Incidence, associated disease burden and healthcare utilization due to Staphylococcus aureus prosthetic joint infection in European hospitals: the COMBACTE-NET ARTHR-IS multi-centre study

BACKGROUND

The aim of this study was to estimate the incidence, associated disease burden and healthcare utilization due to Staphylococcus aureus prosthetic joint infections (SA-PJI) after primary hip and knee arthroplasty in European centres.

METHODS

This study was conducted in patients who underwent primary hip and knee arthroplasty in 19 European hospitals between 2014 and 2016. The global incidence of PJI and SA-PJI was calculated. The associated disease burden was measured indirectly as infection-related mortality plus loss of function. For healthcare utilization, number and duration of hospitalizations, number and type of surgical procedures, duration of antibiotic treatments, and number of outpatient visits were collected. Subgroup and regression analyses were used to evaluate the impact of SA-PJI on healthcare utilization, controlling for confounding variables.

RESULTS

The incidence of PJI caused by any micro-organism was 1.41%, and 0.40% for SA-PJI. Among SA-PJI, 20.7% were due to MRSA with substantial regional differences, and were more frequent in partial hip arthroplasty (PHA). Related deaths and loss of function occurred in 7.0% and 10.2% of SA-PJI cases, respectively, and were higher in patients with PHA. Compared with patients without PJI, patients with SA-PJI had a mean of 1.4 more readmissions, 25.1 more days of hospitalization, underwent 1.8 more surgical procedures, and had 5.4 more outpatient visits, controlling for confounding variables. Healthcare utilization was higher in patients who failed surgical treatment of SA-PJI.

CONCLUSIONS

This study confirmed that the SA-PJI burden is high, especially in PHA, and provided a solid basis for planning interventions to prevent SA-PJI.

Spinal tuberculosis: proposed spinal infection multidisciplinary management project (SIMP) flow chart revision

OBJECTIVE

We propose a revised flow chart of spinal infection multidisciplinary management project (SIMP) aimed to standardize the diagnostic process and management of spinal tuberculosis (TB).

MATERIALS AND METHODS

We reviewed data from all TB cases with osteoarticular involvement treated at a large tertiary teaching hospital in Bologna, Northern Italy, from January 2013 to December 2017. We cross-linked notified osteoarticular TB cases with SIMP database and we analysed clinical, diagnostic, and treatment data of all cases managed by SIMP.

RESULTS

Osteoarticular TB accounted for the 7.8% (n=40) of all TB cases notified between 2013 and 2017 (N=513). Among the identified cases, 52% (n=21/40) had spine involvement: all were enrolled and evaluated by SIMP multidisciplinary group. Females accounted for 57% (12/21) of patients, the median age was 52 years (range 24-82). In the 67% (n=14/21) of cases, the major clinical symptom of spinal TB was back pain reported for a median of 4.5 months (range 1-12 months) before hospital admission. The interferon gamma release assay was positive in 75% (n=16/21) of patients. All patients performed MRI with gadolinium, which indicated spondylodiscitis in 90%. 18F-FDG-PET/CT revealed average maximum standardized uptake value (SUV max) of 12.54 (range 5.3-22) in 17/19 (89.5%). Bacteriological confirmation of TB was obtained in 86% of cases (n=18/21). One-third of patients (7/21) underwent surgery and 95% successfully completed the anti-TB treatment.

CONCLUSIONS

Our data reveal that a multidisciplinary approach to spine tuberculosis facilitates early and accurate diagnosis and can improve medical and surgical management of this disease.

Spondylodiscitis: is really all well defined?

The term spondylodiscitis describes the infection of both the intervertebral disc space and the adjacent vertebrae. Pyogenic Vertebral Osteomyelitis (PVO) is more common in older patients (mean age 59-69 years) with a male preponderance (52-69%). Recent studies reported an alarming increase of incidence over the last 20 years, due to the increase of diagnostic sensibility, the increase of the average lifetime and to the consequent association of chronic disabling pathologies, of immunosuppression, of surgical or invasive procedure. Improvements in radiological diagnosis, surgical techniques, and management of antimicrobial therapy have greatly improved PVO clinical outcome, but morbidity remains significant mostly because of the delay of diagnosis. The non-specific features of this infection can lead to underestimate the patient conditions, ending to a significant delay in diagnosis, reported from 30 to 90 days, and consequently to severe impairments, such as spine deformity and permanent neurological deficit. The duration of medical treatment is not yet established, and further randomized trials are needed to define it.

Spondylodiscitis in familial dysautonomia: a case report

Familial dysautomonia (FD, or Riley-Day syndrome) is a rare but fatal autosomal recessive peripheral neuropathy caused by a point mutation in I-κ-B kinase complex associated protein (IKBCAP) gene. The disease, that affects primarily people of Ashkenazi Jewish origin, prejudices the development of primary sensory neurons determining depletion of autonomic and sensory neurons. Musculoskeletal problems include: spinal deformities, foot deformities, fractures and arthopathies. In this article we review a case of a 34 years old male of non-Jewish origin affected by FD presenting L2-L3 kyphosis and inability to walk due to chronic L2-L3 spondylodiscitis not surgically treated 14 years before as acute disease. De novo spondylodiscitis affecting patients presenting FD and its subsequent management was not previously described in the literature.

Biopsy for suspected spondylodiscitis

BACKGROUND

Vertebral biopsy is fundamental in determining whether a spinal lesion is of infectious or neoplastic etiology. Accurate diagnosis is critical for proper medical and/or surgical treatment and consequently for the prognosis of the patient. CT-guided percutaneous spinal biopsy (CTSB) may minimize the risk of contamination and complications.

AIM

To demonstrate the importance and efficacy of CTSB and subsequent microbiologic/histological examination in the diagnosis of spinal lesions, particularly for those of an infectious nature.

MATERIALS AND METHODS

Two series of spinal infection patients. Prospective series of 69 patients (2009-2011), 24 of whom underwent CTSB. Retrospective series of 130 patients (1999-2008), 65 of whom underwent CTSB. All patients had microbiologic and histological testing of biopsy samples, when possible.

RESULTS

For the 2009-2011 patient series, histological examination yielded a diagnosis in 81.8% of cases, microbiologic culture and PCR for Mycobacterium tuberculosis in 45.8%. For the 1999-2008 series, histological examination yielded a diagnosis in 69% of cases, culture in 38.5%. Spinal lesions in 4 patients with previous histories of malignancy were assumed to be metastatic and treated with radiation at outside institutions. After biopsy, all were revealed to be spondylodiscitis.

CONCLUSIONS

Percutaneous CT-guided needle biopsy is the mainstay of diagnosis for spine lesions of unknown etiology, thus guiding appropriate treatment. Histological diagnosis, when possible, is critical before initiation of therapy and may be helpful in cases where cultures are negative. In the case of a spinal lesion of unknown origin, even in the setting of a previous malignancy, metastasis should not be assumed; infection and new primary lesions should always be considered as part of the differential diagnosis.

Spinal Infection Multidisciplinary Management Project (SIMP): From Diagnosis to Treatment Guideline

Spine infections require a multidisciplinary approach to be treated and solved. A guide line to drive physicians in the deep complexity of such a disease is extremely helpful. SIMP suggests a flow-chart built up on clear concepts such as right and well managed antibiotic therapy, sound stability of the spine, correct and smart use of the standard and functional imaging techniques, such as f18 FDG PET/CT. In 16 months a total of 41 patients have been treated for spondylodiscitis, discitis and vertebral osteomyelitis by our team of physicians and 25 patients have been enrolled in a prospective study whose target is the assessment of the SIMP flow-chart and of every single aspect that characterize it.

Optical coherence tomography, frequency-doubling technology, and colour Doppler imaging in ocular hypertension

PURPOSE

To study in ocular hypertension (OH) the retinal nerve fibre layer (RNFL) with optical coherence tomography (OCT) and the neuronal function with frequency-doubling technology (FDT) to assess which of the two methods was more sensitive in detecting early glaucomatous damage. Furthermore, a colour Doppler imaging (CDI) of the optic nerve was carried out to highlight any correlation with RNFL thickness and FDT abnormality.

MATERIALS AND METHODS

We enrolled 28 ocular hypertensive patients who underwent OCT of the RNFL and FDT. Moreover, we performed a CDI of the ophthalmic artery (OA), central retinal artery (CRA), and posterior ciliary arteries (PCAs).

RESULTS

The patients with OH following OCT revealed a significant thinning in the RNFL as compared to the control group only in the inferior quadrant: 122.250+/-14.091 vs131.750+/-10.729 mum (P<0.045). As regards FDT, there was a significant difference between the two groups only for pattern standard deviation (PSD): 3.873+/-1.488 vs1.938+/-0.704 dB (P<0.044). In OH and in the control group, CDI resistance index (RI) in the OA was 0.768+/-0.012 vs0.745+/-0.019 (P<0.022), in the CRA was 0.66+/-0.012 vs0.645+/-0.019 (P<0.032), and in PCAs was 0.673+/-0.039 vs0.622+/-0.012 (P<0.037). The OCT had a sensitivity of 83% but only in the inferior RNFL quadrant. The FDT-PSD revealed a sensitivity of 85%.

CONCLUSIONS

Both FDT and OCT detect early glaucomatous damage with a slightly superior sensitivity of FDT vsOCT. The CDI measurements suggest that circulatory abnormalities may have a role in the development of OCT and FDT damage.