Bacteremia following different oral procedures: Systematic review and meta-analysis

Indications and contraindications to platelet-rich plasma injections in musculoskeletal diseases in case of infectious, oncological and haematological comorbidities: A 2025 formal consensus from the GRIIP (International Research Group on Platelet Injections)

PURPOSE

Platelet-rich plasma (PRP) could be a vector for certain diseases, and its composition may vary by pathologic condition. The main comorbidities that could affect PRP composition are infectious, oncologic and haematologic. In addition to potential alteration of clinical response, these pathologies could have a significant impact on the local tolerance of PRP as well as a risk of disease dissemination to the injection site. To date, there are few specific recommendations related to these comorbidities to guide clinicians. Therefore, the International Research Group on Platelet Injections (GRIIP) supported a consensus project to develop these recommendations.

METHODS

Following the 'recommendations by formal consensus' methodology, a steering committee performed a literature review and drafted an initial set of recommendations. They were evaluated by an international rating group (15 specialists in musculoskeletal [MSK] diseases, five haematologists, four oncologists, three infectiologists and four scientists specialising in platelet physiology). From this rating, the first set of recommendations was discussed in a plenary meeting and then modified by the steering committee. Finally, four overarching principles and 23 recommendations were re-evaluated by the rating group. Recommendations were classified as appropriate or not, with strong or relative agreement, or uncertain.

RESULTS

From the 23 recommendations, 10 concerned infectious diseases (viral and bacterial infections; dialysis; immunosuppressive drugs; dental care…), five oncologic diseases (local tumour; cured, active or in remission cancer…) and eight haematologic diseases (cytopenia; cured, active or stabilised cured hemopathy; monoclonal gammopathy…). All were considered appropriate by the experts (median = 9; range = 8-9), with strong or relative agreement. Due to the paucity of literature data, the recommendations are mainly based on expert opinion (Grade D).

CONCLUSION

This consensus project provides four overarching principles and 23 recommendations related to contraindications of PRP injections in case of infectious, oncologic or hematologic diseases, validated by an international expert group.

LEVEL OF EVIDENCE

Level I.

Mapping Review of the Correlations Between Periodontitis, Dental Caries, and Endocarditis

Background/Objectives: The correlation between cardiovascular diseases, particularly infective endocarditis, and oral disorders such as periodontitis and dental caries has been widely discussed in the scientific literature. In this mapping review, we aim to examine the available evidence on the link between these conditions, focusing on the pathogenetic mechanisms that underlie the development of endocarditis in patients with oral diseases. Methods: A systematic search was conducted across three major databases-PubMed, Scopus, and ScienceDirect-as well as grey literature in Google Scholar. Relevant articles were selected based on inclusion and exclusion criteria, focusing primarily on systematic reviews. The data extracted included study characteristics, main outcomes, and risk-of-bias evaluations. Results: A total of 13 systematic reviews were included in this mapping review. The findings suggest there is a significant connection between periodontal disease, dental caries, and the incidence of infective endocarditis. The evidence highlights that oral bacteria, particularly Streptococcus species, can enter the bloodstream during daily activities and invasive dental procedures, contributing to the development of endocarditis in susceptible individuals. However, the role of antibiotic prophylaxis in preventing endocarditis following dental procedures remains controversial. Conclusions: This review reinforces the importance of oral health in preventing cardiovascular complications, especially infective endocarditis. Although antibiotic prophylaxis may reduce the risk in high-risk individuals, further research is needed to clarify its effectiveness. Enhanced awareness of and education on the shared risks between oral and cardiovascular health could improve prevention strategies and patient outcomes.

Optimizing Antibiotic Therapy in Musculoskeletal Infections

Research into the optimal antibiotic management of musculoskeletal infections has advanced tremendously over the past quarter century, including over a dozen randomized controlled trials and numerous observational studies. This review examines the rationale for and evidence base supporting modern approaches to antibiotic decision making and stewardship in orthopedic infections. Specific practice advances discussed include the increased and earlier use of oral antibiotics, other principles of antibiotic selection (eg, the notion of "bone penetration" and novel local antimicrobial strategies), individualizing durations of therapy, and increasingly selective approaches to empiric antipseudomonal therapy, suppressive antibiotic therapy, and periprocedural antimicrobial prophylaxis following arthroplasty.

Microbiota of Healthy Dental Pulp Under the Omics Loupe

This study aims to contribute to the understanding of the dental pulp microbiome through metataxonomic analysis of pulp tissues from clinically healthy impacted third molars in 17 patients. Samples from coronal pulp, outer radicular dentin, and negative controls were included. Each sample was spiked with a known bacterial standard. Sequencing of the 16S rRNA V3-V4 region revealed similarity in bacterial taxonomic profiles. The bacterial DNA was detected in all pulp samples, primarily originating from reagent contaminants. Although some oral taxa appeared more abundant in pulp than in dentin or controls, contaminant species overwhelmingly dominated. Most of the extracted DNA was of human origin, rather than bacterial. Our findings question the concept of a core microbiome in healthy pulp and highlight the critical need for rigorous controls in pulpal microbiome studies.

Complications of invasive oral procedures in patients with immune-mediated inflammatory disorders treated with biological and conventional disease-modifying antirheumatic drugs or glucocorticoids: a scoping review of the literature

OBJECTIVES

By a scoping review, to evaluate whether patients with immune-mediated inflammatory disorders (IMIDs) treated with biological and conventional disease-modifying antirheumatic drugs (b/cDMARDs) and/or glucocorticoids (GCs) experience complications after invasive oral procedures.

MATERIALS AND METHODS

Primary search was conducted on PubMed/MEDLINE database, Google Scholar, Embase and Web of Science up to December 31, 2023. The PICO question was "Does a patient with IMIDs and treated with b/cDMARDs in mono/bi or combination therapies have delayed oral wound healing or infectious complications after an invasive oral procedure?". To be included, references had to be primary studies written in English or French. Qualitative assessment was performed.

RESULTS

From 1,494 initial articles, 59 full-text articles were selected, including 47 case reports and case series, 7 comparative non-randomized studies, 1 randomized clinical trial, 2 case-case studies, 1 case-control study, and 1 prospective cohort study. Most reports involved patients with rheumatoid arthritis on methotrexate and/or anti-TNF. Complications (medication-related osteonecrosis of the jaw, delayed healing, local infection) occurred predominantly after tooth extractions, particularly affecting women, patients over 50 with bisphosphonate use, unhealthy lifestyle habits, or diabetes. They were generally managed with prolonged antibiotic and antiseptic courses, and surgical interventions.

CONCLUSIONS

Local infectious complication or jaw osteonecrosis could occur post-invasive procedures, especially tooth extractions, in IMIDs patients on b/cDMARDs and/or GCs, often in patients with comorbidities and/or concurrent medications such as bone-modifying drugs.

CLINICAL RELEVANCE

It is essential for dentists to be alert to the existence of local or focal infectious complications after tooth extraction in patients with IMIDs on immunosuppressive therapy.

Bacteraemia and proinflammatory response after non-surgical periodontal therapy and adjunctive antibiotics in patients with recent acute coronary syndrome

INTRODUCTION

This study compares the incidence of bacteraemia and proinflammatory cytokines in short and long periods after non-surgical periodontal therapy involving premedication with amoxicillin (AMX) followed by AMX and metronidazole (MTZ) in patients with Acute Coronary Syndrome (ACS).

METHODS

This pilot study included twelve individuals with periodontitis and recent ACS. Six patients were treated with subgingival instrumentation (SI), and six with supragingival ultrasonic scaling (US). Amoxicillin 2 g was administered as premedication in the first visit, followed by AMX-MTZ for one week. The incidence of bacteraemia was evaluated using hemoculture, qPCR, and next-generation sequencing (NGS) before the treatment (t0) and 30 min later (t1) (quadrants 1 and 2), and after one-week, pre-post-treatment samples were taken from the re-maining quadrants (t3 and t4). Proinflammatory cytokines were evaluated in serum at baseline (t0), one week (t1), and six months (t5).

RESULTS

Bacteraemia was low in 16.6 %, similar in both treatment groups. Porphyromonas gingivalis and Desulfobulbus oralis (16.6 %), Filifactor alocis, Eubacterium saphenum, Eubacterium brachy (8.3 %) were identified with qPCR. NGS was only detected in a single patient; at time t0, bacteria were more diverse than at t3 and were associated with the phyla Bacteroidetes and Proteobacteria. Interestingly, many clones observed in blood were non-oral. After treatment, all cytokines were reduced significantly in the SI group in the long term (p< 0.05).

CONCLUSIONS

Periodontal therapy reduced bacteremia: despite the antibiotic regimen, bacteria remained in peripheral blood, which could be associated with antimicrobial resistance. SI produced a more efficient reduction of proinflammatory cytokines after periodontal treatment in individuals with ACS.

Risk of Infective Endocarditis Following Invasive Dental Procedures: A Systematic Review and Meta-Analysis

Objectives

This systematic review and meta-analysis aimed to synthesize evidence and determine the association between IE and dental procedures, including invasive and non-invasive procedures.

Methods

We conducted a systematic search of PubMed, Google Scholar, and Cochrane databases for studies involving procedures such as tooth extraction, scaling, endodontic treatment, oral surgery, and periodontal treatment involving individuals aged ≥15 years. The primary outcome was the incidence of IE following these procedures.

Results

An association was found between IE and invasive dental procedures (OR 1.49, 95% CI 1.25-1.76; p < 0.00001). Subgroup analysis showed an increased risk of IE following tooth extraction (OR 2.73, 95% CI 1.46-5.11; p = 0.002) and oral surgery (OR 6.33, 95% CI 2.43-16.49; p = 0.0002) in high-risk patients.

Conclusion

Our study found a strong association between invasive dental procedures and increased IE risk, particularly for tooth extraction and oral surgery in high-risk individuals.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023488546, Identifier CRD42023488546.

From gingiva to multiple organs in mice: The trace of Porphyromonas gingivalis via in vivo imaging

Background/purpose

Periodontitis is associated with systemic health. One of the underlying mechanisms is the translocation of periodontal pathogens, among which Porphyromonas gingivalis (Pg) is the most common. Here, we aimed to illustrate the biodistribution and dynamics of Pg from gingiva to multiple organs through blood circulation.

Materials and methods

Pg tagged by Cyanine 7 (Cy7-Pg) was injected into the gingiva of healthy and periodontitis mice. In vivo imaging system (IVIS) was applied to monitor the distribution of Cy7-Pg in multiple organs which were isolated at serial timepoints. Polymerase chain reaction (PCR) was conducted to determine the Pg DNA copies in the gingiva, blood and organs. Cy7-Pg in the gingiva and organs was also confirmed by frozen section staining. Furthermore, to figure out whether the bacteremia derived from oral-gut axis, mice received gavage of Cy7-Pg. Then the blood and organ samples were detected in the similar way as above.

Results

Intra-gingival injection induced larger amounts of Cy7-Pg accumulating in the gingiva of periodontitis mice (P < 0.05) as confirmed by above three methods. Twenty minutes after injection, Pg DNA copies in the blood of periodontitis group were 36.3-fold higher than healthy group (P < 0.05). IVIS results, combined with PCR and frozen sections, demonstrated periodontitis induced longer retention with higher amounts of Cy7-Pg in the periodontitis group. Pg was enriched more significantly in the liver for the longer duration than the kidney and pancreas.

Conclusion

Our study showed Pg, which accumulated in the gingiva, could translocate through blood circulation to multiple organs with varied duration and amounts.

Oral Pathogens' Substantial Burden on Cancer, Cardiovascular Diseases, Alzheimer's, Diabetes, and Other Systemic Diseases: A Public Health Crisis-A Comprehensive Review

This review synthesizes the findings from 252 studies to explore the relationship between the oral pathogens associated with periodontitis, dental caries, and systemic diseases. Individuals with oral diseases, such as periodontitis, are between 1.7 and 7.5 times (average 3.3 times) more likely to develop systemic diseases or suffer adverse pregnancy outcomes, underscoring the critical connection between dental and overall health. Oral conditions such as periodontitis and dental caries represent a significant health burden, affecting 26-47% of Americans. The most important oral pathogens, ranked by publication frequency, include the herpes virus, C. albicans, S. mutans, P. gingivalis, F. nucleatum, A. actinomycetemcomitans, P. intermedia, T. denticola, and T. forsythia. The systemic diseases and disorders linked to oral infections, ranked similarly, include cancer, respiratory, liver, bowel, fever, kidney, complications in pregnancy, cardiovascular bacteremia, diabetes, arthritis, autoimmune, bladder, dementia, lupus, and Alzheimer's diseases. Evidence supports the efficacy of dental and periodontal treatments in eliminating oral infections and reducing the severity of systemic diseases. The substantial burden that oral pathogens have on cancer, cardiovascular diseases, Alzheimer's, diabetes, and other systemic diseases poses a significant public health crisis.

Exploring links between oral health and infective endocarditis

Infective endocarditis (IE) is a bacterial infection of the heart's inner lining. A low incidence rate combined with a high mortality rate mean that IE can be difficult to treat effectively. There is currently substantial evidence supporting a link between oral health and IE with the oral microbiome impacting various aspects of IE, including pathogenesis, diagnosis, treatment, and mortality rates. The oral microbiome is highly diverse and plays a crucial role in maintaining oral health by providing protective functions. However, when dysbiosis occurs, conditions such as periodontal or peri-implant disease can arise, offering a pathway for bacteraemia to develop. The role of the oral microbiome as a coloniser, facilitator and driver of IE remains to be uncovered by next-generation sequencing techniques. Understanding the dysbiosis and ecology of the oral microbiome of IE patients will allow improvements into the diagnosis, treatment, and prognosis of the disease. Furthermore, an increased awareness amongst those at high-risk of developing IE may encourage improved oral hygiene methods and lower incidence rates. This narrative review examines current findings on the relationship between oral health and IE. It draws from key studies on both topics, with manuscripts selected for their pertinence to the subject. It highlights the link between the oral microbiome and IE by exploring diagnostic techniques and treatments for IE caused by oral commensals.

Outer Membrane Vesicles Derived From Fusobacterium nucleatum Trigger Periodontitis Through Host Overimmunity

The virulent bacteria-induced host immune response dominates the occurrence and progression of periodontal diseases because of the roles of individual virulence factors from these pathogens in the initiation and spread of inflammation. Outer membrane vesicles (OMVs) as a pathogenic entity have recently attracted great attention as messenger bridges between bacteria and host tissues. Herein, the novel role of OMVs derived from Fusobacterium nucleatum in the occurrence of periodontitis is dissected. In a rat periodontitis model, it is found that OMVs derived from F. nucleatum caused deterioration of periodontitis by enhancing inflammation of the periodontium and absorption of alveolar bone, which is almost equivalent to the effect of F. nucleatum itself. Furthermore, that OMVs can independently induce periodontitis is shown. The pathogenicity of OMVs is attributed to multiple pathogenic components identified by omics. After entering human periodontal ligament stem cells (hPDLSCs) by endocytosis, OMVs activated NLRP3 inflammasomes and impaired the mineralization of hPDLSCs through NF-κB (p65) signaling, leading to the final injury of the periodontium and damage of alveolar bone in periodontitis. These results provide a new understanding of OMVs derived from pathogens and cues for the prevention of periodontitis.

Effect of Simple Oral Dental Extraction on Systemic Serum Amyloid A Concentrations in Horses

BACKGROUND

The translocation of gingival commensals resulting in measurable systemic inflammation has been described in humans and non-equine veterinary species with dental disorders, particularly periodontal disease. Routine odontoplasty does not result in increased serum amyloid A (SAA) concentration in horses, but a measurable increase in SAA concentration in horses undergoing dental extractions could suggest that local inflammation resulting from more severe dental disease has potential for wider, systemic consequences that warrants further study.

OBJECTIVES

To determine whether SAA increases in horses undergoing simple, oral extraction of non-fractured cheek teeth with and without periodontal disease.

STUDY DESIGN

Prospective cohort study.

METHODS

SAA was measured using a stall-side test in horses undergoing simple oral extraction of cheek teeth with intact clinical crowns at baseline (T = 0), 24 h (T = 24) and 48 h (T = 48) post-extraction.

RESULTS

Eight horses and 4 ponies aged between 4 and 23 years underwent cheek tooth extraction. A statistically significant difference in SAA concentration was noted between groups with and without periodontal disease at both 24 h (p = 0.004) and 48 h (p = 0.043). At 24 h, the median SAA concentration was 135 mg/L (range: 0-260 mg/L; IQR: 77.5-174 mg/L) in horses with periodontal disease and 27.5 mg/L (range: 0-47 mg/L; IQR: 4.8-43.5 mg/L) in horses without periodontal disease. At 48 h, median SAA concentration was 264 mg/L (range: 236-440 mg/L; IQR: 245.5-300.5 mg/L) in horses with periodontal disease and 0 mg/L (range = 0-41 mg/L; IQR: 0-21.8 mg/L) in horses without periodontal disease.

MAIN LIMITATIONS

Small sample group. Horses undergoing extraction of fractured cheek teeth were not included.

CONCLUSIONS

Extraction of non-fractured cheek teeth does not result in a remarkable increase in SAA, except in horses with periodontal disease. These results suggest that periodontal disease in horses is associated with a local inflammatory response, which in turn drives the development of systemic inflammation, resulting in detectable increases in inflammatory markers when diseased periodontal tissues are disturbed.

Antibiotic Prophylaxis Prior to Dental Procedures After Total Hip and Knee Arthroplasty Does Not Decrease the Risk of Periprosthetic Joint Infection

BACKGROUND

Periprosthetic joint infection (PJI) is a devastating complication after total hip and total knee arthroplasty (THA/TKA). While some guidelines no longer recommend routine use of prophylactic antibiotics for dental procedures, many surgeons continue to prescribe antibiotics for their THA/TKA patients. In a setting of increasing antibiotic resistance, it is important to reduce unnecessary antibiotic use. This study aims to evaluate antibiotics prior to dental procedures and the association between dental procedures and PJI.

METHODS

We conducted a retrospective cohort study of patients who underwent THA/TKA between January 1, 2019 and December 31, 2020. The primary outcome was late-presenting PJI, occurring > 90 days after surgery. Patients were designated in the antibiotic group (2,000 mg of amoxicillin) or non-antibiotic group based on their surgeon's prophylaxis protocol. Dental-associated PJIs were considered if the patient had evidence of poor dentition or a recent dental procedure prior to the onset of PJI symptoms.

RESULTS

There were 2,871 (26.4%) patients in the no antibiotics group and 8,023 (73.6%) patients in the antibiotics group. We found 27 (0.3%) late-presenting PJIs and 4 dental-associated PJIs. In the univariate and multivariable analyses, body mass index ≥-30 and revision surgery were the only variables that increased the odds of late-presenting PJI. All 4 dental-associated PJIs occurred in patients prescribed antibiotics.

CONCLUSIONS

We found a low rate of late-presenting PJI. Routine antibiotics prior to dental procedures were not shown to affect the risk of late-presenting PJI. These findings suggest that routine antibiotic prophylaxis before dental procedures is not necessary after THA/TKA.

Stroke Caused by Vasculitis Induced by Periodontitis-Associated Oral Bacteria after Wisdom Teeth Extraction

Invasive dental procedures, such as wisdom teeth removal, have been identified as potential triggers for vascular events due to the entry of oral bacteria into the bloodstream, leading to acute vascular inflammation and endothelial dysfunction. This study presents the case of a 27-year-old healthy male who developed ischemic stroke resulting from bacteremia after undergoing wisdom teeth extraction. Initially, the patient experienced fever and malaise, which were followed by right-sided hemiplegia. Diagnostic imaging, including a CT scan, identified a subacute infarction in the posterior crus of the left internal capsule, and MRI findings indicated inflammatory changes in the masticatory muscles. Further investigations involving biopsies of the masticatory muscles, along with blood and cerebrospinal fluid samples, confirmed bacterial meningitis with associated vasculitis. Notably, oral bacteria linked to periodontitis, including Porphyromonas gingivalis, Fusobacterium nucleatum, Tannerella forsythia, and Parvimonas micra, were found in the biopsies and microbiological analyses. To the best of our knowledge, this is the first reported case showing that bacteremia following dental procedures can lead to such severe neurological outcomes. This case underscores the importance of recognizing bacteremia-induced vasculitis in patients presenting with neurological symptoms post-dental procedures, emphasizing the broader implications of oral infections in such pathologies.

Prevention of infective endocarditis in at-risk patients: how should dentists proceed in 2024?

National Institute for Health and Care Excellence (NICE) guidelines are ambiguous over the need for patients at increased risk of infective endocarditis (IE) to receive antibiotic prophylaxis (AP) prior to invasive dental procedures (IDPs), and this has caused confusion for patients and dentists alike. Moreover, the current law on consent requires clinicians to ensure that patients are made aware of any material risk they might be exposed to by any proposed dental treatment and what can be done to ameliorate this risk, so that the patient can decide for themselves how they wish to proceed. The aim of this article is to provide dentists with the latest information on the IE-risk posed by IDPs to different patient populations (the general population and those defined as being at moderate or high risk of IE), and data on the effectiveness of AP in reducing the IE risk in these populations. This provides the information dentists need to facilitate the informed consent discussions they are legally required to have with patients at increased risk of IE about the risks posed by IDPs and how this can be minimised. The article also provides practical information and advice for dentists on how to manage patients at increased IE risk who present for dental treatment.

New evidence calls into question NICE's endocarditis prevention guidance

In 2008, National Institute for Health and Care Excellence (NICE) guidelines recommended against the use of antibiotic prophylaxis (AP) before invasive dental procedures (IDPs) to prevent infective endocarditis (IE). They did so because of lack of AP efficacy evidence and adverse reaction concerns. Consequently, NICE concluded AP was not cost-effective and should not be recommended. In 2015, NICE reviewed its guidance and continued to recommend against AP. However, it subsequently changed its wording to 'antibiotic prophylaxis against infective endocarditis is not routinely recommended'. The lack of explanation of what constituted routinely (and not routinely), or how to manage non-routine patients, caused enormous confusion and NICE remained out of step with all major international guideline committees who continued to recommend AP for those at high risk.Since the 2015 guideline review, new data have confirmed an association between IDPs and subsequent IE and demonstrated AP efficacy in reducing IE risk following IDPs in high-risk patients. New evidence also shows that in high-risk patients, the IE risk following IDPs substantially exceeds any adverse reaction risk, and that AP is therefore highly cost-effective. Given the new evidence, a NICE guideline review would seem appropriate so that UK high-risk patients can receive the same protection afforded high-risk patients in the rest of the world.

Recent Insights Into Native Valve Infective Endocarditis: JACC Focus Seminar 4/4

This focused review highlights the latest issues in native valve infective endocarditis. Native valve disease moderately increases the risk of developing infective endocarditis. In 2023, new diagnostic criteria were published by the Duke-International Society of Cardiovascular Infectious Diseases group. New pathogens were designated as typical, and findings on computed tomography imaging were included as diagnostic criteria. It is now recognized that a multidisciplinary approach to care is vital, and the role of an "endocarditis team" is highlighted. Recent studies have suggested that a transition from intravenous to oral antibiotics in selected patients may be reasonable, and the role of long-acting antibiotics is discussed. It is also now clear that an aggressive surgical approach can be life-saving in some patients. Finally, results of several recent studies have suggested there is an association between dental and other invasive procedures and an increased risk of developing infective endocarditis. Moreover, data indicate that antibiotic prophylaxis may be effective in some scenarios.

Systematic Dental Screening Before Transcatheter Aortic Valve Replacement: A Call to Action!

Transcatheter aortic valve implantation (TAVR) offers an alternative to surgical aortic valve replacement for high-risk patients. Despite its benefits, concerns arise from its association with prosthetic valve endocarditis (PVE), a severe complication. Recent studies indicate a potential higher incidence of PVE in TAVR recipients, especially within the first year postimplantation. A significant proportion of these cases trace back to oral-pharyngeal bacteria. However, no consensus exists on dental screening for TAVR, unlike the standard procedure for surgical aortic valve replacement. Dental screenings could reduce PVE risks and aid in patient recovery. This article underscores the importance of dental screenings, calling for more research to establish its efficacy and systematic application for TAVRI candidates. Collaborative efforts between oral and maxillofacial surgeons and cardiologists are crucial for optimal patient outcomes.

Laboratory approaches to determining blood culture contamination rates: an ASM Laboratory Practices Subcommittee report

Blood culture contamination (BCC) is the presence of specific commensal and environmental organisms cultivated from a single blood culture set out of a blood culture series and that do not represent true bacteremia. BCC can impact quality of care and lead to negative outcomes, unnecessary antibiotic exposure, prolonged hospital stays, and substantial costs. As part of the laboratory's quality management plan, microbiology laboratory personnel are tasked with monitoring BCC rates, preparing BCC rate reports, and providing feedback to the appropriate committees within their healthcare system. The BCC rate is calculated by the laboratory using pre-set criteria. However, pre-set criteria are not universally defined and depend on the individual institution's patient population and practices. This mini-review provides practical recommendations on elaborating BCC rate reports, the parameters to define for the pre-set criteria, how to collect and interpret the data, and additional analysis to include in a BCC report.

Pathologic Femur Fracture in an Immunocompetent Healthy Young Adult due to Acute Osteomyelitis

An immunocompetent 33-year-old woman presented with a pathologic femur fracture after one month of progressively worsening right thigh pain. Open biopsy demonstrated acute suppurative osteomyelitis despite the lack of clinical risk factors. The polymicrobial infection was successfully treated with three operative procedures and culture-specific antibiotic agents. Acute osteomyelitis, while an uncommon cause of pathologic fracture, must always be on the differential diagnosis, even when no obvious predisposing factors are present. When investigating for an infectious etiology in cases such as our own, considering immunodeficiency syndromes alongside the more typical causes of osteomyelitis is encouraged.