tissue should be performed in any case of PSII. The antibiotic treatment depends on either the implants can be removed or need to be retained or exchanged, respectively. If the causative pathogens are sensitive for biofilm-active antibiotic agents, the duration of antibiotic treatment amounts to 12 weeks with retention of spinal implants. In case of problematic pathogens, the application of antibiotics needs to be prolonged for an individual duration. Antibiotic treatment should always be initiated with an intravenous application for at least 2 weeks.
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Affiliation(s)
- Justus Bürger
- Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Yannick Palmowski
- Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
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28
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Patel MS, Singh AM, Gregori P, Horneff JG, Namdari S, Lazarus MD. Cutibacterium acnes: a threat to shoulder surgery or an orthopedic red herring? J Shoulder Elbow Surg 2020; 29:1920-1927. [PMID: 32499199 DOI: 10.1016/j.jse.2020.02.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/10/2020] [Accepted: 02/20/2020] [Indexed: 02/01/2023]
Abstract
Cutibacterium acnes is a lipophilic, anaerobic, gram-positive bacillus that mainly colonizes the pilosebaceous glands of human skin. It has been implicated as the leading cause of prosthetic joint infection (PJI) after shoulder arthroplasty. However, PJI caused by C acnes rarely manifests as overt clinical, laboratory, or imaging features. In fact, more than 40% of shoulders undergoing revision arthroplasty are likely to be culture positive. However, rates of infection following a positive culture can be as low as 5%. The purpose of this review was to put forth alternative explanations for this discordance between positive cultures and infection. We describe C acnes roles as a commensal, bystander, and/or contaminant organism; the role of cultures in diagnosis and other methods that may be more accurate; its existence in a shoulder microbiome; and the variable virulence of C acnes. C acnes is an important cause of shoulder PJI in some patients. However, there is a large body of literature that suggests other functions that need to be considered. Further research is needed to define the role of C acnes that is logically explained by all of the literature and not only some.
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Affiliation(s)
- Manan S Patel
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA.
| | - Arjun M Singh
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Pietro Gregori
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - John G Horneff
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Surena Namdari
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark D Lazarus
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
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29
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Dudek P, Grajek A, Kowalczewski J, Madycki G, Marczak D. Ultrasound frequency of sonication applied in microbiological diagnostics has a major impact on viability of bacteria causing PJI. Int J Infect Dis 2020; 100:158-163. [PMID: 32827750 DOI: 10.1016/j.ijid.2020.08.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/07/2020] [Accepted: 08/16/2020] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Sonication of explanted prosthesis constitutes an element of microbiological diagnostics. The aim of performing this procedure is to remove biofilm and to increase sensitivity of diagnostics. Ultrasound used in medical purposes are low-frequency and low-intensity. With this wide range of frequency which can be used in sonication process it is necessary to find the golden mean between biofilm dislodging and planktonic bacteria sparing. MATERIALS AND METHODS The aim of this study was to determine the least harming low-intensity ultrasound frequency (35 kHz, 40 kHz or 53 kHz) used during sonication process with other parameters constant. Four bacteria species were examined: S. aureus, E. faecalis, E. coli, K. pneumoniae. Number of microbiological studies (n) for each group (g) counted 40 specimens (based on scheme 1 bacteria type - 4 groups, 40 studies each). RESULTS A detailed analysis of gathered data was conducted. Based on study findings following conclusions were drawn. Sonication has a significant and negative impact on survival of sonicated planktonic bacteria. Part of bacteria in planktonic state are damaged/killed by ultrasound, which is demonstrated by lower CFU count in sonicated samples versus control group. CONCLUSIONS Optimal ultrasound frequencies for sonication of S. aureus, P. aeruginosa and E. coli are 35 kHz and 40 kHz. Ultrasound frequencies used in sonication process (35 kHz, 40 kHz, 53 kHz) of E. coli showed same impact on bacteria survival. It is crucial to perform further assessment of ultrasound parameters on clinical effects of sonication used in PJI diagnostics.
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Affiliation(s)
- Piotr Dudek
- Centre of Postgraduate Medical Education, Department of Orthopaedics and Rheumoorthopaedics, Warsaw, Poland.
| | - Aleksandra Grajek
- Centre of Postgraduate Medical Education, Department of Laboratory Diagnostics, Otwock, Poland
| | - Jacek Kowalczewski
- Centre of Postgraduate Medical Education, Department of Orthopaedics and Rheumoorthopaedics, Warsaw, Poland
| | - Grzegorz Madycki
- Centre of Postgraduate Medical Education, Department of Vascular Surgery and Angiology, Warsaw, Poland
| | - Dariusz Marczak
- Centre of Postgraduate Medical Education, Department of Orthopaedics and Rheumoorthopaedics, Warsaw, Poland
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30
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Gordon O, Miller RJ, Thompson JM, Ordonez AA, Klunk MH, Dikeman DA, Joyce DP, Ruiz-Bedoya CA, Miller LS, Jain SK. Rabbit model of Staphylococcus aureus implant-associated spinal infection. Dis Model Mech 2020; 13:dmm.045385. [PMID: 32586832 PMCID: PMC7406311 DOI: 10.1242/dmm.045385] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/16/2020] [Indexed: 12/22/2022] Open
Abstract
Post-surgical implant-associated spinal infection is a devastating complication commonly caused by Staphylococcus aureus. Biofilm formation is thought to reduce penetration of antibiotics and immune cells, contributing to chronic and difficult-to-treat infections. A rabbit model of a posterior-approach spinal surgery was created, in which bilateral titanium pedicle screws were interconnected by a plate at the level of lumbar vertebra L6 and inoculated with a methicillin-resistant S.aureus (MRSA) bioluminescent strain. In vivo whole-animal bioluminescence imaging (BLI) and ex vivo bacterial cultures demonstrated a peak in bacterial burden by day 14, when wound dehiscence occurred. Structures suggestive of biofilm, visualized by scanning electron microscopy, were evident up to 56 days following infection. Infection-induced inflammation and bone remodeling were also monitored using 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) and computed tomography (CT). PET imaging signals were noted in the soft tissue and bone surrounding the implanted materials. CT imaging demonstrated marked bone remodeling and a decrease in dense bone at the infection sites. This rabbit model of implant-associated spinal infection provides a valuable preclinical in vivo approach to investigate the pathogenesis of implant-associated spinal infections and to evaluate novel therapeutics. Summary: A model of post-surgical methicillin-resistant Staphylococcus aureus implant-associated spinal infection was created in rabbits, recapitulating acute infection as well as chronic low-burden infection, with structures suggestive of biofilm formation and bone remodeling.
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Affiliation(s)
- Oren Gordon
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Robert J Miller
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - John M Thompson
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Alvaro A Ordonez
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Mariah H Klunk
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Dustin A Dikeman
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Daniel P Joyce
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Camilo A Ruiz-Bedoya
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Lloyd S Miller
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Immunology, Janssen Research and Development, Spring House, PA 19477, USA
| | - Sanjay K Jain
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA .,Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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31
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Margaryan D, Renz N, Bervar M, Zahn R, Onken J, Putzier M, Vajkoczy P, Trampuz A. Spinal implant-associated infections: a prospective multicentre cohort study. Int J Antimicrob Agents 2020; 56:106116. [PMID: 32726675 DOI: 10.1016/j.ijantimicag.2020.106116] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/19/2020] [Accepted: 07/21/2020] [Indexed: 12/17/2022]
Abstract
This study evaluated the clinical, laboratory, microbiological, radiological and treatment characteristics of patients with early-onset and late-onset spinal implant-associated infections. Patients diagnosed with spinal implant-associated infection between 2015-2019 were prospectively included and treated according to a standardised algorithm. Infections were classified as early-onset (≤6 weeks) and late-onset (>6 weeks). Among 250 patients, 152 (61%) had early-onset and 98 (39%) had late-onset infection. Local inflammatory signs was the most common manifestation in early-onset infections (84%), whereas late-onset infections presented mainly with persisting or increasing local pain (71%). Sonication fluid was more often positive than peri-implant tissue samples (90% vs. 79%; P = 0.016), particularly in late-onset infections (92% vs. 75%; P = 0.005). Predominant pathogens were coagulase-negative staphylococci, Staphylococcus aureus and Cutibacterium spp. Debridement and implant retention was the most common surgical approach in early-onset infections (85%), whereas partial or complete implant exchange was mainly performed in late-onset infections (62%). Of the 250 patients, 220 (88%) received biofilm-active antibiotics, and median treatment duration was 11.7 weeks. Moreover, 49 patients (20%) needed more than one revision for infection and six patients (2.4%) died during hospital stay. Concluding, most spinal implant-associated infections were acquired during surgery and presented within 6 weeks of surgery. Infections presented mainly with local inflammatory signs in early-onset and with persisting or increasing pain in late-onset infections. Sonication was the most sensitive microbiological method, particularly in late-onset infections. Debridement and implant retention was used in well-integrated implants without loosening, independent of the time of infection onset.
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Affiliation(s)
- Donara Margaryan
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Nora Renz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Maja Bervar
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Robert Zahn
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Julia Onken
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Neurosurgery, Berlin, Germany
| | - Michael Putzier
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Peter Vajkoczy
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Neurosurgery, Berlin, Germany
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany.
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32
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Low-Grade-Infektionen in der Wirbelsäulenchirurgie – Ein Chamäleon? DER ORTHOPADE 2020; 49:669-678. [DOI: 10.1007/s00132-020-03947-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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33
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Bürger J, Palmowski Y, Strube P, Perka C, Putzier M, Pumberger M. Low sensitivity of histopathological examination of peri-implant tissue samples in diagnosing postoperative spinal implant infection. Bone Joint J 2020; 102-B:899-903. [PMID: 32600139 DOI: 10.1302/0301-620x.102b7.bjj-2019-1725.r2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AIMS To evaluate the histopathological examination of peri-implant tissue samples as a technique in the diagnosis of postoperative spinal implant infection (PSII). METHODS This was a retrospective analysis. Patients who underwent revision spinal surgery at our institution were recruited for this study. PSII was diagnosed by clinical signs, histopathology, and microbiological examination of intraoperatively collected samples. Histopathology was defined as the gold standard. The sensitivity for histopathology was calculated. A total of 47 patients with PSII and at least one microbiological and histopathological sample were included in the study. RESULTS PSII occurred in approximately 28% of the study population. Histopathology showed a sensitivity of 51.1% in the diagnosis of PSII. The most commonly found pathogens were Cutibacterium acnes and gram-positive staphylococci. CONCLUSION Histopathology has low sensitivity for detecting PSII. In particular, infections caused by low-virulence microorganisms are insufficiently detected by histopathology. Cite this article: Bone Joint J 2020;102-B(7):899-903.
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Affiliation(s)
- Justus Bürger
- Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Patrick Strube
- Orthopaedic Department, University Hospital Jena, Eisenberg, Germany
| | - Carsten Perka
- Charité - Universitätsmedizin Berlin, Berlin, Germany
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34
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Langvatn H, Schrama J, Cao G, Hallan G, Furnes O, Lingaas E, Walenkamp G, Engesæter L, Dale H. Operating room ventilation and the risk of revision due to infection after total hip arthroplasty: assessment of validated data in the Norwegian Arthroplasty Register. J Hosp Infect 2020; 105:216-224. [DOI: 10.1016/j.jhin.2020.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/06/2020] [Indexed: 01/25/2023]
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Banousi A, Evangelopoulos DS, Stylianakis A, Fandridis E, Chatziioannou S, Sipsas NV, Pneumaticos SG. A comparative study of heterogeneous antibiotic resistance of microbial populations in conventional periprosthetic tissue cultures and sonication fluid cultures of orthopaedics explanted prostheses. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:1307-1318. [PMID: 32449081 DOI: 10.1007/s00590-020-02704-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 05/11/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND "Heterogeneity" describes a phenomenon where subpopulations of seemingly isogenic bacteria exhibit a range of susceptibilities to a particular antibiotic. We aim to investigate the frequency of heterogeneity among microbes isolated from infected prostheses, and its possible correlation with microbial resistance. METHODS Between May 2014 and June 2019, we investigated 234 patients, at our institution, undergoing revision arthroplasty because of loosening of the prostheses or because of periprosthetic joint infection. All patients had periprosthetic tissue culture, sonication of prosthesis and direct inoculation of Sonication fluid into blood culture bottles. We assessed the presence of heterogeneity among all pathogens isolated from infected prostheses. RESULTS Using standard non-microbiological criteria to determine periprosthetic joint infection, it was found that 143 patient (61.1%) had aseptic loosening while 91 patients (38.9%) had periprosthetic joint infection. Comparing the two methods, the results of our study showed that the method of sonication was significantly more sensitive than tissue culture [91% (83-96) vs. 43% (33-54); p < 0.005]. In this study, heterogeneity was reported in 15 cases, 16.5% of all infections and 6.4% in the total population. In our study, Staphylococcus epidermidis was the most commonly isolated strain followed by Staphylococcus aureus, at a rate of 35.2% and 19.8%, respectively. Antibiotics in which the microorganisms exhibited heterogeneous bacterial behavior most frequently were Gendamicin (5.3%), Vancomycin (4.9%). CONCLUSION There is increasing evidence that heterogeneity can lead to therapeutic failure and that the detection of this phenotype is a prerequisite for a proper antibiotic choice to have a successful therapeutic effect.
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Affiliation(s)
- Angeliki Banousi
- 3rd Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Dimitrios S Evangelopoulos
- 3rd Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Stylianakis
- Laboratory of Implant Associated Infections, Department of Microbiology, General Hospital KAT, Athens, Greece
| | - Emmanouil Fandridis
- Hand-Upper Limb and Microsurgery Department, General Hospital KAT, Athens, Greece
| | - Sofia Chatziioannou
- Nuclear Medicine Division, PET/CT section, Foundation for Biomedical Research of the Academy of Athens, Athens, Greece
- 2nd Department of Radiology, Medical School, National and Kapodistrian University of Athens, General University Hospital "ATTIKON", Athens, Greece
| | - Nikolaos V Sipsas
- Department of Pathophysiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyridon G Pneumaticos
- 3rd Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Abstract
UNLABELLED MINI: We compared the sensitivity and specificity of peri-implant tissue culture to the vortexing-sonication technique for the diagnosis of spinal implant infection (SII). Lower thresholds of sonicate fluid culture positivity showed increased sensitivity with maintained specificity. We recommend a threshold of 20 CFU/10 mL for sonicate culture positivity for the diagnosis of SII. STUDY DESIGN This is a retrospective study comparing the diagnosis of spinal implant infection (SII) by peri-implant tissue culture to vortexing-sonication of retrieved spinal implants. OBJECTIVE We hypothesized that vortexing-sonication would be more sensitive than peri-implant tissue culture. SUMMARY OF BACKGROUND DATA We previously showed implant vortexing-sonication followed by culture to be more sensitive than standard peri-implant tissue culture for diagnosing of SII. In this follow-up study, we analyzed the largest sample size available in the literature to compare these two culture methods and evaluated thresholds for positivity for sonicate fluid for SII diagnosis. METHODS We compared peri-implant tissue culture to the vortexing-sonication technique which samples bacterial biofilm on the surface of retrieved spinal implants. We evaluated different thresholds for sonicate fluid positivity and assessed the sensitivity and specificity of the two culture methods for the diagnosis of SII. RESULTS A total of 152 patients were studied. With more than 100 colony forming units (CFU)/10 mL as a threshold for sonicate fluid culture positivity, there were 46 patients with SII. The sensitivities of peri-implant tissue and sonicate fluid culture were 65.2% and 79.6%; the specificities were 88.7% and 93.4%, respectively. With more than 50 CFU/10 mL as a threshold, there were 50 patients with SII. The sensitivities of peri-implant tissue and sonicate fluid culture were 68.0% and 76.0%; the specificities were 92.2% for both methods. Finally, with more than or equal to 20 CFU/10 mL as a threshold, there were 52 patients with SII. The sensitivities of peri-implant tissue and sonicate fluid culture were 69.2% and 82.7%; the specificities were 94.0% and 92.0%, respectively. CONCLUSION Implant sonication followed by culture is a sensitive and specific method for the diagnosis of SII. Lower thresholds for defining sonicate fluid culture positivity allow for increased sensitivity with a minimal decrease in specificity, enhancing the clinical utility of implant sonication. LEVEL OF EVIDENCE 4.
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Abstract
STUDY DESIGN A controlled, interventional animal study. OBJECTIVE Spinal implant infection (SII) is a devastating complication. The objective of this study was to evaluate the efficacy of a novel implant coating that has both a passive antibiotic elution and an active-release mechanism triggered in the presence of bacteria, using an in vivo mouse model of SII. SUMMARY OF BACKGROUND DATA Current methods to minimize the frequency of SII include local antibiotic therapy (vancomycin powder), betadine irrigation, silver nanoparticles, and passive release from antibiotic-loaded poly(methyl methacrylate) cement beads, all of which have notable weaknesses. A novel implant coating has been developed to address some of these limitations but has not been tested in the environment of a SII. METHODS A biodegradable coating using branched poly(ethylene glycol)-poly(propylene sulfide) (PEG-PPS) polymer was designed to deliver antibiotics. The in vivo performance of this coating was tested in the delivery of either vancomycin or tigecycline in a previously established mouse model of SII. Noninvasive bioluminescence imaging was used to quantify the bacterial burden, and implant sonication was used to determine bacterial colony-forming units (CFUs) from the implant and surrounding bone and soft tissue. RESULTS The PEG-PPS-vancomycin coating significantly lowered the infection burden from postoperative day 3 onwards (P < 0.05), whereas PEG-PPS-tigecycline only decreased the infection on postoperative day 5 to 10 (P < 0.05). CFUs were lower on PEG-PPS-vancomycin pins than PEG-PPS-tigecycline and PEG-PPS pins alone on both the implants (2.4 × 10, 8.5 × 10, and 1.0 × 10 CFUs, respectively) and surrounding bone and soft tissue (1.3 × 10, 4.8 × 10, and 5.4 × 10 CFUs, respectively) (P < 0.05). CONCLUSION The biodegradable PEG-PPS coating demonstrates promise in decreasing bacterial burden and preventing SII. The vancomycin coating outperformed the tigecycline coating in this model compared to prior work in arthroplasty models, highlighting the uniqueness of the paraspinal infection microenvironment. LEVEL OF EVIDENCE N/A.
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Lin ZX, Steed LL, Marculescu CE, Slone HS, Woolf SK. Cutibacterium acnes Infection in Orthopedics: Microbiology, Clinical Findings, Diagnostic Strategies, and Management. Orthopedics 2020; 43:52-61. [PMID: 31958341 DOI: 10.3928/01477447-20191213-02] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/30/2019] [Indexed: 02/03/2023]
Abstract
Cutibacterium (formerly called Propionibacterium) acnes is a human skin flora often implicated in orthopedic infections. The unique characteristics of this microorganism make the diagnosis of infection difficult. The diagnosis often is made based on clinical evidence, radiographic signs, and laboratory and/or surgical findings combined. Treatment often involves both pharmacologic and surgical methods. In addition, formation of biofilms and increased resistance to drugs exhibited by the microorganism can require combined antimicrobial therapy. Prophylactic measures are particularly important, but no single method has been shown to fully eliminate the risk of C acnes infections. Previous reports have focused on C acnes infections involving surgical implants or after certain orthopedic procedures, particularly in the shoulder and spine. This article reviews current clinical, diagnostic, and treatment principles for C acnes in orthopedics in general. [Orthopedics. 2020; 43(1):52-61.].
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Bellova P, Knop-Hammad V, Königshausen M, Mempel E, Frieler S, Gessmann J, Schildhauer TA, Baecker H. Sonication of retrieved implants improves sensitivity in the diagnosis of periprosthetic joint infection. BMC Musculoskelet Disord 2019; 20:623. [PMID: 31878902 PMCID: PMC6933748 DOI: 10.1186/s12891-019-3006-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/16/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Sonication is a valuable tool in the diagnosis of periprosthetic joint infections (PJI). However, conditions and definition criteria for PJI vary among studies. The aim of this study was to determine the diagnostic performance (i.e., specificity, sensitivity) of sonicate fluid culture (SFC) against periprosthetic tissue culture (PTC), when using European Bone and Joint Infection Society (EBJIS) criteria. METHODS From March 2017 to April 2018, 257 implants were submitted for sonication. PJI was defined according to the EBJIS criteria as well as according to the International Consensus Meeting criteria of 2018 (ICM 2018). Only cases with at least one corresponding tissue sample were included. Samples were cultured using traditional microbiological plating techniques. Sensitivity and specificity were determined using two-by-two contingency tables. McNemar's test was used to compare proportions among paired samples. Subgroup analysis was performed dividing the cohort according to the site of PJI, previous antibiotic treatment, and time of manifestation. Prevalence of pathogens was determined for all patients as well as for specific subgroups. RESULTS Among the 257 cases, 145 and 112 were defined as PJI and aseptic failure, respectively. When using the EBJIS criteria, the sensitivity of SFC and PTC was 69.0 and 62.8%, respectively (p = .04). Meanwhile, the specificity was 90.2 and 92.9%, respectively (p = .65). When adopting ICM 2018 criteria, the sensitivity of SFC and PTC was 87.5 and 84.4% (p = .63) respectively, while the specificity was 85.1 and 92.5% (p = .05), respectively. The most commonly identified pathogens were coagulase-negative staphylococci (26% overall), while 31% of PJI were culture-negative and 9% polymicrobial. CONCLUSIONS SFC exhibited significantly greater sensitivity versus PTC when using the EBJIS criteria. Nevertheless, the diagnosis of PJI remains a difficult challenge and different diagnostic tools are necessary to optimize the outcome.
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Affiliation(s)
- Petri Bellova
- Department of Orthopedic and Trauma Surgery, Surgical Clinic, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany
| | - Veronika Knop-Hammad
- Department of Microbiology, BG University Clinic Bergmannsheil Bochum, Bochum, Germany
| | - Matthias Königshausen
- Department of Orthopedic and Trauma Surgery, Surgical Clinic, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany
| | - Eileen Mempel
- Department of Orthopedic and Trauma Surgery, Surgical Clinic, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany
| | - Sven Frieler
- Department of Orthopedic and Trauma Surgery, Surgical Clinic, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany
| | - Jan Gessmann
- Department of Orthopedic and Trauma Surgery, Surgical Clinic, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany
| | - Thomas A. Schildhauer
- Department of Orthopedic and Trauma Surgery, Surgical Clinic, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany
| | - Hinnerk Baecker
- Department of Orthopedic and Trauma Surgery, Surgical Clinic, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany
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Prysak MH, Lutz CG, Zukofsky TA, Katz JM, Everts PA, Lutz GE. Optimizing the safety of intradiscal platelet-rich plasma: an in vitro study with Cutibacterium acnes. Regen Med 2019; 14:955-967. [PMID: 31587600 DOI: 10.2217/rme-2019-0098] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Aim: The most common risk associated with intradiscal injection of platelet-rich plasma (PRP) is discitis with Cutibacterium acnes. It is hypothesized that antimicrobial activity of PRP can be enhanced through inclusion of leukocytes or antibiotics in the injectate. Materials & methods: Multiple PRP preparations of varying platelet and leukocyte counts were co-cultured with C. acnes with or without cefazolin, with viable bacterial colony counts being recovered at 0, 4, 24 and 48 hours post-inoculation. Results: A direct correlation between C. acnes recovery and granulocyte counts were observed. Conclusion: We observed the greatest antimicrobial activity with the leukocyte-rich, high platelet PRP preparation combined with an antibiotic in the injectate. However, cefazolin did not completely clear the bacteria in this assay.
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Affiliation(s)
- Meredith H Prysak
- Orthobond Corporation, 671 Suite B, US 1 North, North Brunswick, NJ 08902, USA
| | - Cole G Lutz
- Regenerative SportsCare Institute, 62 East 88th Street, New York, NY 10128, USA
| | - Tyler A Zukofsky
- Orthobond Corporation, 671 Suite B, US 1 North, North Brunswick, NJ 08902, USA
| | - Jordan M Katz
- Orthobond Corporation, 671 Suite B, US 1 North, North Brunswick, NJ 08902, USA
| | - Peter A Everts
- Gulf Coast Biologics, 4331 Veronica S Shoemaker Blvd. #4 Fort Myers, FL 33916, USA
| | - Gregory E Lutz
- Regenerative SportsCare Institute, 62 East 88th Street, New York, NY 10128, USA
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Pumberger M, Bürger J, Strube P, Akgün D, Putzier M. Unexpected positive cultures in presumed aseptic revision spine surgery using sonication. Bone Joint J 2019; 101-B:621-624. [PMID: 31039032 DOI: 10.1302/0301-620x.101b5.bjj-2018-1168.r1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS During revision procedures for aseptic reasons, there remains a suspicion that failure may have been the result of an undetected subclinical infection. However, there is little evidence available in the literature about unexpected positive results in presumed aseptic revision spine surgery. The aims of our study were to estimate the prevalence of unexpected positive culture using sonication and to evaluate clinical characteristics of these patients. PATIENTS AND METHODS All patients who underwent a revision surgery after instrumented spinal surgery at our institution between July 2014 and August 2016 with spinal implants submitted for sonication were retrospectively analyzed. Only revisions presumed as aseptic are included in the study. During the study period, 204 spinal revisions were performed for diagnoses other than infection. In 38 cases, sonication cultures were not obtained, leaving a study cohort of 166 cases. The mean age of the cohort was 61.5 years (sd 20.4) and there were 104 female patients. RESULTS Sonication cultures were positive in 75 cases (45.2%). Hardware failure was the most common indication for revision surgery and revealed a positive sonication culture in 26/75 cases (35%) followed by adjacent segment disease (ASD) in 23/75 cases (30%). Cutibacterium acnes and Staphylococcus epidermidis were the most commonly isolated microorganisms, observed in 45% and 31% of cases, respectively. C. acnes was isolated in 65.2% of cases when the indication for revision surgery was ASD. CONCLUSION Infection must always be considered as a possibility in the setting of spinal revision surgery, especially in the case of hardware failure, regardless of the lack of clinical signs. Sonication should be routinely used to isolate microorganisms adherent to implants. Cite this article: Bone Joint J 2019;101-B:621-624.
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Affiliation(s)
- M Pumberger
- Charité - Universitätsmedizin Berlin, Berlin, Germany.,Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - J Bürger
- Charité - Universitätsmedizin Berlin, Berlin, Germany.,Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - P Strube
- Universitätsklinikum Jena, Campus Waldkliniken Eisenberg, Eisenberg, Germany
| | - D Akgün
- Charité - Universitätsmedizin Berlin, Berlin, Germany.,Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - M Putzier
- Charité - Universitätsmedizin Berlin, Berlin, Germany.,Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
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Surgical site infections and the microbiome: An updated perspective. Infect Control Hosp Epidemiol 2019; 40:590-596. [PMID: 30786943 DOI: 10.1017/ice.2018.363] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To address 3 questions: What are the origins of bacteria causing surgical site infections (SSIs)? Is there evidence that the offending bacteria are present at the incision site when surgery begins? What are the estimates of the proportion of SSIs that can be prevented with perioperative control of the microbiome? DESIGN Review of the literature, examining recognized sources of bacteria causing surgical site infections. METHODS Specifically, I examined the impact of improved control of the microbiome of the skin and nares on reducing SSIs. The initial effort was to examine the reduction of SSIs linked solely to preoperative skin preparation regimens and to either topical nasal antibiotics or pre- and postoperative nasal antiseptic regimens. To corroborate the concept of the importance of the microbiome, a review of studies showing the relationship of SSIs and marker organisms (eg, Propionobacterium acnes) present at the incision sites was performed. The relationships of SSIs to the microbiome of the skin and nares were summarized. RESULTS Depending on key assumptions, ∼70%-95% of all SSIs arise from the microbiome of the patients' skin or nares. Data from the studies of marker organisms suggest that the infecting bacteria are present at the incision site at the time of surgery. CONCLUSIONS Almost all SSIs arise from the patient's microbiome. The occurrence of SSIs can be viewed as a perioperative failure to control the microbiome.
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Ascione T, Barrack R, Benito N, Blevins K, Brause B, Cornu O, Frommelt L, Gant V, Goswami K, Hu R, Klement MR, Komnos G, Malhotra R, Mirza Y, Munhoz Lima AL, Nelson C, Noor SS, O'Malley M, Oussedik S, Portillo ME, Prieto H, Saxena A, Sessa G. General Assembly, Diagnosis, Pathogen Isolation - Culture Matters: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S197-S206. [PMID: 30360977 DOI: 10.1016/j.arth.2018.09.071] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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Agarwal A, Lin B, Wang JC, Schultz C, Garfin SR, Goel VK, Anand N, Agarwal AK. Efficacy of Intraoperative Implant Prophylaxis in Reducing Intraoperative Microbial Contamination. Global Spine J 2019; 9:62-66. [PMID: 30775210 PMCID: PMC6362554 DOI: 10.1177/2192568218780676] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
STUDY DESIGN A prospective single-center study. OBJECTIVES Assess to what degree contamination of pedicle screws occur in standard intraoperative practice and if use of an impermeable guard could mitigate or reduce such an occurrence. METHODS Two groups of sterile prepackaged pedicle screws, one with an intraoperative guard (group 1) and the other without such a guard (group 2), each consisting of 5 samples distributed over 3 time points, were loaded onto the insertion device by the scrub tech and left on the sterile table. Approximately 20 minutes later, the lead surgeon who had just finished preparing the surgical site touches the pedicle screw. Then instead of implantation it was transferred to a sterile container using fresh clean gloves for bacterial and gene analysis. Guarded screw implies that even after unwrapping from the package, the screw carries an impermeable barrier along its entire length, which is only removed seconds prior to implantation. RESULTS The standard unguarded pedicle screws presented bioburden in the range of 105 to 107 (colony forming units/implant) with bacterial genus mostly consisting of Staphylococcus and Micrococcus, the 2 most common genera found in surgical site infection reports. The common species among them were Staphylococcus epidermis, Staphylococcus aureus, Micrococcus luteus, and Staphylococcus pettenkoferi, whereas the guarded pedicle screws showed no bioburden. CONCLUSIONS Shielding the pedicle screws intraoperatively using a guard provides a superior level of asepsis than currently practiced. All unshielded pedicles screws were carrying bioburden of virulent bacterial species, which provides an opportunity for the development of postoperative infections.
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Affiliation(s)
- Aakash Agarwal
- University of Toledo, Toledo, OH, USA,Aakash Agarwal, Engineering Center for Orthopaedic Research Excellence, University of Toledo, 5051 Nitschke Hall MS 303, 2801 W, Bancroft St, Toledo, OH 43606, USA.
| | - Boren Lin
- University of Toledo, Toledo, OH, USA
| | | | | | | | | | - Neel Anand
- Cedars Sinai Medical Center, Los Angeles, CA, USA
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Bürger J, Akgün D, Strube P, Putzier M, Pumberger M. Sonication of removed implants improves microbiological diagnosis of postoperative spinal infections. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:768-774. [DOI: 10.1007/s00586-019-05881-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 01/06/2019] [Indexed: 12/17/2022]
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Abstract
This article examines new imaging, diagnostic, and assessment techniques that may affect the care of patients with orthopedic trauma and/or infection. Three-dimensional imaging has assisted in fracture assessment preoperatively, whereas improvement in C-arm technology has allowed real-time evaluation of implant placement and periarticular reduction before leaving the operating room. Advances in imaging techniques have allowed earlier and more accurate diagnosis of nonunion and infection. Innovations in bacteriologic testing have improved the sensitivity and specificity of perioperative and peri-implant infections. It is critical that surgeons remain up to date on the options available for optimal patient care.
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Renz N, Mudrovcic S, Perka C, Trampuz A. Orthopedic implant-associated infections caused by Cutibacterium spp. - A remaining diagnostic challenge. PLoS One 2018; 13:e0202639. [PMID: 30125299 PMCID: PMC6101412 DOI: 10.1371/journal.pone.0202639] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 08/07/2018] [Indexed: 12/22/2022] Open
Abstract
Background The definition criteria and clinical characteristics of implant-associated infection (IAI) caused by Cutibacterium (formerly Propionibacterium) spp. are poorly known. We analyzed microbiologically proven Cutibacterium orthopedic IAI in a prospective cohort. Methods Patients with periprosthetic joint infections (PJI) and fixation device–associated infections (FDAI) caused by Cutibacterium spp. were prospectively included. IAI was defined by significant growth of Cutibacterium spp. and presence of at least one non-microbiological criterion for infection. The McNemar’s chi-squared or binomial test was used to compare the performance of diagnostic tests. Results Of 121 patients with Cutibacterium IAI, 62 patients (51%) had PJI and 59 (49%) had FDAI. 109 infections (90%) were caused by C. acnes and 12 (10%) by C. avidum. The median time from implantation until diagnosis of infection was 15.7 months (interquartile range, 5–46.5 months). Clinical local signs were present in 30 patients (28%) and radiological implant loosening in 64 patients (63%). Culture sensitivity of sonication fluid was 84%, of peri-implant tissue 84% and of synovial or peri-implant fluid 56% after 14 days of incubation. Conclusion Cutibacterium IAI was diagnosed late in the disease course and presented with subtle signs. Prolonged culture incubation and implant sonication improved the poor performance of conventional microbiological tests. Due to lack of reliable diagnostic tests, Cutibacterium remains difficult to detect making the diagnosis challenging.
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Affiliation(s)
- Nora Renz
- Charité –Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
- * E-mail:
| | - Stasa Mudrovcic
- Charité –Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Carsten Perka
- Charité –Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Berlin, Germany
| | - Andrej Trampuz
- Charité –Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Berlin, Germany
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Rodríguez Duque JC, Galindo Rubín P, González Humara B, Quesada Sanz AA, Busta Vallina MB, Fernández-Sampedro M. Fusobacterium nucleatum prosthetic hip infection: Case report and review of the literature of unusual anaerobic prosthetic joint infection. Anaerobe 2018; 54:75-82. [PMID: 30118892 DOI: 10.1016/j.anaerobe.2018.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 07/26/2018] [Accepted: 08/12/2018] [Indexed: 12/26/2022]
Abstract
The anaerobic Gram-negative rod Fusobacterium nucleatum is an oral commensal and periodontal pathogen that has been associated with a wide variety of infections, yet it is extremely rare to be associated with prosthetic joint infection. After an exhaustive literature review, only two cases of prosthetic joint infection by F. nucleatum have been previously reported. To our knowledge, the case we report on here is the first combined with periprosthetic abscess and related with hemochromatosis. We therefore sought to provide a comprehensive literature review of case reports or series of less commonly encountered anaerobic microorganisms isolated from prosthetic joint infections.
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Affiliation(s)
- J C Rodríguez Duque
- Infectious Diseases Unit, Department of Medicine, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain.
| | - P Galindo Rubín
- Department of Orthopaedic Surgery, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain.
| | - B González Humara
- Department of Radiology, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain.
| | - A A Quesada Sanz
- Service of Microbiology, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain.
| | - M B Busta Vallina
- Department of Orthopaedic Surgery, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain.
| | - M Fernández-Sampedro
- Infectious Diseases Unit, Department of Medicine, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain.
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Postoperative Infection in Patients Undergoing Posterior Lumbosacral Spinal Surgery: A Pictorial Guide for Diagnosis and Early Treatment. Clin Spine Surg 2018; 31:225-238. [PMID: 29595747 DOI: 10.1097/bsd.0000000000000633] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Surgical site infections after posterior spinal surgery may lead to spondylodiscitis, pseudarthrosis, correction loss, adverse neurological sequelae, sepsis, and poor outcomes if not treated immediately. Infection rates vary depending on the type and extent of operative procedures, use of instrumentation, and patients' risk factors. Image evaluation is crucial for early diagnosis and should be complementary to clinical routes, laboratory survey, and treatment timing. Magnetic resonance imaging detects early inflammatory infiltration into the vertebrae and soft tissues, including hyperemic changes of edematous marrow, vertebral endplate, and abscess or phlegmon accumulation around the intervertebral disk, epidural, and paravertebral spaces. Aggressive surgical treatment can eradicate infection sources, obtain a stable wound closure, decrease morbidity, and restore spinal integrity. Organ/space infection is defined as any body parts opened to manipulate other than superficial/deep incision. Advanced magnetic resonance imaging evaluating abnormal fluid accumulation, heterogenous contrast enhancement of the endplate erosion due to cage/screw infection is categorized to inform a presumptive diagnosis for early implant salvage. However, patients' defense response, infection severity, bacteriology, treatment timing, spinal stability, and available medical and surgical options must be fully considered. Revision surgery is indicated for pseudarthrosis, implant loosening with correction loss, recalcitrant spondylodiscitis, and adjacent segment diseases for infection control.
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Comparison of Diagnostic Accuracy of Periprosthetic Tissue Culture in Blood Culture Bottles to That of Prosthesis Sonication Fluid Culture for Diagnosis of Prosthetic Joint Infection (PJI) by Use of Bayesian Latent Class Modeling and IDSA PJI Criteria for Classification. J Clin Microbiol 2018; 56:JCM.00319-18. [PMID: 29643202 DOI: 10.1128/jcm.00319-18] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/02/2018] [Indexed: 01/28/2023] Open
Abstract
We have previously demonstrated that culturing periprosthetic tissue in blood culture bottles (BCBs) improves sensitivity compared to conventional agar and broth culture methods for diagnosis of prosthetic joint infection (PJI). We have also shown that prosthesis sonication culture improves sensitivity compared to periprosthetic tissue culture using conventional agar and broth methods. The purpose of this study was to compare the diagnostic accuracy of tissue culture in BCBs (subsequently referred to as tissue culture) to prosthesis sonication culture (subsequently referred to as sonicate fluid culture). We studied 229 subjects who underwent arthroplasty revision or resection surgery between March 2016 and October 2017 at Mayo Clinic in Rochester, Minnesota. Using the Infectious Diseases Society of America (IDSA) PJI diagnostic criteria (omitting culture criteria) as the gold standard, the sensitivity of tissue culture was similar to that of the sonicate fluid culture (66.4% versus 73.1%, P = 0.07) but was significantly lower than that of the two tests combined (66.4% versus 76.9%, P < 0.001). Using Bayesian latent class modeling, which assumes no gold standard for PJI diagnosis, the sensitivity of tissue culture was slightly lower than that of sonicate fluid culture (86.3% versus 88.7%) and much lower than that of the two tests combined (86.3% versus 99.1%). In conclusion, tissue culture in BCBs reached sensitivity similar to that of prosthesis sonicate fluid culture for diagnosis of PJI, but the two tests combined had the highest sensitivity without compromising specificity. The combination of tissue culture in BCBs and sonicate fluid culture is recommended to achieve the highest level of microbiological diagnosis of PJI.
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