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Tay HW, Tay KS. Future directions for early detection of fracture related infections. J Orthop 2024; 55:64-68. [PMID: 38655538 PMCID: PMC11035015 DOI: 10.1016/j.jor.2024.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/26/2024] Open
Abstract
Introduction Fracture related infection (FRI) refers to pathogens infecting a fracture site and hence impeding fracture healing. It is a significant complication that carries substantial disease burden and socio-economic costs, but has had limited scientific development. Hence, this paper will review the existing strategies for early detection of FRI, in the form of serum markers, molecular diagnostics and imaging modalities, and further discuss potential future directions for improved detection of FRI. Existing Strategies for Diagnosis of FRI The Anti-infection Global Expert Committee (AIGEC) developed a consensus definition for FRI in 2017, which includes confirmatory and suggestive criteria for diagnosis of FRI. Existing strategies for diagnosis include clinical, laboratory, histopathological, microbiological and radiological investigations. Future Directions for Early Detection of FRI With increasing recognition of FRI, early detection is crucial for early treatment to be enforced. We have identified potential areas for future development in diagnostics for early detection of FRI, which are discussed in this manuscript. They include inflammatory cytokines, serum calcium levels, platelet count, improved management of histopathological and microbiological specimens, metagenomics, wound biomarkers, gut microbiota analysis, and novel imaging technologies.
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Affiliation(s)
- Hui Wen Tay
- Singapore General Hospital Department of Orthopaedic Surgery, Singapore
| | - Kae Sian Tay
- Singapore General Hospital Department of Orthopaedic Surgery, Singapore
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2
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Hussain SA, Walters S, Ahluwalia AK, Trompeter A. Fracture-related infections. Br J Hosp Med (Lond) 2023; 84:1-10. [PMID: 37646543 DOI: 10.12968/hmed.2022.0545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Fracture-related infection is a serious complication which can occur following musculoskeletal injury and is associated with significant morbidity. These complications can be challenging to recognise, and experts have provided a clearer definition of fracture-related infection to help with the diagnosis and detection of these infections. This system includes clinical, radiological and laboratory-based diagnostic features which are either confirmatory or suggestive of fracture-related infection. Treatment requires a multifaceted approach with multidisciplinary involvement, and generally a combination of surgical techniques and prolonged antibiotics, the timing and choice of which should be optimised. This article provides an evidence-based review of the British Orthopaedic Association Standards for Trauma for the diagnosis and management of fracture-related infections.
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Affiliation(s)
| | - Samuel Walters
- Orthopaedic Trauma/Limb Reconstruction Unit, St George's University Hospital, London, UK
| | - Aashish K Ahluwalia
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK
| | - Alex Trompeter
- Orthopaedic Trauma/Limb Reconstruction Unit, St George's University Hospital, London, UK
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Salar-vidal L, Auñón Á, Esteban J. Molecular Diagnosis of Osteoarticular Implant-Associated Infection: Available Techniques and How We Can Use Them. Prosthesis 2022; 5:1-12. [DOI: 10.3390/prosthesis5010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Despite recent advances during the last few years, microbiological diagnosis of prosthetic joint infections remains a challenge. Molecular biology techniques have been developed to try to overcome this problem, and recently, many of them have become available for many laboratories. Some of them, especially commercial multiplex PCR-based assays and universal 16S rDNA homemade PCR assays, are now available in many laboratories. Moreover, new technologies have appeared, especially metagenomics and next-generation sequencing. These techniques have demonstrated their potential in many studies but appear to be experimental at present. A few studies have evaluated the possible use of these methods in the clinical routine, and a review of the critical aspects for the selection of a molecular method (accuracy, complexity, cost) was performed. Finally, a proposal for a protocol that includes molecular biology techniques was made according to the literature published in this field. In conclusion, molecular biology techniques are ready to be used in the clinical routine of a microbiology laboratory, but their use must be carried out in accordance with the many special characteristics of each laboratory. In all cases, the interpretation of the results must be conducted by a multidisciplinary team with experience in the management of these patients.
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Wagendorf O, Menzel P, Schwarzer R, Neckel N, Preissner S, Heiland M, Nahles S. Sonication versus the conventional method for evaluation of the dental microbiome: a prospective pilot study. BMC Oral Health 2022; 22:348. [PMID: 35962429 PMCID: PMC9375313 DOI: 10.1186/s12903-022-02374-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/03/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives To investigate sonication as a new tool in microbiological probing of dental infections. Methods Comparison of a standard probing method: intraoperative swab, with sonication, and vortex of the removed tooth, was performed on 20 carious destructed teeth. Illumina high throughput sequencing of the 16S-rRNA-gene was used for assessing the microbial composition. Antibiotic susceptibility has been assigned based on known resistances of each detected species. Probing procedures were compared using Bland–Altmann-Test, and antibiotic susceptibility using the Friedmann-Test and alpha-adjusted post-hoc-analysis. Results In total, 60 samples were analysed: 20 intraoperative swabs, 20 vortex fluids, and 20 sonication fluids. Sonication fluid yielded the highest number of bacterial sequencing reads in all three procedures. Comparing the operational taxonomic units (OTUs) of the identified bacteria, significantly more OTUs were found in sonication fluid samples. Phylum and order abundances varied between the three procedures. Significantly more Actinomycetales have been found in sonication fluid samples compared to swab samples. The assigned resistance rates for the identified bacteria (1.79–31.23%) showed no differences between the tested probing procedures. The lowest resistance rates were found for amoxicillin + clavulanate (3.95%) and levofloxacin (3.40%), with the highest in amoxicillin (30.21%) and clindamycin (21.88%). Conclusions By using sonication on extracted teeth, it is possible to get a more comprehensive image of the residing microbial flora compared to the standard procedure. If sonication is not available, vortexing is a potential alternative. In immunocompromised patients, especially when actinomycosis is suspected, sonication should be considered for a more detailed microbiological evaluation of the potential disease-causing microbiome. Due to the high rates of antibiotic resistance, a more targeted antibiotic therapy is favourable. Levofloxacin should be considered as a first-line alternative to amoxicillin + clavulanate in patients with an allergy to penicillin. Supplementary Information The online version contains supplementary material available at 10.1186/s12903-022-02374-0.
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Affiliation(s)
- Oliver Wagendorf
- Department of Oral and Maxillofacial Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
| | - Peter Menzel
- Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
| | | | - Norbert Neckel
- Department of Oral and Maxillofacial Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Saskia Preissner
- Department of Oral and Maxillofacial Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Max Heiland
- Department of Oral and Maxillofacial Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Susanne Nahles
- Department of Oral and Maxillofacial Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
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5
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Fritsche T, Schnetz M, Klug A, Fischer S, Ruckes C, Hunfeld KP, Hoffmann R, Gramlich Y. Tissue sampling is non-inferior in comparison to sonication in orthopedic revision surgery. Arch Orthop Trauma Surg 2022; 143:2901-2911. [PMID: 35612616 DOI: 10.1007/s00402-022-04469-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/24/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to assess the role of sonication fluid cultures in detecting musculoskeletal infections in orthopedic revision surgery in patients suspected of having peri-prosthetic joint infection (PJI), fracture-related infections (FRI), or postoperative spinal implant infections (PSII). METHODS Between 2016 and 2019, 149 cases with a data set including sonication fluid cultures and tissue specimen and histological analysis were included. Accuracy of each diagnostic tool as well as the influence of antibiotic therapy was analyzed. Pathogens identified in the sonication cultures and in the associated tissue samples were compared based on the matching of the antibiograms. Therapeutic benefits were then assessed. RESULTS Of 149 cases, 43.6% (n = 65) were identified as PJI, 2.7% (n = 4) as FRI, 12.8% (n = 19) as PSII, 6.7% (n = 10) as aseptic non-union, and 34.2% (n = 51) as aseptic implant loosening. The sensitivity and specificity of tissue and synovial specimens showed no significant difference with respect to sonication fluid cultures (sensitivity/specificity: tissue: 68.2%/96.7%; sonication fluid cultures: 60.2%/98.4%). The administration of antibiotics over 14 days prior to microbiological sampling (n = 40) resulted in a lower sensitivity of 42.9% each. Histological analysis showed a sensitivity 86.3% and specificity of 97.4%. In 83.9% (n = 125) of the cases, the results of sonication fluid cultures and tissue specimens were identical. Different microorganisms were found in only four cases. In 17 cases, tissue samples (n = 5) or sonication (n = 12) were false-negatives. CONCLUSION Sonication fluid culture showed no additional benefit compared to conventional microbiological diagnostics of tissue and synovial fluid cultures. Preoperative administration of antibiotics had a clearly negative effect on microbiologic test accuracy. In over 83.9% of the cases, sonication fluid and tissue cultures showed identical results. In the other cases, sonication fluid culture did not further contribute to the therapy decision, whereas other factors, such as fistulas, cell counts, or histological analysis, were decisive in determining therapy.
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Affiliation(s)
- Theresa Fritsche
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - Matthias Schnetz
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - Alexander Klug
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - Sebastian Fischer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - Christian Ruckes
- Interdisciplinary Center for Clinical Studies, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, Mainz, Germany
| | - K P Hunfeld
- Institute of Laboratory Medicine, Microbiology and Infection Control, Northwest Medical Center, Medical Faculty Goethe University Frankfurt, Steinbacher Hohl 2-26, 60488, Frankfurt am Main, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - Yves Gramlich
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Nabergoj M, Denard PJ, Collin P, Trebše R, Lädermann A. Radiological changes, infections and neurological complications after reverse shoulder arthroplasty related to different design types and their rates: Part II. EFORT Open Rev 2021; 6:1109-1121. [PMID: 34909229 PMCID: PMC8631237 DOI: 10.1302/2058-5241.6.210040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Early reported complication rates with the Grammont-type reverse shoulder arthroplasty (RSA) were very high, up to 24%.A 'problem' is defined as an intraoperative or postoperative event that is not likely to affect the patient's final outcome, such as intraoperative cement extravasation and radiographic changes. A 'complication' is defined as an intraoperative or postoperative event that is likely to affect the patient's final outcome, including infection, neurologic injury and intrathoracic central glenoid screw placement.Radiographic changes around the glenoid or humeral components of the RSA are very frequently observed and described in the literature.High complication rates related to the Grammont RSA design led to development of non-Grammont designs which led to a dramatic fall in the majority of complications.The percentage of radiological changes after RSA is not negligible and remains unsolved, despite a decrease in its occurrence in the last decade. However, such changes should be now considered as simple problems because they rarely have a negative influence on the patient's final outcome, and their prevalence has dramatically decreased.With further changes in indications and designs for RSA, it is crucial to accurately track the rates and types of complications to justify its new designs and increased indications. Cite this article: EFORT Open Rev 2021;6:1109-1121. DOI: 10.1302/2058-5241.6.210040.
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Affiliation(s)
- Marko Nabergoj
- Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Philippe Collin
- Centre Hospitalier Privé Saint-Grégoire (Vivalto Santé), Saint- Grégoire, France
| | - Rihard Trebše
- Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
Implant-associated infection is one of the most devastating complications following orthopedic surgery. Early identification is crucial for treatment. Currently, however, a reliable diagnostic tool is lacking, partly due to disparate bacteria colonies (virulent vs non-virulent), difficulty in distinguishing infection from inflammatory disease, and highly diverse diagnostic thresholds and testing methods. Given the importance of biomarkers in the initial screening for the infection, an extensive effort has been made to develop serum and synovial biomarkers. In this review, the authors summarize the results from the most relevant studies to provide comprehensive information on biomarkers for the diagnosis of implant-associated infection. [Orthopedics. 2021;44(2):e158-e166.].
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Foster AL, Cutbush K, Ezure Y, Schuetz MA, Crawford R, Paterson DL. Cutibacterium acnes in shoulder surgery: a scoping review of strategies for prevention, diagnosis, and treatment. J Shoulder Elbow Surg 2021; 30:1410-1422. [PMID: 33373684 DOI: 10.1016/j.jse.2020.11.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/02/2020] [Accepted: 11/08/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cutibacterium acnes is a commensal, gram-positive, facultatively anaerobic bacillus that resides in the dermis. Historically thought to be a contaminant when identified on cultured specimens, recent advances in diagnostic technology have now implicated it as the most common organism responsible for postoperative shoulder infections. Despite a recognition of the role of this organism and a significant research interest in recent years, there is clear lack of consensus guideline on strategies to prevent, diagnose, and treat postoperative shoulder infection. METHOD The electronic databases PubMed, MEDLINE, CINAHL, Scopus, and Web of Science were searched in March 2020. All experimental and nonexperimental studies that investigate C acnes in shoulder surgery were included. Inclusion was limited to articles published after 2000 and written in English; reviews, gray literature, or abstracts were excluded. A total of 70 studies were included in this review. This scoping review was performed in accordance with the Extended Preferred Reporting Items of Systematic Reviews and Meta-Analyses Statement for Scoping Reviews (PRISMA-ScR). RESULTS Standard surgical prophylactic regimens such as intravenous antibiotics and topical chlorhexidine are ineffective at removing C acnes from the deep layer of the dermis, and there is a shift toward using topical benzoyl peroxide with significantly improved efficacy. An improved understanding of the bacteria has demonstrated that a prolonged culture time of up to 14 days is needed, especially in cases of established infection. Advances in diagnostics such as sonication and molecular-based testing are promising. Although usually thought to be susceptible to a broad range of antibiotics, resistance is emerging to clindamycin. An improved understanding of its ability to form a biofilm highlights the difficulty in treating an established infection. CONCLUSION The role of C acnes causing postoperative infection following shoulder surgery is being increasingly recognized. Strategies for prevention, diagnosis, and treatment have been outlined from both an antimicrobial and surgical perspective. A number of these strategies are emerging and require further research to demonstrate efficacy before implementation into clinical guidelines.
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Affiliation(s)
- Andrew L Foster
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Department of Surgery, School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Kenneth Cutbush
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Department of Surgery, School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Yukiko Ezure
- University of Queensland Centre for Clinical Research, RBWH Campus, Brisbane, QLD, Australia
| | - Michael A Schuetz
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Ross Crawford
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - David L Paterson
- University of Queensland Centre for Clinical Research, RBWH Campus, Brisbane, QLD, Australia.
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Bellova P, Knop-Hammad V, Königshausen M, Schildhauer TA, Gessmann J, Baecker H. Sonication in the diagnosis of fracture-related infections (FRI)-a retrospective study on 230 retrieved implants. J Orthop Surg Res 2021; 16:310. [PMID: 33985549 PMCID: PMC8117644 DOI: 10.1186/s13018-021-02460-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/06/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In fracture-related infections (FRI), both the diagnosis of the infection and the identification of the causative pathogen are crucial to optimize treatment outcomes. Sonication has been successfully used for periprosthetic joint infections (PJI); however, its role in FRI remains unknown. Our aim was to determine the diagnostic accuracy (sensitivity, specificity) of sonicate fluid culture (SFC). The primary objective was to compare SFC with peri-implant tissue culture (PTC) overall and among subgroups using the consensus definition by Metsemakers et al. The secondary objective was to determine the yield of SFC in possible fracture-related infections (PFRI). METHODS From March 2017 to May 2019, 230 cases of retrieved implants were retrospectively reviewed. To perform sonication, explants were placed in sterile polypropylene jars intraoperatively. After treatment in an ultrasonic bath (Bandelin, Berlin, Germany), sonicate fluid was incubated into blood culture bottles, and conventional culturing was eventually performed. Sensitivity and specificity were determined using two-by-two contingency tables. McNemar's test was used to compare proportions among paired samples while Fisher's exact test was used for comparison between categorical variables. RESULTS Of the 230 cases, 107 were identified as FRI, whereas 123 were aseptic revision cases (ARC). Of the latter, 105 were labeled as PFRI. Sensitivity of SFC was higher in comparison with PTC, although this did not reach statistical significance (90.7% vs. 84.1%; p = .065). The specificity of SFC was significantly lower than that of PTC (73.2% vs. 88.6%; p = .003). In PFRI, SFC yielded significantly more positive results than PTC (33/105 vs. 14/105; p = .003). Overall, 142 pathogens were identified by SFC, whereas 131 pathogens were found by PTC. CONCLUSIONS We found that sonication of fracture fixation devices may be a useful adjunct in FRI, especially in "low-grade" infections lacking confirmatory clinical criteria. Standardized diagnostic protocols are warranted in order to further optimize the diagnostic accuracy.
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Affiliation(s)
- Petri Bellova
- Department of Orthopedics and Trauma Surgery, 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, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Matthias Königshausen
- Department of Orthopedics and Trauma Surgery, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Thomas A Schildhauer
- Department of Orthopedics and Trauma Surgery, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Jan Gessmann
- Department of Orthopedics and Trauma Surgery, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Hinnerk Baecker
- Department of Orthopedics and Trauma Surgery, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
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Ahmed EA, Almutairi MK, Alkaseb AT. Accuracy of Tissue and Sonication Fluid Sampling for the Diagnosis of Fracture-Related Infection: Diagnostic Meta-Analysis. Cureus 2021; 13:e14925. [PMID: 34123624 PMCID: PMC8187062 DOI: 10.7759/cureus.14925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Evidence shows that tissue sample culturing is the gold standard approach for diagnosing fracture-related infection (FRI). Sonication fluid sampling has also been reported to be efficacious and superior to tissue sample culturing with prosthetic joint infection. However, data from the current literature are not enough to validate this hypothesis for FRI. We conducted a meta-analysis to validate the diagnostic accuracy of tissue sample culturing and sonication fluid aspiration and to find which one is superior to the other. An extensive search through the relevant databases was conducted to obtain all the relevant studies. We have included 13 relevant studies, including nine retrospective cohorts and four prospective ones. The overall pooled estimates of sensitivity, specificity, and diagnostic odds ratio (DOR) of tissue sampling culture in diagnosing fracture-related infections were 98% (95% CI, 92% to 99%), 38% (95% CI, 23% to 56%), and 25 (4 to 154), respectively. The overall pooled estimates of sensitivity, specificity, and DOR of sonication fluid sample culture in diagnosing fracture-related infections were 86% (95% CI, 79% to 92%), 98% (95% CI, 93% to 100%), and 353 (78 to 1598), respectively. No significant risk of bias was found regarding the sensitivity and specificity among studies investigating both modalities, however, significant heterogeneity was noticed. Sonication fluid sampling can be used to confirm FRI while tissue sampling can be used to exclude it and both modalities should be combined for obtaining the most accurate outcome.
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Affiliation(s)
- Elsiddig A Ahmed
- Department of Orthopedics and Traumatology, Prince Mutaibb bin Abdulaziz Hospital, Sakaka, SAU
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Iliadis AD, Shivji F, Debuka E, Trompeter A, Narayan B, Heidari N. Current concepts in the prevention, diagnosis and treatment of fracture-related infection (FRI). Eur J Orthop Surg Traumatol 2021; 31:957-66. [PMID: 33778904 DOI: 10.1007/s00590-021-02956-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/21/2021] [Indexed: 12/24/2022]
Abstract
Fracture-related infection (FRI) is one of the most challenging complications following operative management of fractures. It can have profound implications for the patient, can be associated with considerable morbidity and often lead to impaired outcomes. There are significant healthcare-related costs. In recent years, there has been significant progress towards developing preventative strategies. Furthermore, diagnostic algorithms and management protocols have recently been reported. Lack of a strong evidence base has previously hindered efforts to implement these and develop established standards of care. There are multiple aspects of care that need to be considered and a multi-disciplinary approach is recommended. In this narrative review, we present the most up-to-date recommendations in the prevention, diagnosis and management of FRI.
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Abstract
Despite different criteria to diagnose a prosthetic joint infection (PJI), aetiological diagnosis of the causing microorganism remains essential to guide treatment.Molecular-biology-based PJI diagnosis is progressing (faster, higher specificity) in different techniques, from the experimental laboratory into clinical use.Multiplex polymerase chain reaction techniques (custom-made or commercial) provide satisfactory results in clinical series of cases, with specificity close to 100% and sensitivity over 70-80%.Next-generation metagenomics may increase sensitivity while maintaining high specificity.Molecular biology techniques may represent, in the next five years, a significant transformation of the currently available microbiological diagnosis in PJI. Cite this article: EFORT Open Rev 2021;6:93-100. DOI: 10.1302/2058-5241.6.200118.
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Affiliation(s)
- Jaime Esteban
- Servicio de Microbiología Clínica, Hospital Universitario Fundación Jiménez Díaz-IIS-Fundacion Jimenez Diaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Enrique Gómez-Barrena
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario La Paz-IdiPaz, Universidad Autónoma de Madrid, Madrid, Spain
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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. Eur J Orthop Surg Traumatol 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Schulz P, Dlaska CE, Perka C, Trampuz A, Renz N. Preoperative synovial fluid culture poorly predicts the pathogen causing periprosthetic joint infection. Infection 2020; 49:427-436. [PMID: 33141393 PMCID: PMC8159841 DOI: 10.1007/s15010-020-01540-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/12/2020] [Indexed: 11/09/2022]
Abstract
Purpose We investigated the value of preoperative pathogen detection and evaluated its concordance with intraoperative cultures in patients with culture-positive periprosthetic joint infection (PJI). Methods Culture-positive PJI episodes with available preoperative (synovial fluid) and intraoperative cultures (periprosthetic tissue, synovial or sonication fluid) were analyzed. The pathogen detection rate in preoperative and intraoperative cultures was compared using Fisher’s exact test and their concordance was calculated. Results Among 167 included PJI episodes, 150 were monomicrobial with coagulase-negative staphylococci (n = 55, 37%), S. aureus (n = 34, 23%), and streptococci (n = 21, 14%) being the most common pathogens. Seventeen episodes (10%) were polymicrobial infections. The pathogen(s) grew in preoperative culture in 110 and in intraoperative cultures in 153 episodes (66% vs. 92%, p < 0.001). The pathogen detection rate was lower in preoperative compared to intraoperative cultures for low-virulent pathogens (40% vs. 94%, p < 0.001), polymicrobial infections (59% vs. 100%, p = 0.007), and in delayed and late PJI (63% vs. 94%, and 66% vs. 91%, respectively, p < 0.001). Full concordance of preoperative and intraoperative cultures was found in 87 episodes (52%). The pathogen was detected solely preoperatively in 14 episodes (8%) and solely intraoperatively in 57 cases (34%); an additional pathogen was found in 3 episodes (2%) preoperatively and in 6 episodes (4%) intraoperatively. Conclusion The concordance of preoperative and intraoperative cultures was poor (52%). The sole or an additional pathogen was found exclusively in intraoperative cultures in 38% of PJI episodes, hence preoperative synovial fluid cultures are considered unreliable for pathogen detection in PJI.
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Affiliation(s)
- Philipp Schulz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | - Constantin E Dlaska
- Orthopaedic Research Institute of Queensland, 7 Turner Street, Pimlico, Townsville, QLD, 4812, Australia
| | - 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), Charitéplatz 1, 10117, 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), Charitéplatz 1, 10117, 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), Charitéplatz 1, 10117, Berlin, Germany.
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Abstract
Fracture-related infection (FRI) is common and often diagnosed late.Accurate diagnosis is the beginning of effective treatment.Diagnosis can be difficult, particularly when there are no outward signs of infection.The new FRI definition, together with clear protocols for nuclear imaging, microbiological culture and histological analysis, should allow much better study design and a clearer understanding of infected fractures.In recent years, there has been a new focus on defining FRI and avoiding non-specific, poorly targeted treatment. Previous studies on FRI have often failed to define infection precisely and so are of limited value. This review highlights the essential principles of making the diagnosis and how clinical signs, serum tests, imaging, microbiology, molecular biology and histology all contribute to the diagnostic pathway. Cite this article: EFORT Open Rev 2020;5:614-619. DOI: 10.1302/2058-5241.5.190072.
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Affiliation(s)
- Martin McNally
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Geertje Govaert
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maria Dudareva
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
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Johnson AJ, O’toole RV. How to Diagnose Surgical Site Infection After Fracture Surgery: We Have a Problem! Tech Orthop 2020; 35:81-90. [DOI: 10.1097/bto.0000000000000462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hoekstra M, Veltman ES, Nurmohamed RF, van Dijk B, Rentenaar RJ, Vogely HC, van der Wal BC. Sonication Leads to Clinically Relevant Changes in Treatment of Periprosthetic Hip or Knee Joint Infection. J Bone Jt Infect 2020; 5:128-132. [PMID: 32566451 PMCID: PMC7295643 DOI: 10.7150/jbji.45006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/25/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Diagnosis of periprosthetic joint infection (PJI) can be troublesome. Sonication can be a helpful tool in culturing bacteria that are difficult to detect with standard tissue cultures. Aim of this study is to evaluate the clinical importance of our standardized sonication protocol in detecting periprosthetic joint infection. Materials and methods: All patients with revision surgery of a hip or knee prosthesis between 2011 and 2016 were retrospectively reviewed and divided in two groups: clinically suspected of infection or not suspected of infection. For both tissue culture and implant sonication, calculations of sensitivity and specificity were performed. Clinical relevance of sonication was evaluated by calculating in which percentage of patients' sonication influenced clinical treatment. Results: 226 patients with revision of a total hip prosthesis (122 patients) or a total knee prosthesis (104 patients) were included. Sensitivity of perioperatively taken tissue cultures was 94.3% and specificity was 99.3%. For sonication sensitivity was 80.5% and specificity was 97.8%. In the infection group eight patients (9%) with only one positive tissue culture and a positive sonication fluid culture with the same pathogen were found. Interpretation: Although sensitivity and specificity of sonication was lower compared to tissue cultures, periprosthetic joint infection could only be established in 8 patients (9%) suspected of infection because of a positive result of the sonication fluid culture. Sonication leads to clinically relevant changes in treatment and seems therefore to be a helpful diagnostic tool in clinical practice.
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Affiliation(s)
- Marrit Hoekstra
- Department of Orthopaedic Surgery, University Medical Centre Utrecht, the Netherlands
| | - Ewout S. Veltman
- Department of Orthopaedic Surgery, University Medical Centre Utrecht, the Netherlands
| | | | - Bruce van Dijk
- Department of Orthopaedic Surgery, University Medical Centre Utrecht, the Netherlands
| | - Rob J. Rentenaar
- Department of Clinical Microbiology, University Medical Centre Utrecht, the Netherlands
| | - H. Charles Vogely
- Department of Orthopaedic Surgery, University Medical Centre Utrecht, the Netherlands
| | - Bart C.H. van der Wal
- Department of Orthopaedic Surgery, University Medical Centre Utrecht, the Netherlands
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Sigmund IK, Renz N, Feihl S, Morgenstern C, Cabric S, Trampuz A. Value of multiplex PCR for detection of antimicrobial resistance in samples retrieved from patients with orthopaedic infections. BMC Microbiol 2020; 20:88. [PMID: 32290833 PMCID: PMC7155317 DOI: 10.1186/s12866-020-01741-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 03/03/2020] [Indexed: 11/18/2022] Open
Abstract
Background The performance of multiplex PCR (mPCR) for detection of antimicrobial resistance from clinical isolates is unknown. We assessed the ability of mPCR to analyse resistance genes directly from clinical samples. Patients with orthopedic infections were prospectively included. Phenotypical and genotypical resistance was evaluated in clinical samples (synovial and sonication fluid) where identical pathogens were identified by culture and mPCR. Result A total of 94 samples were analysed, including 60 sonication fluid and 34 synovial fluid samples. For coagulase-negative staphylococcus strains, mPCR detected resistance to oxacillin in 10 of 23 isolates (44%) and to rifampin in none of 6 isolates. For S. aureus isolates, detection rate of oxacillin and rifampin-resistance was 100% (2/2 and 1/1, respectively). Fluoroquinolone-resistance was confirmed by mPCR in all 3 isolates of Enterobacteriaceae, in enterococci resistance to aminoglycoside-high level was detected in 1 of 3 isolates (33%) and in streptococci resistance to macrolides/lincosamides in none of 2 isolates. The overall sensitivity for different pathogens and antimicrobials was 46% and specificity 95%, the median concordance was 80% (range, 57–100%). Full agreement was observed for oxacillin in S. aureus, vancomycin in enterococci, carbapenems/cephalosporins in Enterobacteriaceae and rifampin in Cutibacterium species. Conclusion The overall sensitivity for detection of antimicrobial resistance by mPCR directly from clinical samples was low. False-negative mPCR results occurred mainly in coagulase-negative staphylococci, especially for oxacillin and rifampin. However, the specificity of mPCR was high and a positive result reliably predicted antimicrobial resistance. Including universal primers in the PCR test assay may improve the detection rate but requires additional sequencing step. Trial registration www.clinicaltrials.gov No. NCT02530229, registered at 21 August 2015 (retrospectively registered).
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Affiliation(s)
- Irene Katharina Sigmund
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany.,Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - 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), Charitéplatz 1, 10117, Berlin, Germany
| | - Susanne Feihl
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | - Christian Morgenstern
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | - Sabrina Cabric
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany.,Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - 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), Charitéplatz 1, 10117, Berlin, Germany. .,Berlin Institute of Health Center for Regenerative Therapies (BCRT), Föhrer Strasse 15, 13353, Berlin, Germany.
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Giannoudis PV, Tosounidis TH. Acute and chronic infection: Is there a gold standard for management of the wound and bone defect? OTA Int 2020; 3:e068. [PMID: 33937688 DOI: 10.1097/OI9.0000000000000068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 12/14/2019] [Indexed: 11/26/2022]
Abstract
Acute and chronic infections with bone involvement remain a challenge to manage. They pose a significant burden to the patient, the treating surgeon, and society. Multidisciplinary team involvement is mandatory for a successful outcome. Application of a gold standard approach is not possible due to the high heterogeneous patient population and the variable degree of severity of soft tissue and bone involvement. The mainstay of treatment remains the conversion of a septic environment to an aseptic one with aggressive debridement of the affected soft tissues and bone. Reconstruction of the soft tissue defect can be achieved using modern microsurgical techniques, whereas the induced membrane and distraction osteogenesis (bone transport) are currently the 2 most commonly used treatment modalities for bone loss. The safest approach to deal successfully with this multifaceted clinical pathology is to always follow well-established principles of management and adapt treatment to the personalized needs of the patient.
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Govaert GAM, Kuehl R, Atkins BL, Trampuz A, Morgenstern M, Obremskey WT, Verhofstad MHJ, McNally MA, Metsemakers WJ. Diagnosing Fracture-Related Infection: Current Concepts and Recommendations. J Orthop Trauma 2020; 34:8-17. [PMID: 31855973 PMCID: PMC6903359 DOI: 10.1097/bot.0000000000001614] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2019] [Indexed: 02/02/2023]
Abstract
Fracture-related infection (FRI) is a severe complication after bone injury and can pose a serious diagnostic challenge. Overall, there is a limited amount of scientific evidence regarding diagnostic criteria for FRI. For this reason, the AO Foundation and the European Bone and Joint Infection Society proposed a consensus definition for FRI to standardize the diagnostic criteria and improve the quality of patient care and applicability of future studies regarding this condition. The aim of this article was to summarize the available evidence and provide recommendations for the diagnosis of FRI. For this purpose, the FRI consensus definition will be discussed together with a proposal for an update based on the available evidence relating to the diagnostic value of clinical parameters, serum inflammatory markers, imaging modalities, tissue and sonication fluid sampling, molecular biology techniques, and histopathological examination. Second, recommendations on microbiology specimen sampling and laboratory operating procedures relevant to FRI will be provided. LEVEL OF EVIDENCE:: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Geertje A. M. Govaert
- Department of Trauma Surgery, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Richard Kuehl
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland
| | - Bridget L. Atkins
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - 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
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - William T. Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
| | - Michael H. J. Verhofstad
- Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; and
| | - Martin A. McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
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Gits-Muselli M, Villiers S, Hamane S, Berçot B, Donay JL, Denis B, Guigue N, Alanio A, Bretagne S. Time to and differential time to blood culture positivity for assessing catheter-related yeast fungaemia: A longitudinal, 7-year study in a single university hospital. Mycoses 2019; 63:95-103. [PMID: 31630462 DOI: 10.1111/myc.13024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 10/04/2019] [Accepted: 10/10/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Time to positivity (TTP) and differential time to positivity (DTTP) between central and peripheral blood cultures are commonly used for bacteraemia to evaluate the likelihood of central venous catheter (CVC)-related bloodstream infection. Few studies have addressed these approaches to yeast fungaemia. OBJECTIVES This study aimed to evaluate TTP and DTTP to assess CVC-related yeast fungaemia (CVC-RYF). PATIENTS/METHODS We retrospectively analysed the results from 105 adult patients with incident fungaemia, with CVC removed and cultured, collected from 2010 to 2017. The bottles were incubated in a BioMérieux BacT/ALERT 3D and kept for at least 5 days. RESULTS Of the 105 patients included, most were oncology patients (85.7%) and had of long-term CVC (79.6%); 32 (30.5%) had a culture-positive CVC (defined as CVC-RYF) with the same species as in blood culture, and 69.5% had culture-negative CVC (defined as non-CVC-RYF, NCVC-RYF). Candida albicans represented 46% of the episodes. The median TTP was statistically different between CVC-RYF and NCVC-RYF (16.8 hours interquartile range (IQR) [9.7-28.6] vs 29.4 hours [IQR 20.7-41.3]; P = .001). A TTP <10 hours had the best positive likelihood ratio (21.5) for CVC-RYF, although the sensitivity was only 28%. DTTP was available for 52 patients. A DTTP >5 hours had a sensitivity of 100% and a specificity of 71% for CVC-RYF. CONCLUSIONS Since the median TTP was 17 hours and the most performing DTTP >5 hours, these delays are too long to take a decision in the same operational day. More rapid methods for detecting infected catheters should be tested to avoid unnecessary CVC withdrawal.
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Affiliation(s)
- Maud Gits-Muselli
- Parasitology-Mycology Laboratory, Lariboisière Saint-Louis Fernand Widal Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Paris-Diderot, Sorbonne Paris Cité University, Paris, France.,Molecular Mycology Unit, Institut Pasteur, Reference National Center of Invasive Mycoses and Antifungals, CNRS UMR2000, Paris, France
| | - Stéphane Villiers
- Anesthesiology Department, Lariboisière Saint-Louis Fernand Widal Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Samia Hamane
- Parasitology-Mycology Laboratory, Lariboisière Saint-Louis Fernand Widal Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Béatrice Berçot
- Microbiology Department, Lariboisière Saint-Louis Fernand Widal Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Paris-Diderot, IAME UMR-1137, Sorbonne Paris Cité University, Paris, France
| | - Jean-Luc Donay
- Microbiology Department, Lariboisière Saint-Louis Fernand Widal Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Blandine Denis
- Tropical and Infectious Diseases Department, Lariboisière Saint-Louis Fernand Widal Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Nicolas Guigue
- Parasitology-Mycology Laboratory, Lariboisière Saint-Louis Fernand Widal Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Alexandre Alanio
- Parasitology-Mycology Laboratory, Lariboisière Saint-Louis Fernand Widal Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Paris-Diderot, Sorbonne Paris Cité University, Paris, France.,Molecular Mycology Unit, Institut Pasteur, Reference National Center of Invasive Mycoses and Antifungals, CNRS UMR2000, Paris, France
| | - Stéphane Bretagne
- Parasitology-Mycology Laboratory, Lariboisière Saint-Louis Fernand Widal Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Paris-Diderot, Sorbonne Paris Cité University, Paris, France.,Molecular Mycology Unit, Institut Pasteur, Reference National Center of Invasive Mycoses and Antifungals, CNRS UMR2000, Paris, France
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Fuchs M, Kinzel S, Gwinner C, Perka C, Renz N, von Roth P. Clinically Asymptomatic Patients Show a High Bacterial Colonization Rate of Osteosynthetic Implants Around the Knee but Not the Hip. J Arthroplasty 2019; 34:1761-6. [PMID: 31064723 DOI: 10.1016/j.arth.2019.03.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/15/2019] [Accepted: 03/25/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patients with osteosynthetic implants around the hip and knee show higher infection rates after joint arthroplasty. Our aim was to evaluate the bacterial colonization of any osteosynthetic implants around the hip and knee in patients without clinical signs of infection. METHODS Consecutive patients with osteosynthetic implant removal because of related soft tissue irritations or before elective total joint arthroplasty of the hip and knee were prospectively included. Patients with signs of infection were excluded. Based on sonication fluid cultures, implants were classified according to microbial growth as negative (no growth), contaminated (nonsignificant growth), or colonized (significant growth). RESULTS Sonication cultures were positive in 54 of 203 implants (27%), including 8 of 34 (24%) after orthopedic and 46 of 169 (27%) after traumatological surgery. Of 203 sonication cultures, 22 (11%) grew significant bacterial counts. Most common microorganisms were coagulase-negative staphylococci (46%). Implants around the knee showed a significantly higher rate of positive sonication cultures compared with those around the hip (14% vs 2%, P = .017). CONCLUSIONS We detected high bacterial implant colonization rates regardless of the initial type of surgery. Predominant pathogens were staphylococci, the most common causative agents of periprosthetic joint infections. Positive sonication results do not necessarily lead to postoperative surgical complications and thus do not equal infection. It remains unclear if patients with evidence of bacterial implant colonization show a higher risk of periprosthetic joint infection after adjacent subsequent total joint arthroplasty. Nevertheless, surgeons should be aware of a significantly higher colonization rate of implants around the knee and take this into consideration when total knee arthroplasty is scheduled in patients with osteosynthetic devices.
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Li C, Ojeda-Thies C, Trampuz A. Culture of periprosthetic tissue in blood culture bottles for diagnosing periprosthetic joint infection. BMC Musculoskelet Disord 2019; 20:299. [PMID: 31228938 PMCID: PMC6589180 DOI: 10.1186/s12891-019-2683-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/14/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The purpose of this meta-analysis was to evaluate the diagnostic accuracy of periprosthetic tissue culture in blood culture bottles (BCB) for periprosthetic joint infection (PJI). METHODS PubMed, Web of Science, and Embase were systematically searched for eligible studies evaluating the diagnostic performance of periprosthetic tissue culture in BCB for the diagnosis of PJI. The pooled data were analysed by Meta-Disc software. RESULTS Four studies with a total of 1071 patients were included in this meta-analysis. The summarized estimates showed that periprosthetic tissue culture in BCB may be of great value in PJI diagnosis with a pooled sensitivity of 0.70 (95% confidence interval [CI]; 0.66-0.75), specificity of 0.97 (95% CI: 0.95-0.98); positive likelihood ratio (PLR) of 20.98 (95% CI: 11.52-38.2); negative likelihood ratio (NLR) of 0.28 (95% CI: 0.20-0.40); and diagnostic odds ratio (DOR) of 92.26 (95% CI: 43.93-193.78). CONCLUSIONS The present meta-analysis showed that periprosthetic tissue in BCB improves the results of microorganism cultures, with a sensitivity of 70% and a specificity of 97%. However, more large-scale, well-performed studies are needed to verify our findings.
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Affiliation(s)
- Cheng Li
- Charité - Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | | | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
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Li C, Renz N, Thies CO, Trampuz A. Meta-analysis of sonicate fluid in blood culture bottles for diagnosing periprosthetic joint infection. J Bone Jt Infect 2018; 3:273-279. [PMID: 30662820 PMCID: PMC6328302 DOI: 10.7150/jbji.29731] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/29/2018] [Indexed: 12/25/2022] Open
Abstract
Introduction: Periprosthetic joint infection (PJI) is the most serious complication after arthroplasty, and the diagnosis of PJI is still challenging with modern medical technology. To improve the diagnostic rate, combined diagnostic methods are gradually beginning to be used to diagnose PJI. Sonication is one accurate way to diagnose PJI, but there is minimal research regarding the diagnostic value of sonicate fluid (SF) in blood culture bottles (BCB). Therefore, we evaluated this combined diagnostic method by meta-analysis. Methods: We searched English publications in electronic databases regarding the use of sonicate fluid in blood culture bottles (SF-BCB) for diagnosing PJI, screened the literature according to inclusion criteria, assessed the quality of the selected literature, and collected information regarding SF-BCB. Results: This meta-analysis includes 4 studies that evaluated SF-BCB for the diagnosis of PJI. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR) and diagnostic odds ratio (DOR) are 0.85 (95% Confidence interval [CI], 0.77 to 0.91), 0.86 (CI, 0.81 to 0.91), 5.34 (CI, 3.13 to 9.11), 0.16 (CI, 0.06 to 0.48) and 39.01 (CI, 9.04 to 168.35), respectively. The area under the curve (AUC) of the summary receiver operating characteristic (SROC) is 0.9186 (standard error, 0.0205). Conclusion: SF-BCB has great value for the microbiological diagnosis of PJ, especially for patients with prior antibiotic treatment.
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Affiliation(s)
- Cheng Li
- 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
| | | | - 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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Kamaruzzaman NF, Tan LP, Mat Yazid KA, Saeed SI, Hamdan RH, Choong SS, Wong WK, Chivu A, Gibson AJ. Targeting the Bacterial Protective Armour; Challenges and Novel Strategies in the Treatment of Microbial Biofilm. Materials (Basel) 2018; 11:E1705. [PMID: 30217006 PMCID: PMC6164881 DOI: 10.3390/ma11091705] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/07/2018] [Accepted: 09/09/2018] [Indexed: 02/07/2023]
Abstract
Infectious disease caused by pathogenic bacteria continues to be the primary challenge to humanity. Antimicrobial resistance and microbial biofilm formation in part, lead to treatment failures. The formation of biofilms by nosocomial pathogens such as Staphylococcus aureus (S. aureus), Pseudomonas aeruginosa (P. aeruginosa), and Klebsiella pneumoniae (K. pneumoniae) on medical devices and on the surfaces of infected sites bring additional hurdles to existing therapies. In this review, we discuss the challenges encountered by conventional treatment strategies in the clinic. We also provide updates on current on-going research related to the development of novel anti-biofilm technologies. We intend for this review to provide understanding to readers on the current problem in health-care settings and propose new ideas for new intervention strategies to reduce the burden related to microbial infections.
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Affiliation(s)
- Nor Fadhilah Kamaruzzaman
- Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa 16100, Kelantan, Malaysia.
| | - Li Peng Tan
- Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa 16100, Kelantan, Malaysia.
| | - Khairun Anisa Mat Yazid
- Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa 16100, Kelantan, Malaysia.
| | - Shamsaldeen Ibrahim Saeed
- Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa 16100, Kelantan, Malaysia.
| | - Ruhil Hayati Hamdan
- Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa 16100, Kelantan, Malaysia.
| | - Siew Shean Choong
- Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa 16100, Kelantan, Malaysia.
| | - Weng Kin Wong
- School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia.
| | - Alexandru Chivu
- UCL Centre for Nanotechnology and Regenerative Medicine, Division of Surgery & Interventional Science, University College London, London NW3 2PF, UK.
| | - Amanda Jane Gibson
- Royal Veterinary College, Pathobiology and Population Sciences, Hawkshead Lane, North Mymms, Hatfield AL9 7TA, UK.
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Onsea J, Depypere M, Govaert G, Kuehl R, Vandendriessche T, Morgenstern M, McNally M, Trampuz A, Metsemakers WJ. Accuracy of Tissue and Sonication Fluid Sampling for the Diagnosis of Fracture-Related Infection: A Systematic Review and Critical Appraisal. J Bone Jt Infect 2018; 3:173-181. [PMID: 30155402 PMCID: PMC6098816 DOI: 10.7150/jbji.27840] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 08/01/2018] [Indexed: 12/19/2022] Open
Abstract
Introduction: Intraoperatively obtained peri-implant tissue cultures remain the standard for diagnosis of fracture-related infection (FRI), although culture-negative cases may complicate treatment decisions. This paper reviews the evidence on sonication fluid and tissue sampling for the diagnosis of FRI. Methods: A comprehensive search in Pubmed, Embase and Web-of-Science was carried out on April 5, 2018, to identify diagnostic validation studies regarding sonication fluid and tissue sampling for FRI. Results: Out of 2624 studies, nine fulfilled the predefined inclusion criteria. Five studies focused on sonication fluid culture, two on PCR and two on histopathology. One additional histopathology study was found after screening of reference lists. There is limited evidence that sonication fluid culture may be a useful adjunct to conventional tissue culture, but no strong evidence that it is superior or can replace tissue culture. Regarding molecular techniques and histopathology the evidence is even less clear. Overall, studies had variable 'gold standard' criteria for comparison and poorly reported culture methods. Conclusions: Scientific evidence on sonication fluid and tissue sampling, including culture, molecular techniques and histopathology for the diagnosis of FRI is scarce. It is imperative that laboratory protocols become standardized and uniform diagnostic criteria, as recently published in a consensus definition, be implemented.
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Affiliation(s)
- Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Belgium
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Belgium
| | - Geertje Govaert
- Department of Trauma Surgery, University Medical Center Utrecht, The Netherlands
| | - Richard Kuehl
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Switzerland
| | | | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery
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