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Hsu JE, Somerson JS, Vo KV, Matsen FA. What is a “periprosthetic shoulder infection”? A systematic review of two decades of publications. INTERNATIONAL ORTHOPAEDICS 2017; 41:813-822. [DOI: 10.1007/s00264-017-3421-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 01/27/2017] [Indexed: 02/02/2023]
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Neer Award 2017: A rapid method for detecting Propionibacterium acnes in surgical biopsy specimens from the shoulder. J Shoulder Elbow Surg 2017; 26:179-185. [PMID: 27887873 DOI: 10.1016/j.jse.2016.10.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/16/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Propionibacterium (P) acnes infection of the shoulder after arthroplasty is a common and serious complication. Current detection methods for P acnes involve anaerobic cultures that require prolonged incubation periods (typically 7-14 days). We have developed a polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP) approach that sensitively and specifically identifies P acnes in tissue specimens within a 24-hour period. METHODS Primers were designed to amplify a unique region of the 16S rRNA gene in P acnes that contained a unique HaeIII restriction enzyme site. PCR and RFLP analyses were optimized to detect P acnes DNA in in vitro cultures and in arthroscopic surgical biopsy specimens from patients with P acnes infections. RESULTS A 564 base-pair PCR amplicon was derived from all of the known P acnes strains. HaeIII digests of the amplicon yielded a restriction fragment pattern that was unique to P acnes. P acnes-specific amplicons were detected in as few as 10 bacterial cells and in clinical biopsy specimens of infected shoulder tissues. CONCLUSION This PCR-RFLP assay combines the sensitivity of PCR with the specificity of RFLP mapping to identify P acnes in surgical isolates. The assay is robust and rapid, and a P acnes-positive tissue specimen can be confirmed within 24 hours of sampling, facilitating treatment decision making, targeted antibiotic therapy, and monitoring to minimize implant failure and revision surgery.
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153
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Ahsan ZS, Somerson JS, Matsen FA. Characterizing the Propionibacterium Load in Revision Shoulder Arthroplasty: A Study of 137 Culture-Positive Cases. J Bone Joint Surg Am 2017; 99:150-154. [PMID: 28099305 DOI: 10.2106/jbjs.16.00422] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Propionibacterium is commonly recovered from explants or surrounding tissues in revision shoulder arthroplasty. Rather than attempting to differentiate a true infection from a false-positive result on the basis of the number of positive cultures, we characterized the amount of these bacteria in each specimen and shoulder. METHODS The study included 137 revision shoulder arthroplasties from which a minimum of 4 specimens had been submitted for culture and at least 1 was positive for Propionibacterium. Standard microbiology procedures were used to assign a semiquantitative value (0.1, 1, 2, 3, or 4), called the Specimen Propi Value, to the amount of growth in each specimen. The sum of the Specimen Propi Values for each shoulder was defined as the Shoulder Propi Score, which was then divided by the total number of specimens to calculate the Average Shoulder Propi Score. RESULTS The number and percentage of positive specimen-specific cultures (of material obtained from the stem explant, head explant, glenoid explant, humeral membrane, collar membrane, other soft tissue, fluid, or other) per shoulder ranged from 1 to 6 and 14% to 100%. A high percentage of specimens (mean, 43%; median, 50%) from the culture-positive shoulders showed no growth. Only 32.6% of the fluid cultures were positive in comparison with 66.5% of the soft-tissue cultures and 55.6% of the cultures of explant specimens. The average Specimen Propi Value (and standard deviation) for fluid specimens (0.35 ± 0.89) was significantly lower than those for the soft-tissue (0.92 ± 1.50) and explant (0.66 ± 0.90) specimens (p < 0.001). The Shoulder Propi Score was significantly higher in men (3.56 ± 3.74) than in women (1.22 ± 3.11) (p < 0.001). Similarly, men had a significantly higher Average Shoulder Propi Score (0.53 ± 0.51) than women (0.19 ± 0.43) (p < 0.001). CONCLUSIONS This investigation suggests that Propionibacterium is unevenly distributed within culture-positive revised shoulders. As a result, the specimen number and source (explant, soft tissue, or fluid) have major influences on the culture results for a revised shoulder arthroplasty. We found no evidence that suggested useful threshold values for defining a true infection. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Zahab S Ahsan
- 1Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington 2University of Texas Medical Branch, Galveston, Texas
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154
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Optimal Periprosthetic Tissue Specimen Number for Diagnosis of Prosthetic Joint Infection. J Clin Microbiol 2016; 55:234-243. [PMID: 27807152 DOI: 10.1128/jcm.01914-16] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 11/01/2016] [Indexed: 01/16/2023] Open
Abstract
We recently demonstrated improved sensitivity of prosthetic joint infection (PJI) diagnosis using an automated blood culture bottle system for periprosthetic tissue culture [T. N. Peel et al., mBio 7(1):e01776-15, 2016, https://doi.org/10.1128/mBio.01776-15]. This study builds on the prior research by examining the optimal number of periprosthetic tissue specimens required for accurate PJI diagnosis. Current guidelines recommend five to six, which is impractical. We applied Bayesian latent class modeling techniques for estimating diagnostic test properties of conventional culture techniques (aerobic and anaerobic agars and thioglycolate broth) compared to inoculation into blood culture bottles. Conventional, frequentist receiver operating characteristic curve analysis was conducted as a sensitivity analysis. The study was conducted at Mayo Clinic, Rochester, MN, from August 2013 through April 2014 and included 499 consecutive patients undergoing revision arthroplasty from whom 1,437 periprosthetic tissue samples were collected and processed. For conventional periprosthetic tissue culture techniques, the greatest accuracy was observed when four specimens were obtained (91%; 95% credible interval, 77 to 100%), whereas when using inoculation of periprosthetic tissues into blood culture bottles, the greatest accuracy of diagnosis was observed when three specimens were cultured (92%; 95% credible intervals, 79 to 100%). Results of this study show that the greatest accuracy of PJI diagnosis is obtained when three periprosthetic tissue specimens are obtained and inoculated into blood culture bottles or four periprosthetic tissue specimens are obtained and cultured using standard plate and broth cultures. Increasing the number of specimens to five or more, per current recommendations, does not improve accuracy of PJI diagnosis.
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155
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Hsu JE, Gorbaty JD, Whitney IJ, Matsen FA. Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium. J Bone Joint Surg Am 2016; 98:2047-2051. [PMID: 28002367 DOI: 10.2106/jbjs.16.00149] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Revision shoulder arthroplasties are often culture-positive for Propionibacterium. This study tests the hypothesis that the functional outcomes of revising Propionibacterium culture-positive failed arthroplasties with a single-stage revision and immediate antibiotic therapy are not inferior to the clinical outcomes of revising failed shoulder arthroplasties that are not culture-positive. METHODS Fifty-five shoulders without obvious clinical evidence of infection had a single-stage revision arthroplasty. The patient self-assessed functional outcomes for shoulders with ≥2 positive cultures for Propionibacterium (the culture-positive group) were compared with shoulders with no positive cultures or only 1 positive culture (the control group). RESULTS The culture-positive group had 89% male patients, with a mean age (and standard deviation) of 63.5 ± 7.2 years. The mean Simple Shoulder Test (SST) scores for the 27 culture-positive shoulders improved from 3.2 ± 2.8 points before the surgical procedure to 7.8 ± 3.3 points at a mean follow-up of 45.8 ± 11.7 months after the surgical procedure (p < 0.001), a mean improvement of 49% of the maximum possible improvement. The control group had 39% male patients, with a mean age of 67.1 ± 8.1 years. The mean SST scores for the 28 control shoulders improved from 2.6 ± 1.9 points preoperatively to 6.1 ± 3.4 points postoperatively at a mean follow-up of 49.6 ± 11.8 months (p < 0.001), a mean improvement of 37% of the maximum possible improvement. Subsequent procedures for persistent pain or stiffness were required in 3 patients (11%) in the culture-positive group and in 3 patients (11%) in the control group; none of the revisions were culture-positive. Fourteen patients reported side effects to antibiotics. CONCLUSIONS Clinical outcomes after single-stage revision for Propionibacterium culture-positive shoulders were at least as good as the outcomes in revision procedures for control shoulders. Two-stage revision procedures may not be necessary in the management of these cases. Patients should be educated with regard to potential antibiotic side effects. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jason E Hsu
- 1Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington 2University of Washington School of Medicine, Seattle, Washington 3South Texas Regional Medical Center, Jourdanton, Texas
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De Vecchi E, Bortolin M, Signori V, Romanò CL, Drago L. Treatment With Dithiothreitol Improves Bacterial Recovery From Tissue Samples in Osteoarticular and Joint Infections. J Arthroplasty 2016; 31:2867-2870. [PMID: 27282488 DOI: 10.1016/j.arth.2016.05.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 04/29/2016] [Accepted: 05/03/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Prosthetic implants, periprosthetic and osteoarticular tissues are specimens of choice for diagnosis of bone and joint infections. Homogenization is considered the best procedure for treatment of tissues samples, but, it is not always performed in all laboratories. Dithiothreitol (DTT) has been proposed as an alternative treatment to sonication for microbiological diagnosis of prosthetic joint infections. In this study, the applicability of DTT treatment for processing of periprosthetic and osteoarticular tissues for diagnosis of bone and joint infections was evaluated and compared with normal saline solution treatment. METHODS Periprosthetic tissue samples were collected from 70 consecutive patients (25 infected and 45 not infected). For each patient, samples from the same site were randomly allocated to DTT or saline treatment. Treated samples were centrifuged at 3000 rpm for 10 minutes. Aliquots from the concentrated samples were plated on agar plates and inoculated in broths. Sensitivity and specificity were calculated for each treatment. RESULTS Microbial growth was observed in samples from 14 and 11 infected patients after DTT and saline treatments, respectively. Concordance between the 2 methods was observed in the 85.7% of cases. Sensitivity was 88.0% for DTT and 72.0% for saline. Specificity was 97.8% and 91.1% for DTT and saline, respectively. Treatment with DTT showed higher sensitivity and specificity with respect to the method routinely used in our laboratory. CONCLUSION DTT treatment may be considered a practicable strategy for microbiological analysis of tissues for diagnosis of bone and joint infections.
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Affiliation(s)
- Elena De Vecchi
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | - Monica Bortolin
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | - Valentina Signori
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | - Carlo L Romanò
- Department of Bone and Joint Infections and Reconstructive Surgery, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | - Lorenzo Drago
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy; Laboratory of Clinical Microbiology, Department of Biomedical Science for Health, University of Milan, Milan, Italy
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157
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Abdulmassih R, Makadia J, Como J, Paulson M, Min Z, Bhanot N. Propionibacterium acnes: Time-to-Positivity in Standard Bacterial Culture From Different Anatomical Sites. J Clin Med Res 2016; 8:916-918. [PMID: 27829959 PMCID: PMC5087633 DOI: 10.14740/jocmr2753w] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2016] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Propionibacterium acnes infections are likely under-recognized and underreported. This is partly because of low clinical suspicion, perceived non-pathogenicity, or lack of adequate culture incubation time. We conducted a study to assess the optimal incubation period to recover P. acnes from specimens acquired during the workup of suspected clinical infections. METHODS A 5-year retrospective chart review was conducted between January 2010 and December 2014 at a single tertiary-care hospital. All patient cases from which P. acnes was recovered were included for analysis. Source of infection, antibiotic use, and culture time-to-positivity (TTP) were recorded. RESULTS Implanted devices comprised the single most common source of P. acnes infection. In the majority of cases, P. acnes was the only organism identified. The mean incubation TTP for all isolates was 5.73 days. CONCLUSIONS Standard 5-day culture incubation periods are insufficient to recover P. acnes. As a result, P. acnes is likely a much more common etiology of a variety of clinical infections than previously reported.
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Affiliation(s)
- Rasha Abdulmassih
- Division of Infectious Diseases, Allegheny General Hospital, 420 East North Ave., Pittsburgh, PA 15212, USA
| | - Jina Makadia
- Division of Infectious Diseases, Allegheny General Hospital, 420 East North Ave., Pittsburgh, PA 15212, USA
| | - James Como
- Division of Infectious Diseases, Allegheny General Hospital, 420 East North Ave., Pittsburgh, PA 15212, USA
| | - Michelle Paulson
- Division of Infectious Diseases, Allegheny General Hospital, 420 East North Ave., Pittsburgh, PA 15212, USA
| | - Zaw Min
- Division of Infectious Diseases, Allegheny General Hospital, 420 East North Ave., Pittsburgh, PA 15212, USA
| | - Nitin Bhanot
- Division of Infectious Diseases, Allegheny General Hospital, 420 East North Ave., Pittsburgh, PA 15212, USA
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158
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Optimal Length of Cultivation Time for Isolation of Propionibacterium acnes in Suspected Bone and Joint Infections Is More than 7 Days. J Clin Microbiol 2016; 54:3043-3049. [PMID: 27733637 DOI: 10.1128/jcm.01435-16] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/05/2016] [Indexed: 01/24/2023] Open
Abstract
Diagnosis of Propionibacterium acnes bone and joint infection is challenging due to the long cultivation time of up to 14 days. We retrospectively studied whether reducing the cultivation time to 7 days allows accurate diagnosis without losing sensitivity. We identified patients with at least one positive P. acnes sample between 2005 and 2015 and grouped them into "infection" and "no infection." An infection was defined when at least two samples from the same case were positive. Clinical and microbiological data, including time to positivity for different cultivation methods, were recorded. We found 70 cases of proven P. acnes infection with a significant faster median time to positivity of 6 days (range, 2 to 11 days) compared to 9 days in 47 cases with P. acnes identified as a contamination (P < 0.0001). In 15 of 70 (21.4%) patients with an infection, tissue samples were positive after day 7 and in 6 patients (8.6%) after day 10 when a blind subculture of the thioglycolate broth was performed. The highest sensitivity was detected for thioglycolate broth (66.3%) and the best positive predictive values for anaerobic agar plates (96.5%). A prolonged transportation time from the operating theater to the microbiological laboratory did not influence time to positivity of P. acnes growth. By reducing the cultivation time to 7 days, false-negative diagnoses would increase by 21.4%; thus, we recommend that biopsy specimens from bone and joint infections be cultivated to detect P. acnes for 10 days with a blind subculture at the end.
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159
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Wasko MK, Goodman SB. Emperor's new clothes: Is particle disease really infected particle disease? J Orthop Res 2016; 34:1497-504. [PMID: 27175824 PMCID: PMC5529039 DOI: 10.1002/jor.23292] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 05/10/2016] [Indexed: 02/04/2023]
Abstract
Aseptic loosening remains the most significant long-term complication of total hip replacement. The current paradigm points to an inflammatory response to wear particles as its main trigger. Recently, there have been increasing numbers of positive bacterial isolates reported among patients with clinically absent infection. This paper reviews existing evidence on possible involvement of bacteria and microbial-associated molecular patterns in the pathology of so-called "aseptic loosening." © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1497-1504, 2016.
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Affiliation(s)
- Marcin K. Wasko
- Department of Orthopaedic and Rheumoorthopaedic Surgery, The Medical Centre of Postgraduate Education, Warsaw, Poland,Foundation for the Development of Medicine, Slupsk, Poland,SPSK im. Prof. A. Grucy, Konarskiego 13, Otwock 05-400, Poland
| | - Stuart B. Goodman
- Department of Orthopaedic Surgery, Orthopaedic Surgery Laboratories, Stanford University, Stanford, California,Department of Bioengineering, Stanford University, Stanford, California
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160
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Clinical Analysis of Propionibacterium acnes Infection After Total Knee Arthroplasty. J Arthroplasty 2016; 31:1986-9. [PMID: 27036925 DOI: 10.1016/j.arth.2016.02.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 01/13/2016] [Accepted: 02/08/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Propionibacterium acnes is a common cause of upper extremity arthroplasty infection and usually presents in an indolent subacute fashion. It is not well described how total knee arthroplasty (TKA) patients infected with P acnes present. METHODS We retrospectively compared patients undergoing revision TKA for infection from P acnes and methicillin-sensitive Staphylococcal aureus (MSSA) in our institutional infection database. Patients were classified as having a periprosthetic joint infection based on the Musculoskeletal Infection Society criteria and were excluded if they had a polymicrobial culture. Patient demographics, preoperative laboratory values, microbiology data, and synovial fluid white blood cell (WBC) counts were analyzed. RESULTS Sixteen patients with a P acnes and 30 with an MSSA TKA periprosthetic joint infection were identified. Median erythrocyte sedimentation rate was significantly higher in the MSSA group compared to the P acnes group (56.0 mm/h; interquartile range [IQR], 44.3-72.9 vs 23.0 mm/h; IQR, 18.5-52.0; respectively, P = .03) as were C-reactive protein levels (5.9 mg/dL; IQR, 3.7-26.9 vs 2.0 mg/dL; IQR, 0.5-14.0; respectively, P = .04). WBC count, synovial fluid WBC, and percentage of synovial polymorphonuclear cells were similar between groups. Mean time to culture was 8.3 ± 2.0 days in the P acnes group and 1.8 ± 0.8 days in the MSSA group. CONCLUSION P acnes TKA infections are associated with more acute inflammatory symptoms than typically appreciated, and long hold anaerobic cultures up to 14 days are necessary to accurately identify this organism as the causative agent of TKA periprosthetic infection.
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161
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Le Huec JC. Answers to the Letters to the Editor of P. Lambert et al. and L. G. Czaplewski concerning "Prospective study using anterior approach did not show association between Modic 1 changes and low grade infection in lumbar spine" by Rigal J, Thelen T, Byrne F, Cogniet A, Boissière L, Aunoble S, Le Huec JC (Eur Spine J [2016]; 25(4):1000-5. doi:10.1007/s00586-016-4396-5). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:3381-3382. [PMID: 27566302 DOI: 10.1007/s00586-016-4754-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 08/16/2016] [Indexed: 11/29/2022]
Affiliation(s)
- J-Ch Le Huec
- Ortho-Spine Department, Surgical Research Laboratory, Bordeaux University Hospital, Bordeaux, France.
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162
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Abstract
ABSTRACT
The immunocompromised host is a particularly vulnerable population in whom routine and unusual infections can easily and frequently occur. Prosthetic devices are commonly used in these patients and the infections associated with those devices present a number of challenges for both the microbiologist and the clinician. Biofilms play a major role in device-related infections, which may contribute to failed attempts to recover organisms from routine culture methods. Moreover, device-related microorganisms can be difficult to eradicate by antibiotic therapy alone. Changes in clinical practice and advances in laboratory diagnostics have provided significant improvements in the detection and accurate diagnosis of device-related infections. Disruption of the bacterial biofilm plays an essential role in recovering the causative agent in culture. Various culture and nucleic acid amplification techniques are more accurate to guide directed treatment regimens. This chapter reviews the performance characteristics of currently available diagnostic assays and summarizes published guidelines, where available, for addressing suspected infected prosthetic devices.
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163
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Kvich L, Jensen PØ, Justesen US, Bjarnsholt T. Incidence of Propionibacterium acnes in initially culture-negative thioglycollate broths-a prospective cohort study at a Danish University Hospital. Clin Microbiol Infect 2016; 22:941-945. [PMID: 27521804 DOI: 10.1016/j.cmi.2016.07.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/08/2016] [Accepted: 07/31/2016] [Indexed: 11/19/2022]
Abstract
The aim of this study was to prospectively investigate the incidence of Propionibacterium acnes in thioglycollate broths reported as culture-negative at the Department of Clinical Microbiology, Rigshospitalet, to evaluate whether 5 days of incubation was enough to find all relevant cases. Five hundred thioglycollate broths reported as culture-negative after 5 days were consecutively collected and incubated for at least a further 9 days (at least 14 days of incubation in total). Only tissue samples from sterile sites of the body (n = 298), bone tissue (n = 197) and foreign material (n = 5) were included in this study. Samples were divided into two groups: infected group and control group. This made it possible to compare findings between groups, thereby making it possible to estimate the level of true-positive findings and contamination. Samples from 296 participants were included in this study. After exclusion criteria were met, P. acnes was cultured from ten out of 151 patients (6.6%) in the infected group and from one out of 138 participants (0.7%) in the control group. This resulted in more findings of P. acnes in the infected group on day 14 than on day 5 (p 0.002). Furthermore, P. acnes was cultured more often from bone tissue and tissue surrounding foreign materials on day 14 than on day 5 (p 0.04). Clinical microbiology laboratories should consider incubating thioglycollate broths for at least 14 days to find all relevant cases of P. acnes, especially when it comes to bone tissue and tissue surrounding foreign materials.
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Affiliation(s)
- L Kvich
- Department of Clinical Microbiology, Copenhagen University Hospital-Rigshospitalet, Denmark
| | - P Ø Jensen
- Department of Clinical Microbiology, Copenhagen University Hospital-Rigshospitalet, Denmark
| | - U S Justesen
- Department of Clinical Microbiology, Copenhagen University Hospital-Rigshospitalet, Denmark
| | - T Bjarnsholt
- Department of Clinical Microbiology, Copenhagen University Hospital-Rigshospitalet, Denmark; Department of International Health, Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
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164
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Lucas RM, Hsu JE, Whitney IJ, Wasserburger J, Matsen FA. Loose glenoid components in revision shoulder arthroplasty: is there an association with positive cultures? J Shoulder Elbow Surg 2016; 25:1371-5. [PMID: 26948006 DOI: 10.1016/j.jse.2015.12.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/15/2015] [Accepted: 12/25/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Glenoid loosening is one of the most common causes of total shoulder failure. High rates of positive cultures of Propionibacterium and coagulase-negative staphylococcus have been found among shoulders having surgical revision for glenoid loosening. This study reviewed the culture results in a series of surgical revisions for failed total shoulder arthroplasty to determine the relationship between glenoid loosening and positive cultures. METHODS The medical records of 221 patients without obvious evidence of infection who underwent revision total shoulder arthroplasty were reviewed to examine the association between the security of fixation of the glenoid component and the results of cultures obtained at revision surgery. RESULTS Of the revised shoulders, 53% had positive cultures; 153 of the shoulders (69%) had a loose glenoid component, whereas 68 (31%) had secure glenoid component fixation. Of the 153 loose glenoid components, 82 (54%) had at least 1 positive culture and 44 (29%) had 2 or more positive cultures of the same microorganism. Similarly, of the 68 secure glenoid components, 35 (51%) had at least 1 positive culture (P = .77) and 14 (21%) had 2 or more positive cultures of the same microorganism (P = .25). Explanted glenoid components that were loose had a higher rate of culture positivity (56% [24/43]) in comparison to explanted glenoid components that were well fixed (13% [1/8]) (P = .05). CONCLUSION Propionibacterium and coagulase-negative staphylococcus are commonly recovered in revision shoulder arthroplasty, whether or not the glenoid components are loose.
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Affiliation(s)
- Robert M Lucas
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Jason E Hsu
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Ian J Whitney
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | | | - Frederick A Matsen
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA.
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165
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Pinder EM, Ong JCY, Bale RS, Trail IA. Ten questions on prosthetic shoulder infection. Shoulder Elbow 2016; 8:151-7. [PMID: 27583013 PMCID: PMC4950280 DOI: 10.1177/1758573216632464] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 01/18/2016] [Indexed: 01/02/2023]
Abstract
Prosthetic shoulder infection can cause significant morbidity secondary to pain and stiffness. Symptoms may be present for years before diagnosis because clinical signs are often absent and inflammatory markers may be normal. An emerging common culprit, Propionibacterium acnes, is hard to culture and so prolonged incubation is necessary. A negative culture result does not always exclude infection and new synovial fluid biochemical markers such as α defensin are less sensitive than for lower limb arthroplasty. A structured approach is necessary when assessing patients for prosthetic shoulder joint infection. This includes history, examination, serum inflammatory markers, plain radiology and aspiration and/or biopsy. A classification for the likelihood of prosthetic shoulder infection has been described based on culture, pre-operative and intra-operative findings. Treatment options include antibiotic suppression, debridement with component retention, one-stage revision, two-stage revision and excision arthroplasty. Revision arthroplasty is associated with the best outcomes.
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Affiliation(s)
| | | | | | - Ian A Trail
- Professor Ian A Trail, Upper Limb Unit, Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, Lancashire WN6 9EP, UK.
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166
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Abstract
Hip joint replacement is 1 of the most successful surgical procedures of the last century and the number of replacements implanted is steadily growing. An infected hip arthroplasty is a disaster, it leads to patient suffering, surgeon's frustration and significant costs to the health system. The treatment of an infected hip replacement is challenging, healing rates can be low, functional results poor with decreased patient satisfaction. However, if a patient-adapted treatment of infected hip joints is used a success rate of above 90% can be obtained.Patient-adapted treatment is based on 5 important concepts: teamwork; understanding the biofilm; diagnostic accuracy; correct definition and classification of PJI; and patient-tailored treatment.This review presents a patient-adapted treatment strategy to prosthetic hip infection. It incorporates the best aspects of the single and staged surgical strategies and promotes the short interval philosophy for the 2-stage approach.
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Shields MV, Abdullah L, Namdari S. The challenge of Propionibacterium acnes and revision shoulder arthroplasty: a review of current diagnostic options. J Shoulder Elbow Surg 2016; 25:1034-40. [PMID: 27038565 DOI: 10.1016/j.jse.2016.01.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 12/19/2015] [Accepted: 01/07/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Propionibacterium acnes is the most common cause of infection after shoulder arthroplasty. Whereas there are several methods that can aid in the diagnosis of P. acnes infection, there is not a single "gold standard" because of the difficulties inherent in identifying this bacterium. We present an evidence-based discussion of the demographic, clinical, and radiographic predictors of P. acnes infection and review the current options for diagnosis. METHODS This review was written after a comprehensive analysis of the current literature related to shoulder periprosthetic joint infection and P. acnes identification. RESULTS AND CONCLUSIONS Of the techniques reviewed, α-defensin had the highest sensitivity in detecting P. acnes infection (63%). C-reactive protein level and erythrocyte sedimentation rate were often normal in cases of infection. Whereas P. acnes can be challenging to successfully diagnose, there are several options that are considered preferable because of their higher sensitivities and specificities. The current gold standard is intraoperative culture, but major advances in molecular techniques may provide future improvements in diagnostic accuracy.
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Affiliation(s)
- Margaret V Shields
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Leath Abdullah
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Surena Namdari
- Rothman Institute Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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168
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Hudek R, Sommer F, Abdelkawi AF, Kerwat M, Müller HH, Gohlke F. Propionibacterium acnes in shoulder surgery: is loss of hair protective for infection? J Shoulder Elbow Surg 2016; 25:973-80. [PMID: 26763856 DOI: 10.1016/j.jse.2015.10.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 10/13/2015] [Accepted: 10/18/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Propionibacterium acnes (P acnes) has been linked to chronic infections in shoulder surgery. It was recently observed during first-time shoulder surgery in healthy patients at a rate between 36% and 56%. Male gender and the anterolateral approach were reported risk factors. Because the skin biology greatly differs, we aimed to correlate skin complaints with P acnes-positive intraoperative cultures from different tissue layer samples in patients undergoing shoulder surgery for the first time. METHODS Intraoperative samples (1 skin, 1 superficial, 1 deep tissue, and 1 control sample) from 112 patients (70 men, 42 women; aged 59.2 years) were cultured. The association between the presence of P acnes in the deep or superficial tissue, or both, and 10 items of a validated preoperative questionnaire for skin pathology was explored. RESULTS The cultures were positive for P acnes in 38.4% (n = 43) of the cases. Skin samples were positive for P acnes in 8% (n = 9), superficial samples were positive in 23% (n = 26), and deep samples were positive in 30% (n = 34). Self-reported "loss of hair" was significantly negatively associated with the presence of P acnes in the superficial or deep tissue sample (P = .00028). DISCUSSION Patients who report having "loss of hair" show fewer P acnes-positive cultures in intraoperative tissue samples taken during open shoulder surgery. Whether this subgroup is at a lesser risk for P acnes infections remains to be substantiated. LEVEL OF EVIDENCE Basic Science Study; Microbiology.
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Affiliation(s)
- Robert Hudek
- Klinik für Schulterchirurgie, RHÖN-KLINIKUM AG, Bad Neustadt, Germany.
| | - Frank Sommer
- Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Phillipps-Universität Marburg, Marburg, Germany
| | - Ayman F Abdelkawi
- Klinik für Schulterchirurgie, RHÖN-KLINIKUM AG, Bad Neustadt, Germany
| | - Martina Kerwat
- Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Phillipps-Universität Marburg, Marburg, Germany
| | - Hans-Helge Müller
- Institut für Medizinische Biometrie und Epidemiologie, Philipps-Universität Marburg, Marburg, Germany
| | - Frank Gohlke
- Klinik für Schulterchirurgie, RHÖN-KLINIKUM AG, Bad Neustadt, Germany
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169
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Tyner H, Patel R. Propionibacterium acnes biofilm - A sanctuary for Staphylococcus aureus? Anaerobe 2016; 40:63-7. [PMID: 27241780 DOI: 10.1016/j.anaerobe.2016.05.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/16/2016] [Accepted: 05/26/2016] [Indexed: 10/21/2022]
Abstract
The purpose of this study was to measure the effect of combined culture of Propionibacterium acnes and Staphylococcus aureus on biofilm formation under different oxygen concentrations. We measured planktonic growth and biofilm formation of P. acnes and S. aureus alone and together under aerobic and anaerobic conditions. Both P. acnes and S. aureus grew under anaerobic conditions. When grown under anaerobic conditions, P. acnes with or without S. aureus formed a denser biomass biofilm than did S. aureus alone. Viable S. aureus was recovered from a16-day old combined P. acnes and S. aureus biofilm, but not a monomicrobial S. aureus biofilm.
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Affiliation(s)
- Harmony Tyner
- Division of Infectious Diseases, Department of Medicine, USA
| | - Robin Patel
- Division of Infectious Diseases, Department of Medicine, USA; Division Clinical Microbiology, Department of Laboratory Medicine and Pathology, USA.
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170
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Wallander K, Jorup-Rönström C, Ullberg M, Törnblom I, Ottosson C, Giske CG. Etiology of bone and joint infections: a case series of 363 consecutive patients from an orthopaedic infection unit. Infect Dis (Lond) 2016; 48:618-25. [PMID: 27187631 DOI: 10.1080/23744235.2016.1183814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Bone and joint infections remain a clinical challenge with potentially serious consequences. Nevertheless there is a lack of studies with strict criteria for diagnosis and etiology. The primary aim of this study was to determine the causative agents in orthopaedic infections using strict diagnostic criteria for infection and etiology. The secondary aim was to assess the timing of post-operative infections in relation to pathogens and to compare causative bacteria in different parts of the body. METHODS A retrospective registry study of 363 consecutive cases of bone and joint infections was performed. Microbiological data on sampling and culture results were registered. RESULTS Staphylococcus aureus dominated in both operated (45%) and non-operated (44%) patients, followed in frequency by coagulase-negative staphylococci (CoNS) in operated patients (11%) and beta-haemolytic streptococci in non-operated patients (16%) (p < 0.001). There were no polymicrobial infections in non-surgical cases (p < 0.001). For operated patients, Gram-negative bacilli were observed in 6%, almost exclusively isolated from the lower extremity. Propionibacterium spp. was the most common finding after spinal surgery. In 90/363 (25%), the agent responsible for the infection could not be defined according to the strict criteria used. CONCLUSION S. aureus dominated as etiological agent in all bone and joint infections, including operated patient given peri-operative prophylaxis. Improved timing of antibiotic prophylaxis seen after the introduction of the Swedish national project PRISS may have changed this. The number of infections with uncertain etiology was high, stressing the importance of more studies on diagnostics, as well as strict diagnostic algorithms.
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Affiliation(s)
- Katja Wallander
- a Department of Infectious Diseases , Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden
| | - Christina Jorup-Rönström
- b Department of Clinical Science and Education , Stockholm South General Hospital, Karolinska Institutet , Stockholm , Sweden
| | - Måns Ullberg
- c Department of Clinical Microbiology , Karolinska University Hospital , Stockholm , Sweden
| | - Inger Törnblom
- c Department of Clinical Microbiology , Karolinska University Hospital , Stockholm , Sweden
| | - Carin Ottosson
- b Department of Clinical Science and Education , Stockholm South General Hospital, Karolinska Institutet , Stockholm , Sweden
| | - Christian G Giske
- c Department of Clinical Microbiology , Karolinska University Hospital , Stockholm , Sweden ;,d Division of Clinical Microbiology, Department of Laboratory Medicine , Karolinska Institutet Stockholm , Sweden
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171
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Hsu JE, Bumgarner RE, Matsen FA. Propionibacterium in Shoulder Arthroplasty: What We Think We Know Today. J Bone Joint Surg Am 2016; 98:597-606. [PMID: 27053589 DOI: 10.2106/jbjs.15.00568] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Propionibacterium is a slow-growing gram-positive rod that is part of the normal skin microbiome but can be found on culture of specimens from a large number of patients having revision shoulder arthroplasty performed for pain, stiffness, and component loosening. ➤ Propionibacterium infections do not present with obvious signs of infection, such as swelling, erythema, drainage, or tenderness, but rather are of the so-called stealth type, presenting with unexplained pain, stiffness, or component loosening months to years after the index arthroplasty. ➤ Not all propionibacteria are the same: certain subtypes of Propionibacterium are enriched with virulence factors that may enhance deep infection. ➤ Because propionibacteria typically reside in the pilosebaceous glands of the oily skin of the chest and back, standard surgical skin preparation solutions and even perioperative intravenous antibiotics are often inadequate at sterilizing the incision site; therefore, other prophylactic measures such as meticulous implant handling to avoid contact with dermal structures need to be considered. ➤ Recovery of Propionibacterium from the surgical wounds requires that multiple specimens for culture be taken from different areas of the shoulder to reduce sampling error, and cultures should be held for two weeks on multiple culture media. ➤ Future research efforts can be focused on reducing the risk of implant infection and point-of-care methods for identifying Propionibacterium infections.
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Affiliation(s)
- Jason E Hsu
- Departments of Orthopaedics and Sports Medicine (J.E.H and F.A.M.) and Microbiology (R.E.B.), University of Washington, Seattle, Washington
| | - Roger E Bumgarner
- Departments of Orthopaedics and Sports Medicine (J.E.H and F.A.M.) and Microbiology (R.E.B.), University of Washington, Seattle, Washington
| | - Frederick A Matsen
- Departments of Orthopaedics and Sports Medicine (J.E.H and F.A.M.) and Microbiology (R.E.B.), University of Washington, Seattle, Washington
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172
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Risk Factors for Infection After Rotator Cuff Repair. Arthroscopy 2016; 32:428-34. [PMID: 26483170 DOI: 10.1016/j.arthro.2015.08.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 07/24/2015] [Accepted: 08/11/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To identify risk factors for infection after rotator cuff repair. We hypothesized that patient characteristics and surgical technique would affect the rate of infection. METHODS The records of 1,824 rotator cuff repairs performed by a single surgeon from 1995 to 2010 were reviewed retrospectively. Fourteen patients had an early deep postoperative wound infection that was treated with surgical irrigation and debridement. One hundred eighty-five control patients who were treated with rotator cuff repair and did not develop an infection were selected randomly for comparison and statistical analysis. Data regarding preoperative and intraoperative risk factors for infection were recorded, and a multiple logistic regression was conducted to investigate predictors of infection. RESULTS The infection rate was 0.77% (14/1,822). On average 2.1 (range 1 to 4) surgical debridements were performed in addition to treatment with intravenous antibiotics. Patients who had open or miniopen rotator cuff repair had a significantly greater risk of acute postoperative infection (odds ratio [OR] = 8.63, P = .002). Seventy-nine percent of the patients in the infection group had an open or miniopen repair, whereas only 28% of the control group had an open or miniopen repair. Male patients also had a significantly greater risk of acute postoperative infection (OR = 9.52, P = .042). A total of 92% of the infection patients were male compared with 58% of the control group. In addition, as body mass index increased there was a reduction in the odds of infection (OR = 0.81, P = .023). CONCLUSIONS The results of this case control study demonstrate that open or miniopen surgical technique and male sex are significant risk factors for infection after rotator cuff repair. In our study, arthroscopic rotator cuff repair reduced the risk of infection compared with open techniques. LEVEL OF EVIDENCE Level IV.
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173
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Brand JC. Editorial Commentary: Arthroscopic Rotator Cuff Repair--Infection Rate After Rotator Cuff Repair With Arthroscopic, Open, and Mini-open Techniques. Arthroscopy 2016; 32:435. [PMID: 26945949 DOI: 10.1016/j.arthro.2015.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 12/18/2015] [Indexed: 02/02/2023]
Abstract
In "Risk Factors for Infection After Rotator Cuff Repair," B. G. Vopat et al. report a lower rate of postoperative infection with an arthroscopic rotator cuff repair than with an open or mini-open approach. Although there were only 14 infections (infection rate of 0.77%), the reason for the preponderance of male patients, 13 of the 14 infections, needs further research to determine effective preventive strategies.
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174
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Raina UK, Bhushan G, Arora S, Rathie N. A rare case of delayed onset capsular block syndrome managed using 25-gauge vitrector. Oman J Ophthalmol 2016; 8:183-4. [PMID: 26903727 PMCID: PMC4738666 DOI: 10.4103/0974-620x.169895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
We report a case of delayed onset capsular block syndrome in a patient 6 years after undergoing cataract surgery. Ocular examination revealed marked diminution of vision accompanied with a collection of milky fluid between the intraocular lens and posterior capsule. To treat and to understand the pathology of the condition, aspiration of fluid using 25-gauge vitrector through pars plana was done, and contents sent for microbiological analysis which did not reveal any growth. Postoperative period was uneventful with the absence of intraocular inflammation and excellent visual recovery.
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175
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Bémer P, Léger J, Tandé D, Plouzeau C, Valentin AS, Jolivet-Gougeon A, Lemarié C, Kempf M, Héry-Arnaud G, Bret L, Juvin ME, Giraudeau B, Corvec S, Burucoa C. How Many Samples and How Many Culture Media To Diagnose a Prosthetic Joint Infection: a Clinical and Microbiological Prospective Multicenter Study. J Clin Microbiol 2016; 54:385-91. [PMID: 26637380 PMCID: PMC4733176 DOI: 10.1128/jcm.02497-15] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 12/01/2015] [Indexed: 01/22/2023] Open
Abstract
Although numerous perioperative samples and culture media are required to diagnose prosthetic joint infection (PJI), their exact number and types have not yet been definitely determined with a high level of proof. We conducted a prospective multicenter study to determine the minimal number of samples and culture media required for accurate diagnosis of PJI. Over a 2-year period, consecutive patients with clinical signs suggesting PJI were included, with five perioperative samples per patient. The bacteriological and PJI diagnosis criteria were assessed using a random selection of two, three, or four samples and compared with those obtained using the recommended five samples (references guidelines). The results obtained with two or three culture media were then compared with those obtained with five culture media for both criteria. The times-to-positivity of the different culture media were calculated. PJI was confirmed in 215/264 suspected cases, with a bacteriological criterion in 192 (89%). The PJI was monomicrobial (85%) or polymicrobial (15%). Percentages of agreement of 98.1% and 99.7%, respectively, for the bacteriological criterion and confirmed PJI diagnosis were obtained when four perioperative samples were considered. The highest percentages of agreement were obtained with the association of three culture media, a blood culture bottle, a chocolate agar plate, and Schaedler broth, incubated for 5, 7, and 14 days, respectively. This new procedure leads to significant cost saving. Our prospective multicenter study showed that four samples seeded on three culture media are sufficient for diagnosing PJI.
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Affiliation(s)
- Pascale Bémer
- CHU Nantes, Laboratoire de Bactériologie, Nantes, France
| | | | - Didier Tandé
- CHU Brest, Laboratoire de Bactériologie, Brest, France
| | - Chloé Plouzeau
- CHU Poitiers, Laboratoire de Bactériologie, Poitiers, France
| | | | | | - Carole Lemarié
- CHU Angers, Laboratoire de Bactériologie, Angers, France
| | - Marie Kempf
- CHU Angers, Laboratoire de Bactériologie, Angers, France
| | | | - Laurent Bret
- CH Orléans, Laboratoire de Bactériologie, Orléans, France
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176
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Improved Diagnosis of Prosthetic Joint Infection by Culturing Periprosthetic Tissue Specimens in Blood Culture Bottles. mBio 2016; 7:e01776-15. [PMID: 26733067 PMCID: PMC4725002 DOI: 10.1128/mbio.01776-15] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Despite known low sensitivity, culture of periprosthetic tissue specimens on agars and in broths is routine. Culture of periprosthetic tissue samples in blood culture bottles (BCBs) is potentially more convenient, but it has been evaluated in a limited way and has not been widely adopted. The aim of this study was to compare the sensitivity and specificity of inoculation of periprosthetic tissue specimens into blood culture bottles with standard agar and thioglycolate broth culture, applying Bayesian latent class modeling (LCM) in addition to applying the Infectious Diseases Society of America (IDSA) criteria for prosthetic joint infection. This prospective cohort study was conducted over a 9-month period (August 2013 to April 2014) at the Mayo Clinic, Rochester, MN, and included all consecutive patients undergoing revision arthroplasty. Overall, 369 subjects were studied; 117 (32%) met IDSA criteria for prosthetic joint infection, and 82% had late chronic infection. Applying LCM, inoculation of tissues into BCBs was associated with a 47% improvement in sensitivity compared to the sensitivity of conventional agar and broth cultures (92.1 versus 62.6%, respectively); this magnitude of change was similar when IDSA criteria were applied (60.7 versus 44.4%, respectively; P = 0.003). The time to microorganism detection was shorter with BCBs than with standard media (P < 0.0001), with aerobic and anaerobic BCBs yielding positive results within a median of 21 and 23 h, respectively. Results of our study demonstrate that the semiautomated method of periprosthetic tissue culture in blood culture bottles is more sensitive than and as specific as agar and thioglycolate broth cultures and yields results faster. Prosthetic joint infections are a devastating complication of arthroplasty surgery. Despite this, current microbiological techniques to detect and diagnose infections are imperfect. This study examined a new approach to diagnosing infections, through the inoculation of tissue samples from around the prosthetic joint into blood culture bottles. This study demonstrated that, compared to current laboratory practices, this new technique increased the detection of infection. These findings are important for patient care to allow timely and accurate diagnosis of infection.
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177
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Microbiological Diagnosis of Implant-Related Infections: Scientific Evidence and Cost/Benefit Analysis of Routine Antibiofilm Processing. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 971:51-67. [PMID: 27815925 DOI: 10.1007/5584_2016_154] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Prosthetic joint infection is one of the most severe complication following joint arthroplasty, producing a significant worsening of patient's quality of life. Management of PJIs requires extended courses of antimicrobial therapy, multiple surgical interventions and prolonged hospital stay, with a consequent economic burden, which is thought to markedly increase in the next years due to the expected burden in total joint arthroplasties. The present review summarizes the present knowledge on microbiological diagnosis of prosthetic joint infections, focusing on aethiological agents and discussing pros and cons of the available strategies for their diagnosis.Intra-operative clinical diagnosis and pathogen identification is considered the diagnostic benchmark, however the presence of bacterial biofilm makes pathogen detection with traditional microbiological techniques highly ineffective. Diagnosis of PJIs is a rather complex challenge for orthopedics and requires a strict collaboration between different specialists: orthopaedics, infectivologists, microbiologists, pathologists and radiologists. Diagnostic criteria have been described by national and international association and scientific societies. Clinicians should be trained on how to use it, but more importantly they should know potential and limitation of the available tests in order to use them appropriately.
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178
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Piggott DA, Higgins YM, Melia MT, Ellis B, Carroll KC, McFarland EG, Auwaerter PG. Characteristics and Treatment Outcomes of Propionibacterium acnes Prosthetic Shoulder Infections in Adults. Open Forum Infect Dis 2015; 3:ofv191. [PMID: 26933665 PMCID: PMC4772881 DOI: 10.1093/ofid/ofv191] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 12/30/2015] [Indexed: 12/14/2022] Open
Abstract
P. acnes shoulder prosthetic joint infections were predominantly characterized by pain and functional loss. Inflammatory marker elevation occurred in just under 50% of cases. Isolates were broadly susceptible to guideline concordant antimicrobials. Antibiotic-only and combined antibiotic-surgical intervention outcomes were similar. Background. Prosthetic joint infections (PJIs) significantly complicate joint arthroplasties. Propionibacterium acnes is an increasingly recognized PJI pathogen, yet limited clinical and therapeutic data exist. We sought to examine characteristics of P. acnes shoulder PJIs and compare surgical and nonsurgical management outcomes. Methods. A retrospective analysis of P. acnes shoulder PJIs was conducted at an academic center in Baltimore, Maryland from 2000 to 2013. Results. Of 24 cases of P. acnes shoulder PJIs, 92% were diagnosed after extended culture implementation; 42% in the delayed and 46% in the late postsurgical period. Joint pain and diminished function were the predominant presenting clinical signs. Erythrocyte sedimentation rate and C-reactive protein elevations occurred in 47% and 44%, respectively. All tested isolates were susceptible to β-lactams, moxifloxacin, vancomycin, and rifampin. Clindamycin resistance was identified in 6%. Of the antibiotic-only treated cases, 67% had a favorable clinical outcome compared with 71% (P = 1.0) of cases with a combined antibiotic-surgical approach. Favorable outcome with and without rifampin therapy was 73% and 60% (P = .61), respectively. Conclusions. Propionibacterium acnes PJI diagnoses increased with extended culture. Inflammatory markers were elevated in a minority of cases. Isolates maintained broad antimicrobial susceptibility. Compared to combined antibiotic-surgical approaches, antibiotic-only approaches were similarly successful in selected cases.
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Affiliation(s)
- Damani A Piggott
- Division of Infectious Diseases; Department of Epidemiology, Johns Hopkins University School of Public Health
| | | | | | | | - Karen C Carroll
- Division of Infectious Diseases; Division of Medical Microbiology, Department of Pathology
| | - Edward G McFarland
- Division of Shoulder Surgery, Department of Orthopedic Surgery , Johns Hopkins University School of Medicine
| | - Paul G Auwaerter
- Division of Infectious Diseases; Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Baltimore, Maryland
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179
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Shah NB, Tande AJ, Patel R, Berbari EF. Anaerobic prosthetic joint infection. Anaerobe 2015; 36:1-8. [DOI: 10.1016/j.anaerobe.2015.08.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 08/23/2015] [Accepted: 08/24/2015] [Indexed: 12/01/2022]
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180
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Metcalf K, Ko JWK, Quilici S, Barnes P, Crawford DC. Differentiating Occult Propionibacterium acnes Infection From Aseptic "Biologic" Interference Screw Hydrolysis After Anterior Cruciate Ligament Reconstruction: Introducing a Novel Culture Protocol for Detecting Low-Virulence Organisms. Orthop J Sports Med 2015; 3:2325967115611872. [PMID: 26779549 PMCID: PMC4714573 DOI: 10.1177/2325967115611872] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Kathryn Metcalf
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon, USA
| | - Jia-Wei Kevin Ko
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon, USA
| | - Samantha Quilici
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon, USA
| | - Penelope Barnes
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon, USA
| | - Dennis C Crawford
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon, USA
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181
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Lood R, Waldetoft KW, Nordenfelt P. Localization-triggered bacterial pathogenesis. Future Microbiol 2015; 10:1659-68. [PMID: 26437846 DOI: 10.2217/fmb.15.89] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Bacterial infections are becoming an increasing problem worldwide and there is a need for a deeper understanding of how bacteria turn pathogenic. Here, we suggest that one answer may be found by taking into account the localization of the bacteria, both at an anatomical level and at a microenvironment level. Both commensals and traditional pathogens alter their interaction with the human host depending on the local surroundings--turning either more or less virulent. These localization effects could derive from the characteristics of different anatomical sites but also from local differences within a microenvironment. In order to understand the adaptive functions of bacterial virulence factors, we need to study the bacteria in the environments where they have evolved.
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Affiliation(s)
- Rolf Lood
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, SE-221 84 Lund, Sweden
| | | | - Pontus Nordenfelt
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, SE-221 84 Lund, Sweden
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182
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Hou C, Gupta A, Chen M, Matsen FA. How do revised shoulders that are culture positive for Propionibacterium differ from those that are not? J Shoulder Elbow Surg 2015; 24:1427-32. [PMID: 25725967 DOI: 10.1016/j.jse.2015.01.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 12/24/2014] [Accepted: 01/03/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Many shoulder arthroplasties revised for pain, stiffness, or component loosening are culture positive for Propionibacterium. The culture results are unknown until days or weeks after surgery, too late to inform intraoperative surgical decisions and immediate postsurgical antibiotic treatment. The objective of this study was to identify preoperative and intraoperative characteristics that may alert surgeons to an increased likelihood of positive cultures. METHODS We analyzed the records of 132 shoulders that underwent surgical revision of a shoulder arthroplasty, 66 of which became culture positive for Propionibacterium and 66 did not. RESULTS Propionibacterium-positive and Propionibacterium-negative shoulders were similar with respect to many characteristics; however, Propionibacterium-negative shoulders were revised sooner after the index procedure and were significantly more likely to be female, to have sustained a fall, to have instability, and to have rotator cuff deficiency. Intraoperatively, Propionibacterium-positive shoulders demonstrated more glenoid erosions, glenoid osteolysis, glenoid loosening, and a higher incidence of a soft tissue membrane between the humeral component and humeral endosteum. Shoulders culture positive for Propionibacterium were more likely to be culture positive for another bacteria. CONCLUSIONS Although Propionibacterium-positive and Propionibacterium-negative shoulders have many similarities, factors such as male gender, delayed presentation, glenoid osteolysis and loosening, humeral membrane, and the absence of instability or cuff failure should arouse suspicion of Propionibacterium and suggest the need for deep cultures and consideration of aggressive surgical and medical treatment.
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Affiliation(s)
- Clifford Hou
- Department of Orthopaedics and Sports Medicine, University of Washington, Clyde Hill, WA, USA
| | - Akash Gupta
- Department of Orthopaedics and Sports Medicine, University of Washington, Clyde Hill, WA, USA
| | - Michael Chen
- Department of Orthopaedics and Sports Medicine, University of Washington, Clyde Hill, WA, USA
| | - Frederick A Matsen
- Department of Orthopaedics and Sports Medicine, University of Washington, Clyde Hill, WA, USA.
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183
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Is Biopsying the Paravertebral Soft Tissue as Effective as Biopsying the Disk or Vertebral Endplate? 10-Year Retrospective Review of CT-Guided Biopsy of Diskitis-Osteomyelitis. AJR Am J Roentgenol 2015; 205:123-9. [PMID: 26102390 DOI: 10.2214/ajr.14.13545] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The purpose of this study was to determine whether there is a difference in biopsying bone (endplate), disk, or paravertebral soft tissue to culture the pathogenic organism causing diskitis-osteomyelitis. MATERIALS AND METHODS A retrospective review was conducted of 111 spinal biopsies performed between 2002 and 2011. Pathologic examination was used as the reference standard for detecting diskitis-osteomyelitis. Microbiologic yield, sensitivity, and specificity were calculated. The yields for different groups were compared by use of Fisher exact test. The analysis was repeated with biopsy samples from patients not being treated with antibiotics at the time of biopsy. RESULTS A total of 122 biopsy specimens were obtained from 111 spinal biopsy procedures on 102 patients. Overall, 27 (22%) biopsies were performed on the endplate-disk, 61 (50%) on the disk only, and 34 (28%) on paravertebral soft tissue only. The microbiologic yield was 36% for all biopsies, 19% for endplate-disk biopsies, 39% for disk-only biopsies, and 44% for soft-tissue biopsies. The sensitivity and specificity of the microbiologic results for all specimens were 57% and 89%; endplate-disk, 38% and 86%; disk only, 57% and 89%; and paravertebral soft tissue, 68% and 92%. There was no statistically significant difference between the yields of the endplate-disk, disk-only, and paravertebral soft-tissue biopsies. CONCLUSION Paravertebral soft-tissue changes, when present, may be considered a viable target for biopsy in cases of diskitis-osteomyelitis, even in the absence of a paravertebral abscess.
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184
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Abstract
Orthopaedic infections that occur after trauma are common. Clinical examination, laboratory markers, imaging modalities, and culture and molecular technologies are used to aid the diagnosis of infection. Culture methods comprise the backbone of diagnostic systems used in hospital laboratory settings; however, several studies have questioned the ability of these techniques to adequately identify infections, particularly in cases where orthopaedic implants were used or when the presence of biofilm bacteria is suspected. Advances in imaging and molecular diagnostics can provide orthopaedic surgeons with an improved means of diagnosing and treating infections.
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185
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Frangiamore SJ, Saleh A, Grosso MJ, Kovac MF, Higuera CA, Iannotti JP, Ricchetti ET. α-Defensin as a predictor of periprosthetic shoulder infection. J Shoulder Elbow Surg 2015; 24:1021-7. [PMID: 25672257 DOI: 10.1016/j.jse.2014.12.021] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 11/26/2014] [Accepted: 12/06/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Diagnosis of periprosthetic joint infection (PJI) in revision shoulder arthroplasty can be challenging because of the indolent nature of the common offending organisms. The purpose of this study was to evaluate the diagnostic utility of synovial fluid α-defensin levels in identifying PJI of the shoulder. METHODS Thirty patients evaluated for painful shoulder arthroplasty were prospectively enrolled and underwent revision surgery (n = 33 cases). Cases were categorized into infection (n = 11) and no-infection (n = 22) groups on the basis of preoperative and intraoperative findings. Synovial fluid was obtained from preoperative aspirations or intraoperative aspiration before arthrotomy. α-Defensin was tested by the Synovasure (CD Diagnostics, Wynnewood, PA, USA) test for joint infection. Synovial fluid was also obtained intraoperatively from a control group undergoing arthroscopic rotator cuff repair (n = 16) for baseline data on normal α-defensin levels in the shoulder. A receiver operating characteristic curve was used to determine the diagnostic utility of synovial fluid α-defensin. RESULTS Synovial α-defensin had an area under the curve, sensitivity, specificity, and positive and negative likelihood ratios of 0.78, 63%, 95%, 12.1, and 0.38, respectively. There was a significant difference in α-defensin levels between the infection (median, 3.2 S/CO [signal to cutoff ratio]) and no-infection groups (median, 0.21 S/CO; P = .006). Synovial α-defensin was elevated in the presence of a culture positive for Propionibacterium acnes (median, 1.33 S/CO; P = .03) and showed moderate correlation with the number of positive cultures. CONCLUSION Synovial fluid α-defensin was more effective than current diagnostic testing in predicting positive cultures and may be an effective adjunct in the workup of shoulder PJI.
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Affiliation(s)
| | - Anas Saleh
- Department of Orthopedic Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Matthew J Grosso
- Department of Orthopedic Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mario Farias Kovac
- Department of Orthopedic Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Carlos A Higuera
- Department of Orthopedic Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Joseph P Iannotti
- Department of Orthopedic Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Eric T Ricchetti
- Department of Orthopedic Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA.
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186
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Mullen M, Piponov HI, Stewart R, Cohen-Rosenblum A, Shi LL. Propionibacterium acnes-mediated distal clavicular osteolysis: a case report. J Shoulder Elbow Surg 2015; 24:e185-9. [PMID: 25940382 DOI: 10.1016/j.jse.2015.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 03/07/2015] [Indexed: 02/01/2023]
Affiliation(s)
- Martin Mullen
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL, USA
| | - Hristo I Piponov
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL, USA
| | - Robert Stewart
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL, USA
| | - Anna Cohen-Rosenblum
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL, USA
| | - Lewis L Shi
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL, USA.
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187
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Sabetta JR, Rana VP, Vadasdi KB, Greene RT, Cunningham JG, Miller SR, Sethi PM. Efficacy of topical benzoyl peroxide on the reduction of Propionibacterium acnes during shoulder surgery. J Shoulder Elbow Surg 2015; 24:995-1004. [PMID: 26067191 DOI: 10.1016/j.jse.2015.04.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 04/14/2015] [Accepted: 04/15/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Propionibacterium acnes infection is a significant problem after shoulder surgery. Residual P. acnes is found on the skin up to 29% of the time immediately after surgical skin preparation and in 70% of dermal biopsy specimens. These residual bacteria may be a source for infection. Identifying more ideal skin preparation may help reduce the risk of infection. The purpose of this study was to evaluate the effect that topical benzoyl peroxide (BPO), with chlorhexidine skin preparation, would have on the presence of P. acnes cultured at the time of shoulder surgery. We hypothesized that adding topical BPO to our skin preparation would reduce the number of positive P. acnes cultures identified during surgery. METHODS Fifty patients undergoing first-time shoulder surgery were treated with topical 5% BPO cream 48 hours before surgery. After skin preparation, 13 samples per subject were obtained. Cultures were held for 14 days. RESULTS Fifty patients underwent arthroscopic shoulder surgery; 650 culture specimens were obtained. The skin was positive at the initiation of surgery in 6% of cases. Tissue samples were positive in 6%. The skin was positive in 10% at the end of surgery. None of these rates of positive culture were different from the 4% rate observed with a control swab. CONCLUSION Application of BPO is an effective way to reduce P. acnes on skin at the beginning and, importantly, at the end of a surgical procedure. This may result in a lower risk for postoperative infection.
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Affiliation(s)
- James R Sabetta
- Section of Infectious Diseases, Greenwich Hospital, Greenwich, CT, USA
| | - Vishal P Rana
- Orthopaedic & Neurosurgery Specialists, Greenwich, CT, USA
| | | | | | | | - Seth R Miller
- Orthopaedic & Neurosurgery Specialists, Greenwich, CT, USA
| | - Paul M Sethi
- Orthopaedic & Neurosurgery Specialists, Greenwich, CT, USA.
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188
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Hasan SS, Ricchetti ET. When Is a Positive Culture in Shoulder Surgery Not an Infection? Commentary on an article by William R. Mook, MD, et al.: "The Incidence of Propionibacterium acnes in Open Shoulder Surgery. A Controlled Diagnostic Study". J Bone Joint Surg Am 2015; 97:e51. [PMID: 26085539 DOI: 10.2106/jbjs.o.00375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - Eric T Ricchetti
- Orthopaedic & Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
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189
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Emerging technologies for the clinical microbiology laboratory. Clin Microbiol Rev 2015; 27:783-822. [PMID: 25278575 DOI: 10.1128/cmr.00003-14] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In this review we examine the literature related to emerging technologies that will help to reshape the clinical microbiology laboratory. These topics include nucleic acid amplification tests such as isothermal and point-of-care molecular diagnostics, multiplexed panels for syndromic diagnosis, digital PCR, next-generation sequencing, and automation of molecular tests. We also review matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) and electrospray ionization (ESI) mass spectrometry methods and their role in identification of microorganisms. Lastly, we review the shift to liquid-based microbiology and the integration of partial and full laboratory automation that are beginning to impact the clinical microbiology laboratory.
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190
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Drago L, De Vecchi E, Cappelletti L, Vassena C, Toscano M, Bortolin M, Mattina R, Romanò CL. Prolonging culture to 15 days improves bacterial detection in bone and joint infections. Eur J Clin Microbiol Infect Dis 2015; 34:1809-13. [PMID: 26054716 DOI: 10.1007/s10096-015-2416-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 05/18/2015] [Indexed: 01/11/2023]
Abstract
Since the optimal incubation period of cultures for diagnosis of bone and joint infections is still a matter of debate, the present study aimed to evaluate the effects of different incubation periods (5 and 15 days) on microbial isolation. Samples from 387 patients with bone and joint infections (including prosthetic ones) were analyzed from March 2012 to February 2014. In 197 patients (51 %) growth was obtained within 48 hrs, while in 124 (32 %) and 66 (17 %) patients cultures yielded positive results within and after 5 days of incubation, respectively. Of 449 microorganisms isolated, 247 grew within 48 hrs, 131 within the first 5 days of incubation while 71 were isolated after 5 days. Staphylococcus aureus was the most frequently isolated pathogen within 48 hrs, while Propionibacteria were prevalently isolated after 5 days of incubation. Interestingly, about 25 % of microorganisms isolated after 5 days of incubation were coagulase-negative staphylococci. Extending incubation period of broth cultures improves isolation rates of pathogens involved in bone and joint infections thus improving management of these infections.
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Affiliation(s)
- L Drago
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Galeazzi Orthopaedic Institute, Via R. Galeazzi 4, 20161, Milan, Italy,
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191
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Propionibacterium acnes infection in shoulder arthroscopy patients with postoperative pain. J Shoulder Elbow Surg 2015; 24:838-43. [PMID: 25979553 DOI: 10.1016/j.jse.2015.03.008] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 02/22/2015] [Accepted: 03/07/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recent studies have identified Propionibacterium acnes as the causal organism in an increasing number of postoperative shoulder infections. Most reports have found a high rate of P acnes infection after open surgery, particularly shoulder arthroplasty. However, there are limited data regarding P acnes infections after shoulder arthroscopy. MATERIALS AND METHODS We prospectively collected data on all shoulder arthroscopies performed by the senior author from January 1, 2009, until April 1, 2013. Cultures were taken in all revision shoulder arthroscopy cases performed for pain, stiffness, or weakness. In addition, 2 cultures were taken from each of a cohort of 32 primary shoulder arthroscopy cases without concern for infection to determine the false-positive rate. RESULTS A total of 1,591 shoulder arthroscopies were performed during this period, 68 (4.3%) of which were revision procedures performed for pain, stiffness, or weakness. A total of 20 revision arthroscopies (29.4%) had positive culture findings, and 16 (23.5%) were positive for P acnes. In the control group, 1 patient (3.2%) had P acnes growth. CONCLUSIONS The rate of P acnes infection in patients undergoing revision shoulder arthroscopy is higher than previously published and should be considered in cases characterized by refractory postoperative pain and stiffness.
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192
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Propionibacterium can be isolated from deep cultures obtained at primary arthroplasty despite intravenous antimicrobial prophylaxis. J Shoulder Elbow Surg 2015; 24:844-7. [PMID: 25547858 DOI: 10.1016/j.jse.2014.10.016] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 10/10/2014] [Accepted: 10/19/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Propionibacterium organisms are commonly recovered from deep cultures obtained at the time of revision arthroplasty. This study sought to determine whether deep cultures obtained at the time of primary arthroplasty can be substantially positive for Propionibacterium despite thorough skin preparation and preoperative intravenous antibiotic prophylaxis. METHODS After timely administration of preoperative antibiotics chosen specifically for their activity against Propionibacterium and after double skin preparation, specimens from the dermis, fascia, capsule, synovium, and glenoid tissue were sterilely harvested from 10 male patients undergoing primary shoulder arthroplasty and were submitted for culture for Propionibacterium. RESULTS Of the 50 specimens, 7 were positive for Propionibacterium: 3 in each of 2 patients and 1 in 1 patient. The specimen sources having positive anaerobic cultures were the dermis (1 of 10), fascia (2 of 10), synovium (1 of 10), and glenoid tissue (3 of 10). None of these patients had evidence of infection at the time of the arthroplasty. DISCUSSION AND CONCLUSION Preoperative antibiotics and skin preparation do not always eliminate Propionibacterium from the surgical field of primary shoulder arthroplasty. The presence of these bacteria in the arthroplasty wound may pose a risk of delayed shoulder arthroplasty failure from the subtle type of periprosthetic infection typically associated with Propionibacterium.
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193
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Sethi PM, Sabetta JR, Stuek SJ, Horine SV, Vadasdi KB, Greene RT, Cunningham JG, Miller SR. Presence of Propionibacterium acnes in primary shoulder arthroscopy: results of aspiration and tissue cultures. J Shoulder Elbow Surg 2015; 24:796-803. [PMID: 25483906 DOI: 10.1016/j.jse.2014.09.042] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 09/23/2014] [Accepted: 09/27/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Infection after shoulder surgery has a serious impact on patient outcome and costs associated with care. Propionibacterium acnes infection may be insidious and manifest years after index surgery with resultant joint arthropathy or prosthesis infection. Our goal was to evaluate the presence of P. acnes in a group of patients undergoing primary arthroscopic shoulder surgery to better understand this organism. METHODS Samples were collected from 57 patients undergoing first-time shoulder arthroscopy. Demographic data and medical comorbidities were collected. A control, 2 skin swabs, synovial fluid, and 3 tissue samples were obtained. All samples were placed on aerobic plates, on anaerobic plates, and in thioglycolate broth and held for 28 days. RESULTS Fifty-seven patients underwent arthroscopic shoulder surgery. The mean age was 51 years. Eighty-one samples (21.8%) were positive for P. acnes when cultures were held 14 days; 32 subjects (56%) had at least 1 culture that grew P. acnes. Positive skin cultures for P. acnes increased from 15.8% before incision to 40.4% at closure. This was even more pronounced in men as positive skin cultures increased from 31.3% before incision to 63.0% at closure. Thirteen patients (22.8%) had more than 3 cultures positive. None of the patients in this study have had signs or symptoms to suggest clinical P. acnes infection. CONCLUSIONS Of all subjects studied, 56% had at least 1 positive culture; 21% (of all 371 culture specimens obtained) grew P. acnes. We suspect that it is a consequence of true positive cultures from imperfect skin preparation and dermal contamination.
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Affiliation(s)
- Paul M Sethi
- Orthopaedic & Neurosurgery Specialists, ONS Foundation for Clinical Research and Education, Greenwich, CT, USA.
| | - James R Sabetta
- Section of Infectious Diseases, Greenwich Hospital, Greenwich, CT, USA
| | - Samantha J Stuek
- Orthopaedic & Neurosurgery Specialists, ONS Foundation for Clinical Research and Education, Greenwich, CT, USA
| | - Storm V Horine
- Orthopaedic & Neurosurgery Specialists, ONS Foundation for Clinical Research and Education, Greenwich, CT, USA
| | - Katherine B Vadasdi
- Orthopaedic & Neurosurgery Specialists, ONS Foundation for Clinical Research and Education, Greenwich, CT, USA
| | - R Timothy Greene
- Orthopaedic & Neurosurgery Specialists, ONS Foundation for Clinical Research and Education, Greenwich, CT, USA
| | - James G Cunningham
- Orthopaedic & Neurosurgery Specialists, ONS Foundation for Clinical Research and Education, Greenwich, CT, USA
| | - Seth R Miller
- Orthopaedic & Neurosurgery Specialists, ONS Foundation for Clinical Research and Education, Greenwich, CT, USA
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194
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Abstract
Periprosthetic joint infection remains a clinical challenge with no benchmark for diagnosis. The diagnosis is based on many different clinical variables that may be difficult to interpret, especially in the setting of chronic systemic disease. Synovial fluid aspiration, diagnostic imaging, traditional culture, peripheral serum inflammatory markers, and intraoperative frozen sections each have their limitations but continue to be the mainstay for diagnosis of periprosthetic joint infection. As molecular- and biomarker-based technologies improve, the way we interpret and diagnose periprosthetic joint infection will ultimately change and may even improve diagnostic accuracy and turnaround time. Future research on this topic should be focused on improving diagnostic criteria for low-virulence organisms, improving interpretation of intraoperative frozen sections, and establishing improved synovial fluid and peripheral serum biomarker profiles for periprosthetic joint infection.
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195
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Saper D, Capiro N, Ma R, Li X. Management of Propionibacterium acnes infection after shoulder surgery. Curr Rev Musculoskelet Med 2015; 8:67-74. [PMID: 25596729 PMCID: PMC4596189 DOI: 10.1007/s12178-014-9256-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Propionibacterium acnes (P. acnes) is a gram-positive anaerobic bacillus commonly isolated from the flora of the face, chest, and axilla region. It has emerged as a major pathogen responsible for postoperative shoulder infections after both arthroscopy and arthroplasty procedures. Patients with P. acnes shoulder infection typically present with normal laboratory values (white blood cells (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP)) making diagnosis difficult. Several intraoperative tissue cultures should be obtained and cultured in both agar plate and broth in aerobic and anaerobic conditions for a minimum of 13 days to optimize the sensitivity and specificity to detect P. acnes. The utilization of intraoperative frozen sections to detect P. acnes infection is not reliable. Risk factors include male, cloudy synovial fluid, lucencies around the implant, and periprosthetic membrane formation. Managements include irrigation and debridement, single or two-staged revision, and intravenous antibiotics. Open biopsy prior to the final implantation (two-staged revision) may help detect persistent P. acnes infection. Penicillin and cephalosporins are effective against clinical P. acnes infection and biofilm in vitro. Combination antibiotic therapy with rifampin and daptomycin may further increase the clinical efficacy of treatment.
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Affiliation(s)
- David Saper
- />Boston Medical Center, Department of Orthopaedic Surgery, Boston University School of Medicine, 720 Harrison Avenue - Suite # 808, Boston, MA 02118 USA
| | - Nina Capiro
- />Boston Medical Center, Department of Orthopaedic Surgery, Boston University School of Medicine, 720 Harrison Avenue - Suite # 808, Boston, MA 02118 USA
| | - Richard Ma
- />Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, MO USA
| | - Xinning Li
- />Boston Medical Center, Department of Orthopaedic Surgery, Boston University School of Medicine, 720 Harrison Avenue - Suite # 808, Boston, MA 02118 USA
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196
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Propionibacterium acnes: from commensal to opportunistic biofilm-associated implant pathogen. Clin Microbiol Rev 2015; 27:419-40. [PMID: 24982315 DOI: 10.1128/cmr.00092-13] [Citation(s) in RCA: 414] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Propionibacterium acnes is known primarily as a skin commensal. However, it can present as an opportunistic pathogen via bacterial seeding to cause invasive infections such as implant-associated infections. These infections have gained more attention due to improved diagnostic procedures, such as sonication of explanted foreign materials and prolonged cultivation time of up to 14 days for periprosthetic biopsy specimens, and improved molecular methods, such as broad-range 16S rRNA gene PCR. Implant-associated infections caused by P. acnes are most often described for shoulder prosthetic joint infections as well as cerebrovascular shunt infections, fibrosis of breast implants, and infections of cardiovascular devices. P. acnes causes disease through a number of virulence factors, such as biofilm formation. P. acnes is highly susceptible to a wide range of antibiotics, including beta-lactams, quinolones, clindamycin, and rifampin, although resistance to clindamycin is increasing. Treatment requires a combination of surgery and a prolonged antibiotic treatment regimen to successfully eliminate the remaining bacteria. Most authors suggest a course of 3 to 6 months of antibiotic treatment, including 2 to 6 weeks of intravenous treatment with a beta-lactam. While recently reported data showed a good efficacy of rifampin against P. acnes biofilms, prospective, randomized, controlled studies are needed to confirm evidence for combination treatment with rifampin, as has been performed for staphylococcal implant-associated infections.
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197
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Immunoproteomic Identification of In Vivo-Produced Propionibacterium acnes Proteins in a Rabbit Biofilm Infection Model. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2015; 22:467-76. [PMID: 25694647 DOI: 10.1128/cvi.00760-14] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 02/17/2015] [Indexed: 01/17/2023]
Abstract
Propionibacterium acnes is well-known as a human skin commensal but can also act as an invasive pathogen causing implant-associated infections. In order to resolve these types of P. acnes infections, the implants must be removed, due to the presence of an established biofilm that is recalcitrant to antibiotic therapy. In order to identify those P. acnes proteins produced in vivo during a biofilm infection, we established a rabbit model of implant-associated infection with this pathogen. P. acnes biofilms were anaerobically grown on dextran beads that were then inoculated into the left tibias of rabbits. At 4 weeks postinoculation, P. acnes infection was confirmed by radiograph, histology, culture, and PCR. In vivo-produced and immunogenic P. acnes proteins were detected on Western blot using serum samples from rabbits infected with P. acnes after these bacterial proteins were separated by two-dimensional gel electrophoresis. Those proteins that bound host antibodies were then isolated and identified by tandem mass spectrometry. Radiographs and histology demonstrated a disruption in the normal bone architecture and adherent biofilm communities in those animals with confirmed infections. A total of 24 immunogenic proteins were identified; 13 of these proteins were upregulated in both planktonic and biofilm modes, including an ABC transporter protein. We successfully adapted a rabbit model of implant-associated infection for P. acnes to identify P. acnes proteins produced during a chronic biofilm-mediated infection. Further studies are needed to evaluate the potential of these proteins for either a diagnostic test or a vaccine to prevent biofilm infections caused by P. acnes.
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198
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Hyaluronidase in Clinical Isolates of Propionibacterium acnes. INTERNATIONAL JOURNAL OF BACTERIOLOGY 2015; 2015:218918. [PMID: 26904745 PMCID: PMC4745459 DOI: 10.1155/2015/218918] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 01/14/2015] [Accepted: 02/02/2015] [Indexed: 11/18/2022]
Abstract
Objectives. We sought to describe the prevalence of a hyaluronidase gene and hyaluronidase production in 197 clinical isolates of P. acnes; we assessed kinetics of hyaluronidase production in a subset of three isolates. Methods. The hyaluronidase gene was detected using polymerase chain reaction. Hyaluronidase production was detected by growing isolates on BHI agar containing 400 μg/mL hyaluronic acid and 1% albumin and flooding plates with 2 N glacial acetic acid to precipitate unbound hyaluronic acid, with a zone of clearing representing a positive phenotype. Hyaluronidase production kinetics were measured as a function of hyaluronic acid digestion over time in a liquid medium. Results. A hyaluronidase gene and hyaluronidase production were detected in 100 and 97% of P. acnes isolates, respectively. Hyaluronidase production in liquid medium was detectable after 96 hours of growth. Conclusions. Hyaluronidase production is nearly universal among P. acnes isolates. Three days appear to be required for significant hyaluronidase production in a liquid medium. Detection of hyaluronidase in tissue specimens may be a strategy to differentiate P. acnes infection from colonization when P. acnes is isolated from a clinical specimen.
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199
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Fisher TJ, Osti OL. Do bacteria play an important role in the pathogenesis of low back pain? ANZ J Surg 2015; 85:808-14. [PMID: 25648861 DOI: 10.1111/ans.12983] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2014] [Indexed: 11/30/2022]
Abstract
Considerable interest has been generated recently regarding an alternative hypothesis for the pathogenesis of low back pain and radiculopathy in the presence of intervertebral disc prolapse. Traditionally, back pain and radicular (sciatic) symptoms have been attributed to mechanical compression of neural tissue by herniated disc material and to inflammation caused by exposure of the nerve roots to disc tissue. Recent research however has suggested that low-grade infection within the intervertebral disc by anaerobic bacteria may be responsible. The development of Modic changes in the corresponding adjacent vertebral endplates has also been suggested as an indicator of infection. This article is a thorough review of the current literature regarding the hypothesis that low-grade anaerobic bacterial infection may be the cause of disabling low back pain and radiculopathy.
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Affiliation(s)
- Thomas J Fisher
- Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, South Australia, Australia
| | - Orso L Osti
- Department of Surgery, Calvary Healthcare North Adelaide Campus, Adelaide, South Australia, Australia
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200
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McGoldrick E, McElvany MD, Butler-Wu S, Pottinger PS, Matsen FA. Substantial cultures of Propionibacterium can be found in apparently aseptic shoulders revised three years or more after the index arthroplasty. J Shoulder Elbow Surg 2015; 24:31-5. [PMID: 25022444 DOI: 10.1016/j.jse.2014.05.008] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 04/28/2014] [Accepted: 05/04/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Revisions of apparently "aseptic" shoulder arthroplasties are not infrequently culture positive for Propionibacterium, organisms that may be introduced at the time of the index surgery when the dermal sebaceous glands are transected. This report seeks to answer the question, Do surgeons performing revision shoulder arthroplasty years after the index procedure need to be concerned about the persistence of Propionibacterium? METHODS We reviewed the medical records of 148 revision arthroplasties performed between July 2008 and June 2013 to find those revisions performed at least 3 years after the index procedure and at which intraoperative cultures were strongly positive for Propionibacterium. RESULTS We identified 14 cases of revision surgery performed 8 ± 4 years after the original arthroplasty for which deep cultures were strongly positive for Propionibacterium. A total of 109 specimens were obtained, 84 of which were positive. All 14 patients were male. CONCLUSION Shoulder arthroplasties revised for the mechanical problems of loosening or stiffness can be substantially culture positive for Propionibacterium, even if the revision is performed many years after the index procedure. Therefore, even in shoulder arthroplasties revised for mechanical problems years after the index procedures, surgeons should consider submitting multiple deep specimens for specific Propionibacterium culture. In the presence of persistent Propionibacterium, surgeons should consider the need for directed surgical and medical treatment in their management of a failed arthroplasty.
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Affiliation(s)
- Erik McGoldrick
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Matthew D McElvany
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Susan Butler-Wu
- Department of Laboratory Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Paul S Pottinger
- Department of Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Frederick A Matsen
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, WA, USA.
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