201
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Jorge LS, Fucuta PS, Oliveira MGL, Nakazone MA, de Matos JA, Chueire AG, Salles MJC. Outcomes and Risk Factors for Polymicrobial Posttraumatic Osteomyelitis. J Bone Jt Infect 2018; 3:20-26. [PMID: 29545992 PMCID: PMC5852844 DOI: 10.7150/jbji.22566] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 02/03/2018] [Indexed: 11/05/2022] Open
Abstract
Background: We hypothesized that polymicrobial posttraumatic osteomyelitis (PTO) may be associated with worse outcomes when compared to monomicrobial PTO. We therefore attempted to show the outcomes and predisposing factors associated with polymicrobial PTO. Methods: A single-center case-control study was carried out from 2007 to 2012. The outcome variables analyzed were: the need for additional surgical and antibiotic treatments, rates of amputation, and mortality associated with the infection. Univariate and multivariable analyses using multiple logistic regression were performed to identify risk factors associated with polymicrobial PTO, and p < 0.05 was considered significant. Results: Among the 193 patients identified, polymicrobial PTO was diagnosed in 37.8%, and was significantly associated with supplementary surgical debridement (56.1% vs. 31%; p < 0.01), a higher consumption of antibiotics, and more amputations (6.5% vs 1.3%; p < 0.01). Factors associated with polymicrobial PTO in the multivariable analysis were older age (odds ratio [OR] = 1.02, 95% confidence interval [CI] = 1.01 to 1.03, p = 0.04), working in agriculture (OR = 2.86, 95% CI = 1.05 to 7.79, p = 0.04), open fracture Gustilo type III (OR = 2.38, 95% CI = 1.02 to 5.56, p = 0.04), need for blood transfusion (OR = 2.15, 95% CI = 1.07 to 4.32, p = 0.03), and need for supplementary debridement (OR = 2.58, 95% CI = 1.29 to 5.16, p = 0.01). Conclusions: PTO is polymicrobial in more than one-third of patients, associated with extra surgical and clinical treatment, and worse outcomes including higher rates of amputation.
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Affiliation(s)
- Luciana Souza Jorge
- Hospital de Base, Infection Control Unit, São José do Rio Preto Medical School, São Paulo, Brazil
| | - Patrícia Silva Fucuta
- Hospital de Base, Infection Control Unit, São José do Rio Preto Medical School, São Paulo, Brazil
| | | | | | | | - Alceu Gomes Chueire
- Orthopedics and Traumatology Unit, São José do Rio Preto Medical School, São Paulo, Brazil
| | - Mauro José Costa Salles
- Division of Infectious Diseases, Department of Internal Medicine; Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
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202
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Abstract
BACKGROUND Infections after osteosynthesis are a feared complication of the surgical treatment of fractures and should be dealt with by a multidisciplinary team. In addition to the surgeon, also included in this multidisciplinary team are a specialist for infectious diseases, a microbiologist, a radiologist and often a plastic surgeon. This review article describes the current knowledge on the pathogenesis, diagnostics, classification and treatment. The aim is to demonstrate some basic rules in the treatment of infections associated with implants and to show potential therpeutic approaches. MATERIAL AND METHODS The principles of diagnostics and combined surgical and antibiotic treatment are presented based on the current specialist literature. RESULTS With the help of a team approach the goals of treatment of an infected osteosynthesis, i.e. fracture healing, return to function and eradication of infection can be achieved. While the osteosynthesis material can usually be retained in acute infections, it is better to remove the infected hardware in chronic infections as eradication of the mature biofilm is no longer possible. DISCUSSION With adequate local wound débridement, the use of local and systemic antibiotics, as indicated by the specialist for infectious diseases and appropriate soft tissue coverage and wound closure, acute as well as chronic infections can be successfully treated. Nowadays, the surgeon has many different options for the management of bone defects. Depending on the anatomical location and the size of the defect a variety of techniques ranging from acute shortening to the Masquelet technique up to the Ilizarov distraction technique are available. These techniques should be combined with local bactericidal treatment.
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Affiliation(s)
- O Borens
- Abteilung für Traumatologie und Abteilung für Septische Chirurgie, Klinik für Orthopaedie und Traumtologie, Universitätsspital Lausanne - CHUV, Universität Lausanne, Rue du Bugnon 46, 1011, Lausanne, Schweiz.
| | - N Helmy
- Abteilung für Orthopaedie und Traumtologie des Bewegungsapparates, Bürgerspital Solothurn, Solothurn, Schweiz
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203
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Alcântara JEDE, Aguiar RADE, Sampaio JGL, Azi ML, Sadigursky D, Alencar DFDE. FACTORS ASSOCIATED WITH THE DEVELOPMENT OF EARLY INFECTION AFTER SURGICAL TREATMENT OF FRACTURES. ACTA ORTOPEDICA BRASILEIRA 2018; 26:22-26. [PMID: 29977139 PMCID: PMC6025494 DOI: 10.1590/1413-785220182601173883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 09/13/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Infection after the internal fixation of fractures is a major complication. Early infection is particularly challenging, because it occurs when the fracture is not yet united. The objective of this study is to identify possible factors related to the development of early infection in patients treated with internal fixation for fractures. METHOD This retrospective observational study analyzed 24 patients with long bone fractures who underwent internal fixation and developed infections in the post-operatory period. The infections were classified as early (diagnosis in the first two weeks after surgery) or late (diagnosis after 2 weeks). RESULTS Of the 24 patients studied, 11 (46%) developed early infections and 13 (54%) were diagnosed with late infections. The early infection group was significantly younger (37.8 versus 53.1 [p = 0.05]) and underwent more surgeries prior to internal fixation (1.2 versus 0.2 [p < 0.00]). CONCLUSION Risk factors for the development of early infection in the postoperative period should be considered when treating patients with internal fracture fixation in order to diagnose this condition as early as possible. Level of Evidence IV; Case series.
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Affiliation(s)
- João Eurípedes DE Alcântara
- . Manoel Victorino Hospital, Secretary of Health for the State of Bahia. Praça Conselheiro Almeida Couto S/N, 40050-410, Salvador, Bahia, Brazil
| | - Rogger Aguiar DE Aguiar
- . Manoel Victorino Hospital, Secretary of Health for the State of Bahia. Praça Conselheiro Almeida Couto S/N, 40050-410, Salvador, Bahia, Brazil
| | - Jose Gilvan Leite Sampaio
- . Manoel Victorino Hospital, Secretary of Health for the State of Bahia. Praça Conselheiro Almeida Couto S/N, 40050-410, Salvador, Bahia, Brazil
| | - Matheus Lemos Azi
- . Manoel Victorino Hospital, Secretary of Health for the State of Bahia. Praça Conselheiro Almeida Couto S/N, 40050-410, Salvador, Bahia, Brazil
| | - David Sadigursky
- . Manoel Victorino Hospital, Secretary of Health for the State of Bahia. Praça Conselheiro Almeida Couto S/N, 40050-410, Salvador, Bahia, Brazil
| | - Daniel Figueiredo DE Alencar
- . Manoel Victorino Hospital, Secretary of Health for the State of Bahia. Praça Conselheiro Almeida Couto S/N, 40050-410, Salvador, Bahia, Brazil
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204
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van Vliet KE, de Jong VM, Termaat MF, Schepers T, van Eck-Smit BLF, Goslings JC, Schep NWL. FDG-PET/CT for differentiating between aseptic and septic delayed union in the lower extremity. Arch Orthop Trauma Surg 2018; 138:189-194. [PMID: 28956151 PMCID: PMC5773632 DOI: 10.1007/s00402-017-2806-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/computed tomography (CT) has proven to have a high diagnostic accuracy for the detection of bone infections. In patients with delayed union it may be clinically important to differentiate between aseptic and septic delayed union. The aim of this study was to evaluate the efficacy and to assess the optimal diagnostic accuracy of FDG-PET/CT in differentiating between aseptic and septic delayed union in the lower extremity. METHODS This is a retrospective study of consecutive patients who underwent FDG-PET/CT scanning for suspicion of septic delayed union of the lower extremity. Diagnosis of aseptic delayed union or septic delayed union was made based on surgical deep cultures following PET/CT scanning and information on clinical follow-up. FDG-uptake values were measured at the fractured site by use of the maximum standardized uptake value (SUVmax). Sensitivity, specificity and diagnostic accuracy of FDG-PET/CT were calculated at various SUVmax cut-off points. RESULTS A total of 30 patients were included; 13 patients with aseptic delayed unions and 17 patients with septic delayed unions. Mean SUVmax in aseptic delayed union patients was 3.23 (SD ± 1.21). Mean SUVmax in septic delayed union patients was 4.77 (SD ± 1.87). A cut-off SUVmax set at 4.0 showed sensitivity, specificity and diagnostic accuracy of FDG-PET/CT were 65, 77 and 70% to differentiate between aseptic and septic delayed union, respectively. CONCLUSION Using a semi-quantitative measure (SUVmax) for interpretation of FDG-PET/CT imaging seems to be a promising tool for the discrimination between aseptic and septic delayed union.
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Affiliation(s)
- Kirsten E. van Vliet
- Trauma Unit, Department Surgery, AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Vincent M. de Jong
- Trauma Unit, Department Surgery, AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - M. Frank Termaat
- Trauma Unit, Department of Surgery, LUMC, Leiden, The Netherlands
| | - Tim Schepers
- Trauma Unit, Department Surgery, AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | | | - J. Carel Goslings
- Trauma Unit, Department Surgery, AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Niels W. L. Schep
- Trauma Unit, Department of Surgery, Maasstad ziekenhuis, Rotterdam, The Netherlands
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205
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Pokrowiecki R, Mielczarek A, Zaręba T, Tyski S. Oral microbiome and peri-implant diseases: where are we now? Ther Clin Risk Manag 2017; 13:1529-1542. [PMID: 29238198 PMCID: PMC5716316 DOI: 10.2147/tcrm.s139795] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Peri-implant infective diseases (PIIDs) in oral implantology are commonly known as peri-implant mucositis (PIM) and periimplantitis (PI). While PIM is restricted to the peri-implant mucosa and is reversible, PI also affects implant-supporting bone and, therefore, is very difficult to eradicate. PIIDs in clinical outcome may resemble gingivitis and periodontitis, as they share similar risk factors. However, recent study in the field of proteomics and other molecular studies indicate that PIIDs exhibit significant differences when compared to periodontal diseases. This review aims to elucidate the current knowledge of PIIDs, their etiopathology and diversified microbiology as well as the role of molecular studies, which may be a key to personalized diagnostic and treatment protocols of peri-implant infections in the near future.
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Affiliation(s)
- Rafał Pokrowiecki
- Department of Head and Neck Surgery-Maxillofacial Surgery, Otolaryngology and Ophthalmology, Prof Stanislaw Popowski Voivoid Children Hospital, Olsztyn
| | | | - Tomasz Zaręba
- Department of Antibiotics and Microbiology, National Medicines Institute
| | - Stefan Tyski
- Department of Antibiotics and Microbiology, National Medicines Institute
- Department of Pharmaceutical Microbiology, Medical University of Warsaw, Warsaw, Poland
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206
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Microbiological and functional outcomes after open extremity fractures sustained overseas: The experience of a UK level I trauma centre. JPRAS Open 2017; 15:36-45. [PMID: 32158796 PMCID: PMC7061582 DOI: 10.1016/j.jpra.2017.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 09/22/2017] [Indexed: 11/20/2022] Open
Abstract
Background Open extremity fractures carry a high risk of limb loss and poor functional outcomes. Transfer of extremity trauma patients from developing countries and areas of conflict adds further layers of complexity due to challenges in the delivery of adequate care. The combination of extensive injuries, transfer delays and complex microbiology presents unique challenges. Methods A retrospective review was conducted to analyse the surgical and microbiological themes of patients with open extremity fractures transferred from overseas to our institution (Imperial College NHS Trust) between January 2011 and January 2016. Results Twenty civilian patients with 21 open extremity fractures were referred to our unit from 11 different countries. All patients had poly-microbial wound contamination on initial surveillance cultures. Five patients (25%) underwent amputation depending on the extent of osseous injury; positive surveillance cultures did not preclude limb reconstruction, with seven patients undergoing complex reconstruction and eight undergoing simple reconstruction to achievewound coverage. Hundred percent of patients demonstrated infection-free fracture union on discharge. Conclusion Patients with open extremity fractures transferred from overseas present the unique challenge of poly-microbial infection in addition to extensive traumatic wounds. Favourable outcomes can be achieved despite positive microbiological findings on tissue culture with adequate antimicrobial therapy. The decision to salvage the limb and the complexity of reconstruction used should be based on the chance of achieving meaningful functional recovery, mainly determined by the extent of bony injury. The complexity of reconstruction was based on the predicted long-term functionality of the salvaged limb.
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207
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Walter G. [Evidence of anti-infection strategies in trauma surgery]. Unfallchirurg 2017; 120:1090-1091. [PMID: 29116374 DOI: 10.1007/s00113-017-0436-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- G Walter
- Abteilung Septische Chirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland.
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208
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Delayed Tibial Osteomyelitis after Anterior Cruciate Ligament Reconstruction with Hamstrings Autograft and Bioabsorbable Interference Screw: A Case Report and Review of the Literature. Case Rep Orthop 2017; 2017:6383526. [PMID: 29163995 PMCID: PMC5661094 DOI: 10.1155/2017/6383526] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 09/01/2017] [Accepted: 09/07/2017] [Indexed: 12/05/2022] Open
Abstract
Osteomyelitis following arthroscopically assisted anterior cruciate ligament (ACL) reconstruction has rarely been reported in the literature. We report a case of a 20-year-old female who had delayed tibial osteomyelitis and a pretibial cyst with culture-positive, oxacillin sensitive Staphylococcus epidermidis 15 months after an ACL reconstruction with hamstring autograft. Soft tissue fixation within the tibial tunnel was with a poly-L-D-lactic acid (PLDLA) bioabsorbable interference screw. The patient underwent surgical treatment with curettage, debridement, hardware removal, and bone grafting of the tibial tunnel followed by a course of intravenous antibiotics. Arthroscopic evaluation demonstrated an intact ACL graft without any evidence of intra-articular infection. The patient returned to collegiate athletics without any complications. While the most common biologic complications include pretibial cysts, granuloma formation, tunnel widening, and inflammatory reactions, infection is exceedingly rare. Late infection and osteomyelitis are also rare but can occur and should be considered in the differential diagnosis.
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209
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Zhang X, Ma YF, Wang L, Jiang N, Qin CH, Hu YJ, Yu B. A rabbit model of implant-related osteomyelitis inoculated with biofilm after open femoral fracture. Exp Ther Med 2017; 14:4995-5001. [PMID: 29201204 PMCID: PMC5704256 DOI: 10.3892/etm.2017.5138] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 08/30/2017] [Indexed: 12/17/2022] Open
Abstract
Currently, animal models used in research on implant-associated osteomyelitis primarily use intramedullary fixation and initial inoculum of planktonic bacterial cells. However, these techniques have certain limitations, including lack of rotational stability and instable inoculation. To improve these models, the present study aimed to establish a novel rabbit model of implant-associated osteomyelitis using biofilm as the initial inoculum following plate fixation of the femoral fracture. A total of 24 New Zealand White rabbits were randomly divided into two equal groups. Osteotomy was performed at the right femoral shaft using a wire saw following fixation with a 5-hole stainless steel plate. The plates were not colonized with bacteria in group 1, but colonized with a biofilm of Staphylococcus aureus (American Type Culture Collection, 25923) in group 2. All the rabbits were sacrificed after 21 days for clinical, X-ray, micro-computed tomography and histological assessments of the severity of osteomyelitis. Scanning electron microscopy and confocal laser scanning microscopy were used for biofilm assessment. In group 2, pus formation, periosteal reaction, cortical destruction and absorption were observed in all the rabbits and biofilm formation was observed on all the plates. However, no pus formation was observed except for a slight inflammatory response and all the plates appeared clean without infection in group 1. The differences between the two groups were statistically significant regarding histologic scores and semi-quantification of the bacteria on the plates (P<0.001). In the present study, a novel rabbit model of infection following internal plate fixation of open fracture was successfully established, providing a novel tool for the study of implant-associated osteomyelitis.
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Affiliation(s)
- Xiang Zhang
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China.,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Yun-Fei Ma
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China.,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Lei Wang
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China.,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Nan Jiang
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China.,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Cheng-He Qin
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Yan-Jun Hu
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Bin Yu
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China.,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
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210
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Prevention of fracture-related infection: a multidisciplinary care package. INTERNATIONAL ORTHOPAEDICS 2017; 41:2457-2469. [DOI: 10.1007/s00264-017-3607-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 08/08/2017] [Indexed: 01/25/2023]
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211
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Comparative Genomics Study of Staphylococcus epidermidis Isolates from Orthopedic-Device-Related Infections Correlated with Patient Outcome. J Clin Microbiol 2017; 55:3089-3103. [PMID: 28794175 DOI: 10.1128/jcm.00881-17] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 07/18/2017] [Indexed: 12/16/2022] Open
Abstract
Staphylococcus epidermidis has emerged as an important opportunistic pathogen causing orthopedic-device-related infections (ODRI). This study investigated the association of genome variation and phenotypic features of the infecting S. epidermidis isolate with the clinical outcome for the infected patient. S. epidermidis isolates were collected from 104 patients with ODRI. Their clinical outcomes were evaluated, after an average of 26 months, as either "cured" or "not cured." The isolates were tested for antibiotic susceptibility and biofilm formation. Whole-genome sequencing was performed on all isolates, and genomic variation was related to features associated with "cured" and "not cured." Strong biofilm formation and aminoglycoside resistance were associated with a "not-cured" outcome (P = 0.031 and P < 0.001, respectively). Based on gene-by-gene analysis, some accessory genes were more prevalent in isolates from the "not-cured" group. These included the biofilm-associated bhp gene, the antiseptic resistance qacA gene, the cassette chromosome recombinase-encoding genes ccrA and ccrB, and the IS256-like transposase gene. This study identifies biofilm formation and antibiotic resistance as associated with poor outcome in S. epidermidis ODRI. Whole-genome sequencing identified specific genes associated with a "not-cured" outcome that should be validated in future studies. (The study has been registered at ClinicalTrials.gov with identifier NCT02640937.).
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212
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Sabaté Brescó M, Harris LG, Thompson K, Stanic B, Morgenstern M, O'Mahony L, Richards RG, Moriarty TF. Pathogenic Mechanisms and Host Interactions in Staphylococcus epidermidis Device-Related Infection. Front Microbiol 2017; 8:1401. [PMID: 28824556 PMCID: PMC5539136 DOI: 10.3389/fmicb.2017.01401] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/11/2017] [Indexed: 12/25/2022] Open
Abstract
Staphylococcus epidermidis is a permanent member of the normal human microbiota, commonly found on skin and mucous membranes. By adhering to tissue surface moieties of the host via specific adhesins, S. epidermidis is capable of establishing a lifelong commensal relationship with humans that begins early in life. In its role as a commensal organism, S. epidermidis is thought to provide benefits to human host, including out-competing more virulent pathogens. However, largely due to its capacity to form biofilm on implanted foreign bodies, S. epidermidis has emerged as an important opportunistic pathogen in patients receiving medical devices. S. epidermidis causes approximately 20% of all orthopedic device-related infections (ODRIs), increasing up to 50% in late-developing infections. Despite this prevalence, it remains underrepresented in the scientific literature, in particular lagging behind the study of the S. aureus. This review aims to provide an overview of the interactions of S. epidermidis with the human host, both as a commensal and as a pathogen. The mechanisms retained by S. epidermidis that enable colonization of human skin as well as invasive infection, will be described, with a particular focus upon biofilm formation. The host immune responses to these infections are also described, including how S. epidermidis seems to trigger low levels of pro-inflammatory cytokines and high levels of interleukin-10, which may contribute to the sub-acute and persistent nature often associated with these infections. The adaptive immune response to S. epidermidis remains poorly described, and represents an area which may provide significant new discoveries in the coming years.
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Affiliation(s)
- Marina Sabaté Brescó
- Musculoskeletal Infection, AO Research Institute DavosDavos, Switzerland.,Molecular Immunology, Swiss Institute of Allergy and Asthma Research, University of ZurichDavos, Switzerland
| | - Llinos G Harris
- Microbiology and Infectious Diseases, Institute of Life Science, Swansea University Medical SchoolSwansea, United Kingdom
| | - Keith Thompson
- Musculoskeletal Infection, AO Research Institute DavosDavos, Switzerland
| | - Barbara Stanic
- Musculoskeletal Infection, AO Research Institute DavosDavos, Switzerland
| | - Mario Morgenstern
- Department of Orthopedic and Trauma Surgery, University Hospital BaselBasel, Switzerland
| | - Liam O'Mahony
- Molecular Immunology, Swiss Institute of Allergy and Asthma Research, University of ZurichDavos, Switzerland
| | - R Geoff Richards
- Musculoskeletal Infection, AO Research Institute DavosDavos, Switzerland
| | - T Fintan Moriarty
- Musculoskeletal Infection, AO Research Institute DavosDavos, Switzerland
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213
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Wang L, Jiang N, Lin QR, Qin CH, Hu YJ, Yu B. Cyclooxygenase-2 (COX-2) polymorphism rs689466 may contribute to the increased susceptibility to post-traumatic osteomyelitis in Chinese population. Infect Dis (Lond) 2017; 49:817-823. [PMID: 28682162 DOI: 10.1080/23744235.2017.1347816] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Lei Wang
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Nan Jiang
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Qing-rong Lin
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Cheng-he Qin
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Yan-jun Hu
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Bin Yu
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
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214
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Jorge LS, Chueire AG, Fucuta PS, Machado MN, Oliveira MGL, Nakazone MA, Salles MJ. Predisposing factors for recurrence of chronic posttraumatic osteomyelitis: a retrospective observational cohort study from a tertiary referral center in Brazil. Patient Saf Surg 2017; 11:17. [PMID: 28588645 PMCID: PMC5457537 DOI: 10.1186/s13037-017-0133-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 05/24/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The incidence of posttraumatic osteomyelitis (PTO) is increasing despite new treatment strategies. Assessment of patients' outcomes following PTO is challenging due to multiple variables. The study goals are to determine the frequency of recurrence following PTO treatment and identify factors predisposing patients to treatment failure. METHODS Between August 01, 2007 to August 30, 2012, a single-center retrospective cohort study was performed among 193 patients diagnosed with PTO following orthopedic surgery for fracture care. Bone and soft tissues were collected for cultures and PTO was defined according to CDC/NHSN criteria. Patient, injury, surgery-associated variables, and microbiological records were reviewed for risk factors associated to recurrence of PTO. Univariate and multivariable analyses using logistic regression were performed, with p <0.05 considered significant. RESULTS Thirty-eight patients (20%) of 192 diagnosed and treated for PTO failed their treatment. Factors associated with recurrence were age between 61 and 80 years [hazard ratio (HR) = 6.086, 95% confidence interval (CI) = 2.459;15.061, p = <0.001], age above 80 years [HR = 9.975 (95% CI = 3.591;27.714), p = <0.001], intraoperative blood transfusion [HR = 2.239 (95% CI = 1.138;4.406), p = 0.020], and positive culture for Pseudomonas aeruginosa [HR = 2.700 (95% CI = 1.370;5.319), p = 0.004]. CONCLUSIONS Risk factors associated with recurrence of PTO are difficult to measure. The present study revealed that elderly patients, intraoperative blood transfusions, and infection due to P. aeruginosa were independently associated with recurrence of PTO. These factors should warn clinicians of a higher failure rate following treatment of PTO. Trial registration: ISRCTN71648577. Registered 18 May 2017. Retrospectively registered.
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Affiliation(s)
- Luciana Souza Jorge
- Hospital de Base, Infection Control Unit, São José do Rio Preto Medical School, São Paulo, Brazil
| | - Alceu G Chueire
- Orthopedics and Traumatology Unit, São José do Rio Preto Medical School, São Paulo, Brazil
| | - Patricia Silva Fucuta
- Orthopedics and Traumatology Unit, São José do Rio Preto Medical School, São Paulo, Brazil
| | - Mauricio N Machado
- Orthopedics and Traumatology Unit, São José do Rio Preto Medical School, São Paulo, Brazil
| | | | - Marcelo A Nakazone
- Orthopedics and Traumatology Unit, São José do Rio Preto Medical School, São Paulo, Brazil
| | - Mauro José Salles
- Division of Infectious Diseases, Department of Internal Medicine, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil.,Hospital da Irmandade da Santa Casa de Misericórdia de São Paulo, Rua Dr Cesáreo Mota Jr 112, CEP: 01221-020 São Paulo, SP Brazil
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Metsemakers WJ, Smeets B, Nijs S, Hoekstra H. Infection after fracture fixation of the tibia: Analysis of healthcare utilization and related costs. Injury 2017; 48:1204-1210. [PMID: 28377260 DOI: 10.1016/j.injury.2017.03.030] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 03/21/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION One of the most challenging complications in musculoskeletal trauma surgery is the development of infection after fracture fixation (IAFF). It can delay healing, lead to permanent functional loss, or even amputation of the affected limb. The main goal of this study was to investigate the total healthcare costs and length-of-stay (LOS) related to the surgical treatment of tibia fractures and furthermore identify the subset of clinical variables driving these costs within the Belgian healthcare system. The hypothesis was that deep infection would be the most important driver for total healthcare costs. PATIENTS AND METHODS Overall, 358 patients treated operatively for AO/OTA type 41, 42, and 43 tibia fractures between January 1, 2009 and January 1, 2014 were included in this study. A total of 26 clinical and process variables were defined. Calculated costs were limited to hospital care covered by the Belgian healthcare financing system. The five main cost categories studied were: honoraria, materials, hospitalization, day care admission, and pharmaceuticals. RESULTS Multivariate analysis showed that deep infection was the most significant characteristic driving total healthcare costs and LOS related to the surgical treatment of tibia fractures. Furthermore, this complication resulted in the highest overall increase in total healthcare costs and LOS. Treatment costs were approximately 6.5-times higher compared to uninfected patients. CONCLUSION This study shows the enormous hospital-related healthcare costs associated with IAFF of the tibia. Treatment costs for patients with deep infection are higher than previously mentioned in the literature. Therefore, future research should focus more on prevention rather than treatment strategies, not only to reduce patient morbidity but also to reduce the socio-economic impact.
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Affiliation(s)
- Willem-Jan Metsemakers
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium.
| | - Bart Smeets
- University Hospitals Leuven, Care Program Management, B-3000 Leuven, Belgium
| | - Stefaan Nijs
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium
| | - Harm Hoekstra
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium
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216
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Nishisako H, Kunishima H, Shimizu G, Teruya Y, Yokokawa M, Hirose M, Sakai T, Yamasaki Y, Tsuchida T, Naitou Y, Takashi O, Torikai K, Nakagawa T, Matsuda T. Investigation on prediction formulae for calculating erythrocyte sedimentation rate. J Gen Fam Med 2017; 18:146-147. [PMID: 29264012 PMCID: PMC5689405 DOI: 10.1002/jgf2.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 10/19/2015] [Indexed: 11/16/2022] Open
Affiliation(s)
- Hisashi Nishisako
- Division of General Internal Medicine; Department of Internal Medicine; St. Marianna University School of Medicine; Kanagawa Japan
- Division of General Internal Medicine; Department of Internal Medicine; Kawasaki Tama Municipal Hospital; Kanagawa Japan
| | - Hiroyuki Kunishima
- Division of General Internal Medicine; Department of Internal Medicine; St. Marianna University School of Medicine; Kanagawa Japan
- Division of General Internal Medicine; Department of Internal Medicine; Kawasaki Tama Municipal Hospital; Kanagawa Japan
| | - Gohji Shimizu
- Division of General Internal Medicine; Department of Internal Medicine; St. Marianna University School of Medicine; Kanagawa Japan
| | - Yoko Teruya
- Division of General Internal Medicine; Department of Internal Medicine; St. Marianna University School of Medicine; Kanagawa Japan
- Division of General Internal Medicine; Department of Internal Medicine; Kawasaki Tama Municipal Hospital; Kanagawa Japan
| | - Masatoshi Yokokawa
- Division of General Internal Medicine; Department of Internal Medicine; St. Marianna University School of Medicine; Kanagawa Japan
- Division of General Internal Medicine; Department of Internal Medicine; Kawasaki Tama Municipal Hospital; Kanagawa Japan
| | - Masanori Hirose
- Division of General Internal Medicine; Department of Internal Medicine; St. Marianna University School of Medicine; Kanagawa Japan
- Division of General Internal Medicine; Department of Internal Medicine; Kawasaki Tama Municipal Hospital; Kanagawa Japan
| | - Tsubasa Sakai
- Division of General Internal Medicine; Department of Internal Medicine; St. Marianna University School of Medicine; Kanagawa Japan
- Division of General Internal Medicine; Department of Internal Medicine; Kawasaki Tama Municipal Hospital; Kanagawa Japan
| | - Yukitaka Yamasaki
- Division of General Internal Medicine; Department of Internal Medicine; St. Marianna University School of Medicine; Kanagawa Japan
- Division of General Internal Medicine; Department of Internal Medicine; Kawasaki Tama Municipal Hospital; Kanagawa Japan
| | - Tomoya Tsuchida
- Division of General Internal Medicine; Department of Internal Medicine; St. Marianna University School of Medicine; Kanagawa Japan
- Division of General Internal Medicine; Department of Internal Medicine; Kawasaki Tama Municipal Hospital; Kanagawa Japan
| | - Yoshiyuki Naitou
- Division of General Internal Medicine; Department of Internal Medicine; St. Marianna University School of Medicine; Kanagawa Japan
| | - Ogihara Takashi
- Division of General Internal Medicine; Department of Internal Medicine; St. Marianna University School of Medicine; Kanagawa Japan
| | - Keito Torikai
- Division of General Internal Medicine; Department of Internal Medicine; St. Marianna University School of Medicine; Kanagawa Japan
| | - Teisuke Nakagawa
- Division of General Internal Medicine; Department of Internal Medicine; St. Marianna University School of Medicine; Kanagawa Japan
| | - Takahide Matsuda
- Division of General Internal Medicine; Department of Internal Medicine; St. Marianna University School of Medicine; Kanagawa Japan
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218
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A short artificial antimicrobial peptide shows potential to prevent or treat bone infections. Sci Rep 2017; 7:1506. [PMID: 28473710 PMCID: PMC5431435 DOI: 10.1038/s41598-017-01698-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 04/03/2017] [Indexed: 01/22/2023] Open
Abstract
Infection of bone is a severe complication due to the variety of bacteria causing it, their resistance against classical antibiotics, the formation of a biofilm and the difficulty to eradicate it. Antimicrobial peptides (AMPs) are naturally occurring peptides and promising candidates for treatment of joint infections. This study aimed to analyze the effect of short artificial peptides derived from an optimized library regarding (1) antimicrobial effect on different bacterial species, (2) efficacy on biofilms, and (3) effect on osteoblast‑like cells. Culturing the AMP-modifications with Escherichia coli, Enterococcus faecalis, Pseudomonas aeruginosa, Staphylococcus aureus (including clinical isolates of MRSA and MSSA) and Staphylococcus epidermidis identified one candidate that was most effective against all bacteria. This AMP was also able to reduce biofilm as demonstrated by FISH and microcalorimetry. Osteoblast viability and differentiation were not negatively affected by the AMP. A cation concentration comparable to that physiologically occurring in blood had almost no negative effect on AMP activity and even with 10% serum bacterial growth was inhibited. Bacteria internalized into osteoblasts were reduced by the AMP. Taken together the results demonstrate a high antimicrobial activity of the AMP even against bacteria incorporated in a biofilm or internalized into cells without harming human osteoblasts.
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219
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Govaert GA, IJpma FF, McNally M, McNally E, Reininga IH, Glaudemans AW. Accuracy of diagnostic imaging modalities for peripheral post-traumatic osteomyelitis - a systematic review of the recent literature. Eur J Nucl Med Mol Imaging 2017; 44:1393-1407. [PMID: 28451827 PMCID: PMC5486824 DOI: 10.1007/s00259-017-3683-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 03/16/2017] [Indexed: 12/20/2022]
Abstract
AIMS Post-traumatic osteomyelitis (PTO) is difficult to diagnose and there is no consensus on the best imaging strategy. The aim of this study is to present a systematic review of the recent literature on diagnostic imaging of PTO. METHODS A literature search of the EMBASE and PubMed databases of the last 16 years (2000-2016) was performed. Studies that evaluated the accuracy of magnetic resonance imaging (MRI), three-phase bone scintigraphy (TPBS), white blood cell (WBC) or antigranulocyte antibody (AGA) scintigraphy, fluorodeoxyglucose positron emission tomography (FDG-PET) and plain computed tomography (CT) in diagnosing PTO were considered for inclusion. The review was conducted using the PRISMA statement and QUADAS-2 criteria. RESULTS The literature search identified 3358 original records, of which 10 articles could be included in this review. Four of these studies had a comparative design which made it possible to report the results of, in total, 17 patient series. WBC (or AGA) scintigraphy and FDG-PET exhibit good accuracy for diagnosing PTO (sensitivity ranged from 50-100%, specificity ranged from 40-97% versus 83-100% and 51%-100%, respectively). The accuracy of both modalities improved when a hybrid imaging technique (SPECT/CT & FDG-PET/CT) was performed. For FDG-PET/CT, sensitivity ranged between 86 and 94% and specificity between 76 and 100%. For WBC scintigraphy + SPECT/CT, this is 100% and 89-97%, respectively. CONCLUSIONS Based on the best available evidence of the last 16 years, both WBC (or AGA) scintigraphy combined with SPECT/CT or FDG-PET combined with CT have the best diagnostic accuracy for diagnosing peripheral PTO.
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Affiliation(s)
- Geertje A Govaert
- Department of Surgery, Subdivision of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. .,Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Room number G.04.228, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Frank F IJpma
- Department of Surgery, Subdivision of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Inge H Reininga
- Department of Surgery, Subdivision of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Andor W Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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220
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Zimmerli W, Sendi P. Orthopaedic biofilm infections. APMIS 2017; 125:353-364. [PMID: 28407423 DOI: 10.1111/apm.12687] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 01/10/2017] [Indexed: 02/01/2023]
Abstract
Many infections of the musculoskeletal system are biofilm infections that develop on non-living surfaces. Microorganisms adhere either on dead bone (sequesters) or implants. As a rule for a curative concept, chronic osteomyelitis or implant-associated bone infection must be treated with a combination of surgery and antimicrobial therapy. If an implant is kept in place, or a new device is implanted before complete healing of infection, a biofilm-active antibiotic should be used. Rifamycins are active against biofilms of staphylococci, and fluoroquinolones against those of Gram-negative bacilli. In this review, the management of chronic osteomyelitis, periprosthetic joint infection and implant-associated osteomyelitis of long bones is presented.
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Affiliation(s)
- Werner Zimmerli
- Kantonsspital Baselland, Basel University Medical Clinic and Interdisciplinary Unit for Orthopaedic Infections, Liestal, Switzerland
| | - Parham Sendi
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
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221
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Staphylococcus lugdunensis: a neglected pathogen of infections involving fracture-fixation devices. INTERNATIONAL ORTHOPAEDICS 2017; 41:1085-1091. [PMID: 28405808 DOI: 10.1007/s00264-017-3476-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 03/24/2017] [Indexed: 01/22/2023]
Abstract
PURPOSE Cases of fracture-fixation device infection involving Staphylococcus lugdunensis are not frequent. The clinical characteristics and the choice of treatment strategies of these infections are not obviously known to date. METHODS We performed a review of fracture-fixation device infection involving S. lugdunensis managed by our centres. RESULTS Among the 38 cases of fracture-fixation device infection involving S. lugdunensis, 53% were located in the tibia. Most of our cases (87%) were chronic infections. Purulent discharge, which occurred in 79% of cases, was the most frequent clinical symptom, followed by pain in 63%, local inflammation in 55%, and fever in 37%. Bacteremia and severe sepsis occurred in 10% and 18% of cases, respectively. Four cases (10%) were treated exclusively with antimicrobial treatment alone. Thirty-four cases (89%) were treated with a combination of surgery with antimicrobial therapy including surgical debridement, antibiotics and osteosynthesis device retention in six cases (16%), and osteosynthesis device removal in 27 cases (71%). The mean length of antibiotic treatment was 119 days. The relapse rate was high that was not related to selection of resistant strains. Polymicrobial infection had no impact on clinical outcome. A combination of surgery with antimicrobial therapy was identified as a significant prognostic factor associated with remission (p = 0.042). CONCLUSIONS S. lugdunensis is probably involved in more infections than has been reported. Using appropriate microbiological methods laboratories should routinely identify the species of all coagulase-negative Staphylococci isolates involved in fracture-fixation device infection to better achieve the treatment strategies of fracture-fixation device infection involving S. lugdunensis.
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222
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A Prospective Randomized Trial to Assess Oral Versus Intravenous Antibiotics for the Treatment of Postoperative Wound Infection After Extremity Fractures (POvIV Study). J Orthop Trauma 2017; 31 Suppl 1:S32-S38. [PMID: 28323799 DOI: 10.1097/bot.0000000000000802] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Patients surgically treated for infection after extremity fractures are typically discharged with a 6- to 12-week antibiotic regimen. Intravenous (IV) antibiotics are associated with significant cost and potential complications of deep vein thrombosis, line clotting, and sepsis. Many of the pathogens that cause musculoskeletal infection have both oral (PO) and IV antibiotic options with adequate bioavailability and antibacterial effect, yet IV antibiotics remain the standard of care absent evidence that PO options are clinically as efficacious. The POvIV study is a prospective, multicenter, randomized trial to compare PO with IV antibiotic therapy in patients with postoperative wound infections after extremity fractures. Patients between the ages of 18 and 84 who have a culture-positive surgical site infection after internal fixation for fracture repair or arthrodesis are approached for this study, and if they provide consent, are randomly assigned to receive either PO or IV antibiotics. Antibiotic selection is based on culture and sensitivity results. Randomization determines the route of administration. Patients are followed for 1 year after study enrollment. This study will be the largest prospective randomized trial to evaluate the safety and effectiveness of PO antibiotic use for treatment of postoperative wound infections. Results will inform clinician decisions on antibiotic delivery in patients with postoperative wound infections.
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223
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Wang Y, Liu X, Dou C, Cao Z, Liu C, Dong S, Fei J. Staphylococcal protein A promotes osteoclastogenesis through MAPK signaling during bone infection. J Cell Physiol 2017; 232:2396-2406. [PMID: 28185243 PMCID: PMC5485048 DOI: 10.1002/jcp.25774] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 01/04/2017] [Indexed: 01/31/2023]
Abstract
Bone infection is a common and serious complication in the orthopedics field, which often leads to excessive bone destruction and non‐union. Osteoclast is the only type of cells which have the function of bone resorption. Its over activation is closely related to excessive bone loss. Staphylococcus aureus (S. aureus) is a major pathogen causing bone infection, which can produce a large number of strong pathogenic substances staphylococcal protein A (SPA). However, few studies were reported about the effects of SPA on osteoclastogenesis. In our study, we observed that S. aureus activated osteoclasts and promoted bone loss in bone infection specimens. Then, we investigated the effects of SPA on RANKL‐induced osteoclastogenesis in vitro, the results revealed that SPA promoted osteoclastic differentiation and fusion, and enhanced osteoclastic bone resorption. In addition, we also showed that SPA upregulated the expression of NFATc1 and c‐FOS through the activation of MAPK signaling to promote osteoclastogenesis. Our findings might help us better understand the pathogenic role of S. aureus in bone infection and develop new therapeutic strategies for infectious bone diseases.
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Affiliation(s)
- Yuan Wang
- Center of Trauma of Daping Hospital, Third Military Medical University, Chongqing, China
| | - Xin Liu
- Center of Trauma of Daping Hospital, Third Military Medical University, Chongqing, China
| | - Ce Dou
- Department of Biomedical Materials Science, School of Biomedical Engineering, Third Military Medical University, Chongqing, China
| | - Zhen Cao
- Department of Biomedical Materials Science, School of Biomedical Engineering, Third Military Medical University, Chongqing, China
| | - Chuan Liu
- Department of Biomedical Materials Science, School of Biomedical Engineering, Third Military Medical University, Chongqing, China
| | - Shiwu Dong
- Department of Biomedical Materials Science, School of Biomedical Engineering, Third Military Medical University, Chongqing, China
| | - Jun Fei
- Center of Trauma of Daping Hospital, Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
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224
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Hellebrekers P, Leenen LPH, Hoekstra M, Hietbrink F. Effect of a standardized treatment regime for infection after osteosynthesis. J Orthop Surg Res 2017; 12:41. [PMID: 28279223 PMCID: PMC5345171 DOI: 10.1186/s13018-017-0535-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 02/08/2017] [Indexed: 11/10/2022] Open
Abstract
Background Infection after osteosynthesis is an important complication with significant morbidity and even mortality. These infections are often caused by biofilm-producing bacteria. Treatment algorithms dictate an aggressive approach with surgical debridement and antibiotic treatment. The aim of this study is to analyze the effect of such an aggressive standardized treatment regime with implant retention for acute, existing <3 weeks, infection after osteosynthesis. Methods We conducted a retrospective 2-year cohort in a single, level 1 trauma center on infection occurring within 12 months following any osteosynthesis surgery. The standardized treatment regime consisted of implant retention, thorough surgical debridement, and immediate antibiotic combination therapy with rifampicin. The primary outcome was success. Success was defined as consolidation of the fracture and resolved symptoms of infection. Culture and susceptibility testing were performed to identify bacteria and resistance patterns. Univariate analysis was conducted on patient-related factors in association with primary success and antibiotic resistance. Results Forty-nine patients were included for analysis. The primary success rate was 63% and overall success rate 88%. Factors negatively associated with primary success were the following: Gustilo classification (P = 0.023), higher number of debridements needed (P = 0.015), inability of primary closure (P = 0.017), and subsequent application of vacuum therapy (P = 0.030). Adherence to the treatment regime was positively related to primary success (P = 0.034). Conclusions The described treatment protocol results in high success rates, comparable with success rates achieved in staged exchange in prosthetic joint infection treatment.
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Affiliation(s)
- Pien Hellebrekers
- Department of Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Meriam Hoekstra
- Department of Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
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225
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Varadarajan VV, Dirain CO, Antonelli PJ. Microflora of Retained Intracochlear Electrodes from Infected Cochlear Implants. Otolaryngol Head Neck Surg 2017; 157:85-91. [PMID: 28195822 DOI: 10.1177/0194599817693228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Cochlear implant infections may be refractory to medical management and require device removal with subsequent reimplantation. During device removal, the intracochlear electrode array is commonly left in place to prevent obliteration of the cochlear lumen. If the electrode is colonized with pathogens, this risks contaminating the replacement implant. In this study, we compare the microorganisms detected on infected cochlear implants against those on the retained electrode using culture and microbial gene-sequencing techniques. Study Design Prospective single-cohort study. Setting Tertiary medical center. Subjects and Methods Six patients with refractory cochlear implant infections had the receiver-stimulator and extracochlear electrode removed to facilitate treatment of the infection. The intracochlear electrode was removed at (delayed) reimplantation. Implant specimens were analyzed by microbial culture and 16S DNA gene sequencing. Results Staphylococcus aureus was the organism most commonly identified. None of the 6 patients' intracochlear electrodes yielded microbes by culture. Two intracochlear electrodes revealed bacterial species, and 1 revealed fungal species by gene sequencing. There was no correlation between the microbes on the infected extracochlear implants and the retained intracochlear electrodes. All subjects underwent reimplantation after resolution of their infections. One of 6 subjects developed a second infection after reimplantation, with S aureus in the primary and secondary infections. Conclusions The intracochlear electrodes of infected cochlear implants carry a low microbial burden. Preserving intracochlear electrodes upon removal of infected cochlear implants appears to carry a low risk of contaminating a replacement cochlear implant.
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Affiliation(s)
- Varun V Varadarajan
- 1 Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Carolyn O Dirain
- 1 Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Patrick J Antonelli
- 1 Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
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226
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Bonnevialle P. Operative treatment of early infection after internal fixation of limb fractures (exclusive of severe open fractures). Orthop Traumatol Surg Res 2017; 103:S67-S73. [PMID: 28057476 DOI: 10.1016/j.otsr.2016.06.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 05/23/2016] [Accepted: 06/10/2016] [Indexed: 02/02/2023]
Abstract
Early infection after open reduction and internal fixation (ORIF) of a limb bone is defined as bacteriologically documented, deep and/or superficial surgical-site infection (SSI) diagnosed within 6months after the surgical procedure. This interval is arbitrarily considered sufficient to obtain fracture healing. The treatment of early infection after ORIF should be decided by a multidisciplinary team. The principles are the same as for revision arthroplasty. Superficial SSIs should be differentiated from deep SSIs, based on the results of bacteriological specimens collected using flawless technique. A turning point in the local microbial ecology occurs around the third or fourth week, when a biofilm develops around metallic implants. This biofilm protects the bacteria. The treatment relies on both non-operative and operative measures, which are selected based on the time to occurrence of the infection, condition of the soft tissues, and stage of bone healing. Both the surgical strategy and the antibiotic regimen should be determined during a multidisciplinary discussion. When treating superficial SSIs after ORIF, soft-tissue management is the main challenge. The treatment differs according to whether the hardware is covered or exposed. Defects in the skin and/or fascia can be managed using reliable reconstructive surgery techniques, either immediately or after a brief period of vacuum-assisted closure. In deep SSIs, deciding whether to leave or to remove the hardware is difficult. If the hardware is removed, the fracture site can be stabilised provisionally using either external fixation or a cement rod. Once infection control is achieved, several measures can be taken to stimulate bone healing before the end of the classical 6-month interval. If the hardware was removed, then internal fixation must be performed once the infection is eradicated.
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Affiliation(s)
- P Bonnevialle
- Département d'orthopédie traumatologie, CHU de Toulouse, hôpital P.P.-Riquet, place Baylac, 31052 Toulouse cedex, France.
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Post V, Wahl P, Richards RG, Moriarty TF. Vancomycin displays time-dependent eradication of mature Staphylococcus aureus biofilms. J Orthop Res 2017; 35:381-388. [PMID: 27175462 DOI: 10.1002/jor.23291] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 04/29/2016] [Indexed: 02/04/2023]
Abstract
UNLABELLED This study was carried out to determine the time and concentration profile required to achieve vancomycin-mediated eradication of Staphylococcus aureus biofilm. This information is critical for the identification of performance targets for local antibiotic delivery vehicles that target biofilm infections. S. aureus UAMS-1 biofilms were grown for 7 days on titanium-aluminium-niobium discs in Mueller Hinton broth. After 7 days, the discs were then incubated in Mueller Hinton broth containing vancomycin at concentrations of 100, 200, 500, 1,000, and 2,000 mg/L. Biofilm eradication was assessed under both static and shaking conditions. Samples were retrieved at regular intervals for up to 28 days for quantification of residual biofilm. One additional disc was processed per time point for scanning electron microscopy. Progressive and significant reduction of viable bacteria was observed over time at all concentrations compared to unexposed controls. After 28 days under static conditions, the S. aureus biofilm was completely eradicated at 200 mg/L vancomycin and higher concentrations, but not at 100 mg/L. In contrast, bacterial biofilm could not be eradicated under shaking conditions at any concentration. CLINICAL SIGNIFICANCE The present study shows that it is possible to eradicate mature S. aureus biofilm from metal implants by vancomycin alone although the time concentration profile required cannot be achieved by systemic administration or any of the local delivery vehicles currently available. Identifying targets for antibiotic delivery is the first step in developing fit for purpose local antibiotic delivery vehicles that will successfully and predictably treat established biofilm infection. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:381-388, 2017.
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Affiliation(s)
- Virginia Post
- AO Research Institute Davos, Clavadelerstrasse 8, Davos Platz, 7270, Switzerland
| | - Peter Wahl
- Division for Orthopaedic and Trauma Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - R Geoff Richards
- AO Research Institute Davos, Clavadelerstrasse 8, Davos Platz, 7270, Switzerland
| | - T Fintan Moriarty
- AO Research Institute Davos, Clavadelerstrasse 8, Davos Platz, 7270, Switzerland
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228
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Fang C, Wong TM, Lau TW, To KK, Wong SS, Leung F. Infection after fracture osteosynthesis - Part I. J Orthop Surg (Hong Kong) 2017; 25:2309499017692712. [PMID: 28215118 DOI: 10.1177/2309499017692712] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Bone and surgical site infections after osteosynthesis are notoriously difficult to manage and pose a tremendous burden in fracture management. In this article, we use the term osteosynthesis-associated infection (OAI) to refer to this clinical entity. While relatively few surgically treated fractures become infected, it is challenging to perform a rapid diagnosis. Optimal management strategies are complex and highly customized to each scenario and take into consideration the status of fracture union, the presence of hardware and the degree of mechanical stability. At present, a high level of relevant evidence is unavailable; most findings presented in the literature are based on laboratory work and non-randomized clinical studies. We present this overview of OAI in two parts: an examination of recent literature concerning OAI pathogenesis, diagnosis and classification and a review of treatment options.
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Affiliation(s)
- Christian Fang
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China
| | - Tak-Man Wong
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China.,3 Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Tak-Wing Lau
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China
| | - Kelvin Kw To
- 2 Department of Microbiology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China
| | - Samson Sy Wong
- 2 Department of Microbiology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China
| | - Frankie Leung
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China.,3 Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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Omar M, Klawonn F, Brand S, Stiesch M, Krettek C, Eberhard J. Transcriptome-Wide High-Density Microarray Analysis Reveals Differential Gene Transcription in Periprosthetic Tissue From Hips With Chronic Periprosthetic Joint Infection vs Aseptic Loosening. J Arthroplasty 2017; 32:234-240. [PMID: 27474510 DOI: 10.1016/j.arth.2016.06.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 06/16/2016] [Accepted: 06/20/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Differentiating between periprosthetic hip infection and aseptic hip prosthesis loosening can be challenging, especially in patients with chronic infections. This study used whole-genome microarray analysis to investigate the transcriptomes of periprosthetic hip tissues to identify genes that are differentially transcripted between chronic periprosthetic hip infection and aseptic hip prosthesis loosening. METHODS In this pilot study, a total of 24 patients with either chronic periprosthetic hip infection (n = 12) or aseptic hip prosthesis loosening (n = 12) were analyzed. Periprosthetic hip infection was diagnosed based on modified criteria of the Musculoskeletal Infection Society. To evaluate differences in gene transcription, whole-genome microarray analysis was performed on the mRNA of periprosthetic tissue. RESULTS Microarray analysis revealed differential gene transcription in periprosthetic hip tissue affected by chronic hip infection vs aseptic hip prosthesis loosening. A total of 39 genes had area under the curve values greater than 0.9 for diagnosing chronic periprosthetic hip infection; 5 genes had annotations relevant to infection and metabolism. The 39 genes also included 7 genes that were differentially transcribed but that have no apparent connection to immune response processes plus 27 genes with unknown function. CONCLUSION Differences in gene transcription profiles might represent novel diagnostic targets that can be used to differentiate between chronic periprosthetic hip infections and aseptic hip prosthesis loosening. Secondary metabolites of differentially transcripted genes might serve as easily accessible markers for detecting chronic periprosthetic joint infection in future.
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Affiliation(s)
- Mohamed Omar
- Trauma Department, Hannover Medical School, Hannover, Germany
| | - Frank Klawonn
- Department of Biostatistics, Helmholtz Centre for Infection Research, Braunschweig, Germany; Department of Computer Science, Ostfalia University of Applied Sciences, Wolfenbüttel, Germany
| | - Stephan Brand
- Trauma Department, Hannover Medical School, Hannover, Germany
| | - Meike Stiesch
- Department of Prosthetic Dentistry and Biomedical Materials Science, Hannover Medical School, Hannover, Germany
| | | | - Jörg Eberhard
- Department of Prosthetic Dentistry and Biomedical Materials Science, Hannover Medical School, Hannover, Germany
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230
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Mühlhofer HML, Kanz KG, Pohlig F, Lenze U, Lenze F, Toepfer A, von Eisenhart-Rothe R, Schauwecker J. Implementation of an Algorithm for Prosthetic Joint Infection: Deviations and Problems. Surg Infect (Larchmt) 2016; 18:164-169. [PMID: 27925502 DOI: 10.1089/sur.2015.208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The outcome of revision surgery in arthroplasty is based on a precise diagnosis. In addition, the treatment varies based on whether the prosthetic failure is caused by aseptic or septic loosening. Algorithms can help to identify periprosthetic joint infections (PJI) and standardize diagnostic steps, however, algorithms tend to oversimplify the treatment of complex cases. We conducted a process analysis during the implementation of a PJI algorithm to determine problems and deviations associated with the implementation of this algorithm. PATIENTS AND METHODS Fifty patients who were treated after implementing a standardized algorithm were monitored retrospectively. Their treatment plans and diagnostic cascades were analyzed for deviations from the implemented algorithm. Each diagnostic procedure was recorded, compared with the algorithm, and evaluated statistically. RESULTS We detected 52 deviations while treating 50 patients. In 25 cases, no discrepancy was observed. Synovial fluid aspiration was not performed in 31.8% of patients (95% confidence interval [CI], 18.1%-45.6%), while white blood cell counts (WBCs) and neutrophil differentiation were assessed in 54.5% of patients (95% CI, 39.8%-69.3%). We also observed that the prolonged incubation of cultures was not requested in 13.6% of patients (95% CI, 3.5%-23.8%). In seven of 13 cases (63.6%; 95% CI, 35.2%-92.1%), arthroscopic biopsy was performed; 6 arthroscopies were performed in discordance with the algorithm (12%; 95% CI, 3%-21%). CONCLUSION Self-critical analysis of diagnostic processes and monitoring of deviations using algorithms are important and could increase the quality of treatment by revealing recurring faults.
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Affiliation(s)
- Heinrich M L Mühlhofer
- 1 Department of Orthopedic Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Karl-Georg Kanz
- 2 Department of Trauma Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Florian Pohlig
- 1 Department of Orthopedic Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Ulrich Lenze
- 1 Department of Orthopedic Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Florian Lenze
- 1 Department of Orthopedic Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Andreas Toepfer
- 1 Department of Orthopedic Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | | | - Johannes Schauwecker
- 1 Department of Orthopedic Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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231
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Morgenstern M, Post V, Erichsen C, Hungerer S, Bühren V, Militz M, Richards RG, Moriarty TF. Biofilm formation increases treatment failure in Staphylococcus epidermidis device-related osteomyelitis of the lower extremity in human patients. J Orthop Res 2016; 34:1905-1913. [PMID: 26925869 DOI: 10.1002/jor.23218] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/23/2016] [Indexed: 02/04/2023]
Abstract
UNLABELLED The ability to form biofilm on the surface of implanted devices is often considered the most critical virulence factor possessed by Staphylococcus epidermidis in its role as an opportunistic pathogen in orthopaedic device-related infection (ODRI). Despite this recognition, there is a lack of clinical evidence linking outcome with biofilm forming ability for S. epidermidis ODRIs. We prospectively collected S. epidermidis isolates cultured from patients presenting with ODRI. Antibiotic resistance patterns and biofilm-forming ability was assessed. Patient information was collected and treatment outcome measures were determined after a mean follow-up period of 26 months. The primary outcome measure was cure at follow-up. Univariate logistic regression models were used to determine the influence of biofilm formation and antibiotic resistance on treatment outcome. A total of 124 patients were included in the study, a majority of whom (n = 90) involved infections of the lower extremity. A clear trend emerged in the lower extremity cohort whereby cure rates decreased as the biofilm-forming ability of the isolates increased (84% cure rate for infections caused by non-biofilm formers, 76% cure rate for weak biofilm-formers, and 60% cure rate for the most marked biofilm formers, p = 0.076). Antibiotic resistance did not influence treatment cure rate. Chronic immunosuppression was associated with a statistically significant decrease in cure rate (p = 0.044). CLINICAL SIGNIFICANCE The trend of increasing biofilm-forming ability resulting in lower cure rates for S. epidermidis ODRI indicates biofilm-forming ability of infecting pathogens does influence treatment outcome of infections of the lower extremity. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1905-1913, 2016.
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Affiliation(s)
- Mario Morgenstern
- Department of Trauma-Surgery, Trauma Centre Murnau, Prof. Kuentscher Strasse 8, 82418, Murnau, Germany.,AO Research Institute Davos, AO Foundation, Clavadelerstrasse 8, Davos Platz CH7270, Switzerland
| | - Virginia Post
- AO Research Institute Davos, AO Foundation, Clavadelerstrasse 8, Davos Platz CH7270, Switzerland
| | - Christoph Erichsen
- Department of Trauma-Surgery, Trauma Centre Murnau, Prof. Kuentscher Strasse 8, 82418, Murnau, Germany.,AO Research Institute Davos, AO Foundation, Clavadelerstrasse 8, Davos Platz CH7270, Switzerland
| | - Sven Hungerer
- Department of Trauma-Surgery, Trauma Centre Murnau, Prof. Kuentscher Strasse 8, 82418, Murnau, Germany
| | - Volker Bühren
- Department of Trauma-Surgery, Trauma Centre Murnau, Prof. Kuentscher Strasse 8, 82418, Murnau, Germany
| | - Matthias Militz
- Department of Trauma-Surgery, Trauma Centre Murnau, Prof. Kuentscher Strasse 8, 82418, Murnau, Germany
| | - R Geoff Richards
- AO Research Institute Davos, AO Foundation, Clavadelerstrasse 8, Davos Platz CH7270, Switzerland
| | - T Fintan Moriarty
- AO Research Institute Davos, AO Foundation, Clavadelerstrasse 8, Davos Platz CH7270, Switzerland
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232
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Ovaska MT, Nuutinen T, Madanat R, Mäkinen TJ, Söderlund T. The role of outpatient visit after operative treatment of ankle fractures. Injury 2016; 47:2575-2578. [PMID: 27622614 DOI: 10.1016/j.injury.2016.09.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 07/27/2016] [Accepted: 09/05/2016] [Indexed: 02/02/2023]
Abstract
It is a common practice that patients have a scheduled follow-up visit with radiographs following ankle fracture surgery. The aim of this study was to evaluate whether an early outpatient visit (<3 weeks) after ankle fracture surgery resulted in a change in patient management. For this study, 878 consecutive operatively treated ankle fracture patients with an early outpatient clinical-radiological visit were reviewed. The outcome measure was a change in treatment plan defined as any procedure, medication, or surgical intervention that is not typically implemented during the uncomplicated healing process of an acute fracture. A change in treatment plan was observed in 9.8% of operatively treated ankle fracture patients. The mean age of the patients was 48 years and the mean follow-up time was 64 months. Of the changes in treatment plan, 91% were exclusively due to clinical findings such as infection. Only three of 878 patients required a change in their treatment plan based merely on the findings of the radiographs taken at the outpatient visit. Only 37% of the patients requiring a change in their postoperative management had solicited an unanticipated visit before the scheduled outpatient visit due to clinical problems such as infection or a cast-related issue. Our study showed that every tenth operatively treated ankle fracture patient requires a change in their treatment plan due to a clinical problem such as infection or a cast-related issue. Although at hospital discharge all patients are provided with written instructions on where to contact if problems related to the operated ankle emerge, only one third of the patients are aware of the clinically alarming symptoms and seek care when problems present. Our findings do not support obtaining routine radiographs at the early outpatient visit in an ankle fracture patient without clinical signs of a complication.
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Affiliation(s)
- Mikko T Ovaska
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland.
| | - Timo Nuutinen
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Rami Madanat
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Tatu J Mäkinen
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Tim Söderlund
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
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233
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Bacterial Infection and Implant Loosening in Hip and Knee Arthroplasty: Evaluation of 209 Cases. MATERIALS 2016; 9:ma9110871. [PMID: 28773989 PMCID: PMC5457256 DOI: 10.3390/ma9110871] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 10/02/2016] [Accepted: 10/11/2016] [Indexed: 12/19/2022]
Abstract
The aim of this study was to evaluate bacteria species detected in a large number of patients treated for prosthetic joint infection of the hip and knee at a single specialized center. Furthermore, the rate of implant loosening was investigated in a time-dependent manner for the most frequently detected bacteria species. A retrospective analysis of patients (n = 209) treated for prosthetic joint infection of the hip and knee was performed. The following parameters were evaluated: C-Reactive Protein (CRP) concentration, microbiological evaluation of tissue samples, loosening of the implant, the time that had elapsed since the primary prosthetic joint replacement, and the duration since the last surgical intervention. Coagulase-negative Staphylococcus spp. were most frequently detected, followed by Staphylococcus aureus. Differences in CRP concentration were detected among various bacteria species. Osteolysis was not associated with one causative agent in particular. Patients who had undergone previous revision surgery had a higher probability of implant loosening. Coagulase-negative Staphylococcus spp. are the most common causative agents of prosthetic joint infection and show no significant differences with regard to implant loosening or the time-course when compared to S. aureus. Infections with Enterococcus spp. seem to develop faster than with other bacteria species. The risk of implant loosening increases with revision surgery, in particular in the hip joint.
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234
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ter Boo GJA, Richards RG, Moriarty TF, Grijpma DW, Eglin D. Hyaluronic acid derivatives and its polyelectrolyte complexes with gentamicin as a delivery system for antibiotics. POLYM ADVAN TECHNOL 2016. [DOI: 10.1002/pat.3915] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Gert-Jan A. ter Boo
- AO Research Institute Davos; AO Foundation; Clavadelerstrasse 8 CH7270 Davos Switzerland
- Department of Biomaterials Science and Technology; University of Twente; P.O. Box 217 7500 Enschede the Netherlands
| | - Robert G. Richards
- AO Research Institute Davos; AO Foundation; Clavadelerstrasse 8 CH7270 Davos Switzerland
| | - Thomas F. Moriarty
- AO Research Institute Davos; AO Foundation; Clavadelerstrasse 8 CH7270 Davos Switzerland
| | - Dirk W. Grijpma
- Department of Biomaterials Science and Technology; University of Twente; P.O. Box 217 7500 Enschede the Netherlands
- Department of Biomedical Engineering, W.J. Kolff Institute, UMC Groningen; University of Groningen; Hanzeplein 1 9713 GZ Groningen the Netherlands
| | - David Eglin
- AO Research Institute Davos; AO Foundation; Clavadelerstrasse 8 CH7270 Davos Switzerland
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235
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Sun Y, Liu Y, Zhu H. Advances in antibiotic therapy for infection after the surgical installation of implants to treat internal fractures. INFECTION INTERNATIONAL 2016. [DOI: 10.1515/ii-2017-0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AbstractTo summarize the advances in antibiotic therapy for infection after the surgical installation of implants to treat internal fractures. Recent studies on antibiotic therapy for infection after the surgical installation of implants to internal fractures were reviewed and analyzed. In general, systematic antibiotics are selected based on the results of bacterial culture. The duration of antibiotic treatment lasts for no more than 4 to 6 weeks. Orally administered and intravenously injected antibiotics have similar efficacies. Orally administered antibiotics exhibit a lower incidence of complications and are less costly than intravenously injected antibiotics. In addition, the efficacy of daptomycin in the treatment of bone infection is problematic. Rifampicin or fluoroquinolone antibiotics should be jointly administered when infection with bacterial biofilms is likely to occur. Calcium sulfate is a typical topically applied antibiotic delivery vehicle that can be completely degraded, with good biocompatibility, bone conduction, and drug release. The rational, systematic, and combined topical application of antibiotics can effectively decrease the recurrence rates of infection after the surgical installation of implants to treat internal fractures and can improve the quality of life of patients.
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236
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Association of vitamin D receptor gene TaqI, BsmI, FokI and ApaI polymorphisms and susceptibility to extremity chronic osteomyelitis in Chinese population. Injury 2016; 47:1655-60. [PMID: 27329975 DOI: 10.1016/j.injury.2016.06.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 05/31/2016] [Accepted: 06/02/2016] [Indexed: 02/02/2023]
Abstract
Previous studies have indicated that vitamin D receptor (VDR) TaqI, BsmI, FokI and ApaI gene polymorphisms are associated with the risk of several inflammatory diseases. However, potential association of the VDR gene polymorphisms with susceptibility to extremity chronic osteomyelitis remains unclear. The present study aimed to investigate link between VDR gene polymorphisms and the risk of extremity chronic osteomyelitis in Chinese population. A total of 233 patients with chronic osteomyelitis and 200 healthy controls were genotyped for the 4 single-nucleotide polymorphisms (SNPs) (TaqI, BsmI, FokI and ApaI) in VDR gene using the SNaPshot genotyping method. The frequencies of mutant allele C in rs731236 (P=0.044, OR=1.830, 95% CI 1.009 - 3.319) and rs2228570 (P=0.029, OR=1.347, 95% CI 1.031 - 1.761) were significantly higher in patients than those in healthy controls. In addition, outcomes of the logistic regression analysis adjusted by gender and age revealed that significant links were found between rs731236 (P=0.05, OR=1.887, 95% CI 1.001 - 3.558), rs2228570 (P=0.042, OR=1.594, 95% CI 1.016-2.500) and the risk of developing chronic osteomyelitis by dominant genetic model. In addition, significant association was also found between rs2228570 and the risk of developing the disease by homozygous model (P=0.034, OR=1.803, 95% CI 1.046 - 3.106). However, no significant correlations were found between BsmI (rs1544410) or ApaI (rs7975232) gene polymorphisms and the susceptibility to the disease. To our knowledge, we reported for the first time that VDR gene TaqI (rs731236) and FokI (rs2228570) polymorphisms may contribute to the increased risk of chronic osteomyelitis in Chinese population.
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237
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Predictors of Staphylococcus aureus Colonization and Results after Decolonization. Interdiscip Perspect Infect Dis 2016; 2016:4367156. [PMID: 27528869 PMCID: PMC4977396 DOI: 10.1155/2016/4367156] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 03/22/2016] [Indexed: 11/18/2022] Open
Abstract
Protocols for the screening and decolonization of Staphylococcus aureus prior to total joint arthroplasty (TJA) have become widely adopted. The goals of this study were to determine: (1) whether implementation of a screening protocol followed by decolonization with mupirocin/vancomycin and chlorhexidine reduces the risk of revision compared with no screening protocol (i.e., chlorhexidine alone) and (2) whether clinical criteria could reliably predict colonization with MSSA and/or MRSA. Electronic medical records of primary patients undergoing TJA that were screened (n = 3,927) and were not screened (n = 1,751) for Staphylococcus aureus at least 4 days prior to surgery, respectively, were retrospectively reviewed. All patients received chlorhexidine body wipes preoperatively. Patients carrying MSSA and MRSA were treated preoperatively with mupirocin and vancomycin, respectively, along with the standard preoperative antibiotics and chlorhexidine body wipes. Screened patients were 50% less likely to require revision due to prosthetic joint infection compared to those not screened (p = 0.04). Multivariate regression models were poorly accurate in predicting colonization with MSSA (AUC = 0.58) and MRSA (AUC = 0.62). These results support the routine screening and decolonization of S. aureus prior to TJA.
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238
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Hardware Removal in Craniomaxillofacial Trauma: A Systematic Review of the Literature and Management Algorithm. Ann Plast Surg 2016; 75:572-8. [PMID: 25393499 PMCID: PMC4888926 DOI: 10.1097/sap.0000000000000194] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Craniomaxillofacial (CMF) fractures are typically treated with open reduction and internal fixation. Open reduction and internal fixation can be complicated by hardware exposure or infection. The literature often does not differentiate between these 2 entities; so for this study, we have considered all hardware exposures as hardware infections. Approximately 5% of adults with CMF trauma are thought to develop hardware infections. Management consists of either removing the hardware versus leaving it in situ. The optimal approach has not been investigated. Thus, a systematic review of the literature was undertaken and a resultant evidence-based approach to the treatment and management of CMF hardware infections was devised. Materials and Methods A comprehensive search of journal articles was performed in parallel using MEDLINE, Web of Science, and ScienceDirect electronic databases. Keywords and phrases used were maxillofacial injuries; facial bones; wounds and injuries; fracture fixation, internal; wound infection; and infection. Our search yielded 529 articles. To focus on CMF fractures with hardware infections, the full text of English-language articles was reviewed to identify articles focusing on the evaluation and management of infected hardware in CMF trauma. Each article’s reference list was manually reviewed and citation analysis performed to identify articles missed by the search strategy. There were 259 articles that met the full inclusion criteria and form the basis of this systematic review. The articles were rated based on the level of evidence. There were 81 grade II articles included in the meta-analysis. Result Our meta-analysis revealed that 7503 patients were treated with hardware for CMF fractures in the 81 grade II articles. Hardware infection occurred in 510 (6.8%) of these patients. Of those infections, hardware removal occurred in 264 (51.8%) patients; hardware was left in place in 166 (32.6%) patients; and in 80 (15.6%) cases, there was no report as to hardware management. Finally, our review revealed that there were no reported differences in outcomes between groups. Conclusions Management of CMF hardware infections should be performed in a sequential and consistent manner to optimize outcome. An evidence-based algorithm for management of CMF hardware infections based on this critical review of the literature is presented and discussed.
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239
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Heuker M, Gomes A, van Dijl JM, van Dam GM, Friedrich AW, Sinha B, van Oosten M. Preclinical studies and prospective clinical applications for bacteria-targeted imaging: the future is bright. Clin Transl Imaging 2016; 4:253-264. [PMID: 27512688 PMCID: PMC4960279 DOI: 10.1007/s40336-016-0190-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 06/03/2016] [Indexed: 12/20/2022]
Abstract
Bacterial infections are a frequently occurring and major complication in human healthcare, in particular due to the rapid increase of antimicrobial resistance and the emergence of pan-drug-resistant microbes. Current anatomical and functional imaging modalities are insufficiently capable of distinguishing sites of bacterial infection from sterile inflammation. Therefore, definitive diagnosis of an infection can often only be obtained by tissue biopsy and subsequent culture and, occasionally, a definite diagnosis even appears to be impossible. To accurately diagnose bacterial infections early, novel imaging modalities are urgently needed. In this regard, bacteria-targeted imaging is an attractive option due to its specificity. Here, different bacteria-targeted imaging approaches are reviewed, and their promising future perspectives are discussed.
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Affiliation(s)
- Marjolein Heuker
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Anna Gomes
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Jan Maarten van Dijl
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Gooitzen M. van Dam
- Department of Surgery, Division of Surgical Oncology, Nuclear Medicine and Molecular Imaging, Intensive Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Alexander W. Friedrich
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Bhanu Sinha
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Marleen van Oosten
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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de Assis Gonzaga F, de Miranda TT, Magalhães LMD, Dutra WO, Gollob KJ, Souza PEA, Horta MCR. Effects of Bio-Oss ® and Cerasorb ® dental M on the expression of bone-remodeling mediators in human monocytes. J Biomed Mater Res B Appl Biomater 2016; 105:2066-2073. [PMID: 27401453 DOI: 10.1002/jbm.b.33747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/23/2016] [Accepted: 06/27/2016] [Indexed: 02/04/2023]
Abstract
In contribution to diverse techniques of bone reconstruction involving biomaterials in contemporary dentistry, this study aimed to evaluate the effect of the bone-grafting materials Bio-Oss® and Cerasorb® Dental M on the expression of cytokines associated with bone remodeling by human monocytes in vitro. Bio-Oss® and Cerasorb® Dental M were incubated in separate culture media, and their supernatants were added to mononuclear cells of human peripheral blood, some of which had been stimulated with Porphyromonas gingivalis. The frequency of total monocytes and CD14+ monocytes producing cytokines interleukin 6 (IL-6), IL-8, IL-10, IL-12, and tumor necrosis factor alpha (TNF-α) were determined by flow cytometry. One-way analysis of variance with repeated measures, followed by Tukey's post hoc test, revealed that stimulation with P. gingivalis increased the expression of IL-6 and IL-8 and reduced the expression of TNF-α compared to effects demonstrated in the control group (p < 0.05). Adding biomaterial supernatants did not significantly affect the expression of any cytokine evaluated, however, either in the absence or in the presence of bacterial stimulation. Our data suggest that Bio-Oss® and Cerasorb® Dental M neither stimulate cytokine production in human monocytes nor interfere with mechanisms of cell communication mediated by cytokines evaluated during stimulation with P. gingivalis. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 2066-2073, 2017.
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Affiliation(s)
- Filipe de Assis Gonzaga
- Graduate Program in Dentistry, Department of Dentistry, Pontifícia Universidade Católica de Minas Gerais, Belo Horizonte, Brazil
| | - Tatiana Teixeira de Miranda
- Graduate Program in Dentistry, Department of Dentistry, Pontifícia Universidade Católica de Minas Gerais, Belo Horizonte, Brazil
| | - Luisa Mourão Dias Magalhães
- Department of Morphology, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Walderez Ornelas Dutra
- Department of Morphology, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Instituto Nacional de Ciência e Tecnologia, Doenças Tropicais, Belo Horizonte, Minas Gerais, Brazil
| | - Kenneth John Gollob
- Instituto Nacional de Ciência e Tecnologia, Doenças Tropicais, Belo Horizonte, Minas Gerais, Brazil.,Núcleo de Ensino e Pesquisa do Instituto Mário Penna, Belo Horizonte, Minas Gerais, Brazil
| | - Paulo Eduardo Alencar Souza
- Graduate Program in Dentistry, Department of Dentistry, Pontifícia Universidade Católica de Minas Gerais, Belo Horizonte, Brazil
| | - Martinho Campolina Rebello Horta
- Graduate Program in Dentistry, Department of Dentistry, Pontifícia Universidade Católica de Minas Gerais, Belo Horizonte, Brazil
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Omar M, Suero EM, Liodakis E, Reichling M, Guenther D, Decker S, Stiesch M, Krettek C, Eberhard J. Diagnostic performance of swab PCR as an alternative to tissue culture methods for diagnosing infections associated with fracture fixation devices. Injury 2016; 47:1421-6. [PMID: 27181839 DOI: 10.1016/j.injury.2016.04.038] [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: 02/19/2016] [Revised: 04/21/2016] [Accepted: 04/25/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Molecular procedures could potentially improve diagnoses of orthopaedic implant-related infections, but are not yet clinically implemented. Analysis of sonication fluid shows the highest sensitivity for diagnosing implant infections in cases of revision surgery with implant removal. However, there remains controversy regarding the best method for obtaining specimens in cases of revision surgery with implant retention. Tissue culture is the most common diagnostic method for pathogen identification in such cases. Here we aimed to assess the diagnostic performance of swab PCR analysis compared to tissue culture from patients undergoing revision surgery of fracture fixation devices. METHODS We prospectively investigated 62 consecutive subjects who underwent revision surgery of fracture fixation devices during a two-year period. Tissue samples were collected for cultures, and swabs from the implant surface were obtained for 16S rRNA PCR analysis. Subjects were classified as having an implant-related infection if (1) they presented with a sinus tract or open wound in communication with the implant; or (2) purulence was encountered intraoperatively; or (3) two out of three tissue cultures tested positive for the presence of the same pathogen. Tissue culture and swab PCR results from the subjects were used to calculate the sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and area under the ROC curve (AUC) for identifying an orthopaedic implant-related infection. RESULTS Orthopaedic implant-related infections were detected in 51 subjects. Tissue culture identified infections in 47 cases, and swab PCR in 35 cases. Among the 11 aseptic cases, tissue culture was positive in 2 cases and swab PCR in 4 cases. Tissue culture showed a significantly higher area under the ROC curve for diagnosing infection (AUC=0.89; 95% CI, 0.67-0.96) compared to swab PCR (AUC=0.66; 95% CI, 0.46-0.80) (p=0.033). CONCLUSIONS Compared to swab PCR, tissue culture showed better performance for diagnosing orthopaedic implant-related infection. Although molecular methods are expected to yield higher diagnostic accuracy than cultures, it appears that the method of obtaining specimens plays an important role. Improved methods of specimen collection are required before swab PCR can become a reliable alternative to tissue-consumptive methods.
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Affiliation(s)
- Mohamed Omar
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany.
| | - Eduardo M Suero
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Emmanouil Liodakis
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Moritz Reichling
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Daniel Guenther
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Sebastian Decker
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Meike Stiesch
- Department of Prosthetic Dentistry and Biomedical Materials Science, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Christian Krettek
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Jörg Eberhard
- Department of Prosthetic Dentistry and Biomedical Materials Science, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
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242
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Morgenstern M, Erichsen C, von Rüden C, Metsemakers WJ, Kates SL, Moriarty TF, Hungerer S. Staphylococcal orthopaedic device-related infections in older patients. Injury 2016; 47:1427-34. [PMID: 27178769 DOI: 10.1016/j.injury.2016.04.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/17/2016] [Accepted: 04/19/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Staphylococci are the most common pathogens causing orthopaedic device-related infections (ODRI). The treatment of these infections often involves multiple surgical procedures combined with systemic antibiotic therapy to treat the infection and restore functionality. Older patients frequently present with a compromised health-status and/or low bone quality, and despite growing importance their outcomes are not well described to date. The primary aim of the current study is to describe outcomes in older patients with ODRIs and to determine if they demonstrate lower cure rates and greater risk for complications in contrast to younger patients. PATIENTS AND METHODS Patients treated with an ODRI of the lower extremity at our institution were included in this study. Demographic data, comorbidities and infecting organisms were recorded. Older adult patients were defined as those aged 60 and older. At two-year follow-up post-discharge, we recorded the clinical course, the Lower-Extremity-Functional-Score, the patient reported general health status (SF-12-questionnaire) and the status of infection. The antibiotic resistance pattern of the disease causing pathogens was analysed and compared between the two age groups. RESULTS In total, 163 patients (age: 19-94 years) with a staphylococcal ODRI were included. Sixty-four of these infections occurred in older patients, which showed a significantly higher mortality rate (9%). Within follow-up period recurrence of infection occurred significantly more frequently in younger patients (41%) than in older patients (17%). At two-years follow-up cure, which was defined as eradication of infection and terminated therapy, was achieved in 78% of younger and 75% of older patients. However, an ODRI resulted in older patients in a significantly worse functional outcome and impaired physical quality of live, as well as more frequently in an on-going infection, such as a persisting fistula (14% versus 3% in younger patients). Disease causing staphylococci, isolated from older patients showed more frequently a methicillin or multi-drug resistance than those associated with infections in younger patients. CONCLUSIONS ODRIs in older patients demonstrated higher morality rates rate, poor functional outcome and higher rates of persistent infections. A compromised health status and a poor bone quality may play a crucial role in this specific patient cohort.
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Affiliation(s)
- Mario Morgenstern
- Department of Trauma Surgery, Trauma Center Murnau, Germany; Department of Orthopaedic Surgery and Traumatology, University Hospital Basel, Switzerland; Institute of Biomechanics, Paracelsus Medical University Salzburg, Austria.
| | | | - Christian von Rüden
- Department of Trauma Surgery, Trauma Center Murnau, Germany; Institute of Biomechanics, Paracelsus Medical University Salzburg, Austria
| | | | - Stephen L Kates
- Department of Orthopaedic Surgery, School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | | | - Sven Hungerer
- Department of Trauma Surgery, Trauma Center Murnau, Germany; Institute of Biomechanics, Paracelsus Medical University Salzburg, Austria
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243
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ter Boo GA, Grijpma DW, Richards RG, Moriarty TF, Eglin D. Preparation of gentamicin dioctyl sulfosuccinate loaded poly(trimethylene carbonate) matrices intended for the treatment of orthopaedic infections. Clin Hemorheol Microcirc 2016; 60:89-98. [PMID: 25818154 DOI: 10.3233/ch-151935] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Infection is a common problem in trauma and orthopaedic surgery. Antibiotic-loaded biomaterials are used locally to clear infections as an adjunct to systemic antibiotics. Gentamicin-sulphate (GEN-SULPH) is commonly used in antibiotic-loaded biomaterials, although it displays high water solubility resulting in quick diffusion from the carrier. OBJECTIVE Preparation of a lipophilic derivative of gentamicin to reduce solubility and obtain a slower release. Subsequently, entrapment of this lipophilic gentamicin within poly(trimethylene carbonate) (PTMC) matrices. METHODS Hydrophobic ion-pairing was used to prepare lipophilic gentamicin (GEN-AOT). The susceptibility of Staphylococcus aureus NCTC 12973 and Staphylococcus epidermidis 103.1 for GEN-AOT was tested and the viability of fibroblasts upon exposure to GEN-AOT was assessed. GEN-AOT was then loaded into PTMC films. RESULTS GEN-AOT was successfully prepared as confirmed by FTIR-spectroscopy. GEN-AOT was bactericidal for S. epidermidis and S. aureus at 0.5 μM and 8.5 μM, respectively. At 1.1 μM GEN-AOT no reduction in fibroblast viability was observed. At 11 μM the reduction was ∼50% . PTMC discs loaded with GEN-AOT were prepared by compression molding. CONCLUSIONS Lipophilic GEN-AOT was at least as potent as GEN-SULPH. For S. epidermidis it was even more potent than GEN-SULPH. More than 50% fibroblast cell viability was maintained at bactericidal concentration for both bacterial strains.
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Affiliation(s)
- G A ter Boo
- AO Research Institute Davos, Davos-Platz, Switzerland.,Department of Biomaterials Science & Technology, University of Twente, Enschede, The Netherlands
| | - D W Grijpma
- Department of Biomaterials Science & Technology, University of Twente, Enschede, The Netherlands.,University of Groningen, University Medical Center Groningen, W.J. Kolff Institute, Department of Biomedical Engineering, Groningen, The Netherlands
| | - R G Richards
- AO Research Institute Davos, Davos-Platz, Switzerland
| | - T F Moriarty
- AO Research Institute Davos, Davos-Platz, Switzerland
| | - D Eglin
- AO Research Institute Davos, Davos-Platz, Switzerland
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244
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Physiological uptake values of 18F-FDG in long bones of the lower extremity on PET/CT imaging. Nucl Med Commun 2016; 37:589-92. [DOI: 10.1097/mnm.0000000000000483] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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245
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Dapunt U, Hänsch GM, Arciola CR. Innate Immune Response in Implant-Associated Infections: Neutrophils against Biofilms. MATERIALS 2016; 9:ma9050387. [PMID: 28773509 PMCID: PMC5503022 DOI: 10.3390/ma9050387] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 04/28/2016] [Accepted: 05/06/2016] [Indexed: 12/15/2022]
Abstract
Biofilm has been recognized as a well-protected form of living for bacteria, contributing to bacterial pathogenicity, particularly for opportunistic species. Biofilm-associated infections are marked by their persistence. Extensive research has been devoted to the formation and composition of biofilms. The immune response against biofilms remains rather unexplored, but there is the notion that bacteria within a biofilm are protected from host defences. Here we glance at the mechanisms by which neutrophils recognize and face biofilms in implant infections and discuss the implications of this interplay, as well as speculate on its significance.
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Affiliation(s)
- Ulrike Dapunt
- Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, Heidelberg 69118, Germany.
| | - Gertrud Maria Hänsch
- Institute for Immunology, Heidelberg University, Im Neuenheimer Feld 305, Heidelberg 69120, Germany.
| | - Carla Renata Arciola
- Research Unit on Implant Infections, Rizzoli Orthopaedic Institute, Bologna 40136, Italy.
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna 40126, Italy.
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246
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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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247
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Perez-Jorge C, Gomez-Barrena E, Horcajada JP, Puig-Verdie L, Esteban J. Drug treatments for prosthetic joint infections in the era of multidrug resistance. Expert Opin Pharmacother 2016; 17:1233-46. [PMID: 27054293 DOI: 10.1080/14656566.2016.1176142] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Despite many advances, the management of prosthetic joint infection is still a complex issue. Moreover, in recent years the problem of antimicrobial resistance has emerged as an important challenge. AREAS COVERED We analysed recent advances in different aspects of prosthetic joint infections. The importance of biofilms needs to be considered for antibiotic selection because, when embedded in these structures, bacteria acquire resistant behaviour. Moreover, the presence of resistance mechanisms in some species of organisms increases the difficulty of management. In this sense, the growing importance of methicillin-resistant staphylococci, multidrug-resistant Enterobacteriaceae or Pseudomonas aeruginosa is of increasing concern. Together with these organisms, others with constitutive resistance against most antibiotics (like Enterococcus sp., mycobacteria or fungi) represent a similar problem for selection of therapy. Research into new materials that can be used as drug carriers opens a new field for management of these infections and will likely come to the front line in the coming years. EXPERT OPINION Individualised therapies should carefully consider the aetiology, pathogenesis and antimicrobial susceptibility. Satisfactory clinical outcome could be further fostered by enhancing the multidisciplinary approach, with better collaboration in the antibiotic selection and the surgical management.
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Affiliation(s)
- Concepcion Perez-Jorge
- a Bone and Joint Infection Unit, Department of Clinical Microbiology , IIS-Fundacion Jimenez Diaz, UAM , Madrid , Spain
| | - Enrique Gomez-Barrena
- b Department of Orthopaedic Surgery , IdiPaz-Hospital La Paz Institute for Health Research, UAM , Madrid , Spain
| | - Juan-Pablo Horcajada
- c Service of Infectious Diseases, Hospital del Mar, CEXS Universitat Pompeu Fabra , Institut Hospital del Mar d'Investigacions Mèdiques , Barcelona , Spain
| | - Lluis Puig-Verdie
- d Department of Orthopaedic Surgery , Hospital del Mar, Institut Hospital del Mar d'Investigacions Mèdiques , Barcelona , Spain
| | - Jaime Esteban
- a Bone and Joint Infection Unit, Department of Clinical Microbiology , IIS-Fundacion Jimenez Diaz, UAM , Madrid , Spain
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248
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Moriarty TF, Kuehl R, Coenye T, Metsemakers WJ, Morgenstern M, Schwarz EM, Riool M, Zaat SA, Khana N, Kates SL, Richards RG. Orthopaedic device-related infection: current and future interventions for improved prevention and treatment. EFORT Open Rev 2016; 1:89-99. [PMID: 28461934 PMCID: PMC5367564 DOI: 10.1302/2058-5241.1.000037] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Orthopaedic and trauma device-related infection (ODRI) remains one of the major complications in modern trauma and orthopaedic surgery.Despite best practice in medical and surgical management, neither prophylaxis nor treatment of ODRI is effective in all cases, leading to infections that negatively impact clinical outcome and significantly increase healthcare expenditure.The following review summarises the microbiological profile of modern ODRI, the impact antibiotic resistance has on treatment outcomes, and some of the principles and weaknesses of the current systemic and local antibiotic delivery strategies.The emerging novel strategies aimed at preventing or treating ODRI will be reviewed. Particular attention will be paid to the potential for clinical impact in the coming decades, when such interventions are likely to be critically important.The review focuses on this problem from an interdisciplinary perspective, including basic science innovations and best practice in infectious disease. Cite this article: Moriarty TF, Kuehl R, Coenye T, et al. Orthopaedic device related infection: current and future interventions for improved prevention and treatment. EFORT Open Rev 2016;1:89-99. DOI: 10.1302/2058-5241.1.000037.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Nina Khana
- University Hospital of Basel, Switzerland
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249
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Gorzelanny C, Kmeth R, Obermeier A, Bauer AT, Halter N, Kümpel K, Schneider MF, Wixforth A, Gollwitzer H, Burgkart R, Stritzker B, Schneider SW. Silver nanoparticle-enriched diamond-like carbon implant modification as a mammalian cell compatible surface with antimicrobial properties. Sci Rep 2016; 6:22849. [PMID: 26955791 PMCID: PMC4783782 DOI: 10.1038/srep22849] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 02/23/2016] [Indexed: 02/06/2023] Open
Abstract
The implant-bone interface is the scene of competition between microorganisms and distinct types of tissue cells. In the past, various strategies have been followed to support bony integration and to prevent bacterial implant-associated infections. In the present study we investigated the biological properties of diamond-like carbon (DLC) surfaces containing silver nanoparticles. DLC is a promising material for the modification of medical implants providing high mechanical and chemical stability and a high degree of biocompatibility. DLC surface modifications with varying silver concentrations were generated on medical-grade titanium discs, using plasma immersion ion implantation-induced densification of silver nanoparticle-containing polyvinylpyrrolidone polymer solutions. Immersion of implants in aqueous liquids resulted in a rapid silver release reducing the growth of surface-bound and planktonic Staphylococcus aureus and Staphylococcus epidermidis. Due to the fast and transient release of silver ions from the modified implants, the surfaces became biocompatible, ensuring growth of mammalian cells. Human endothelial cells retained their cellular differentiation as indicated by the intracellular formation of Weibel-Palade bodies and a high responsiveness towards histamine. Our findings indicate that the integration of silver nanoparticles into DLC prevents bacterial colonization due to a fast initial release of silver ions, facilitating the growth of silver susceptible mammalian cells subsequently.
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Affiliation(s)
- Christian Gorzelanny
- Experimental Dermatology, Department of Dermatology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Ralf Kmeth
- Experimental Physics IV, Physics Institute, Augsburg University, Augsburg, Germany
| | - Andreas Obermeier
- Clinic of Orthopedics and Traumatology, Technical University Munich, 81675 Munich, Germany
| | - Alexander T Bauer
- Experimental Dermatology, Department of Dermatology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Natalia Halter
- Experimental Dermatology, Department of Dermatology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Katharina Kümpel
- Clinic of Orthopedics and Traumatology, Technical University Munich, 81675 Munich, Germany
| | | | - Achim Wixforth
- Experimental Physics I, Physics Institute, Augsburg University, Augsburg, Germany.,Augsburg Center for Innovative Technologies, Augsburg, Germany
| | - Hans Gollwitzer
- Clinic of Orthopedics and Traumatology, Technical University Munich, 81675 Munich, Germany
| | - Rainer Burgkart
- Clinic of Orthopedics and Traumatology, Technical University Munich, 81675 Munich, Germany
| | - Bernd Stritzker
- Experimental Physics IV, Physics Institute, Augsburg University, Augsburg, Germany
| | - Stefan W Schneider
- Experimental Dermatology, Department of Dermatology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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250
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Influence of implant properties and local delivery systems on the outcome in operative fracture care. Injury 2016; 47:595-604. [PMID: 26847958 DOI: 10.1016/j.injury.2016.01.019] [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: 07/30/2015] [Accepted: 01/15/2016] [Indexed: 02/02/2023]
Abstract
Fracture fixation devices are implanted into a growing number of patients each year. This may be attributed to an increase in the popularity of operative fracture care and the development of ever more sophisticated implants, which may be used in even the most difficult clinical cases. Furthermore, as the general population ages, fragility fractures become more frequent. With the increase in number of surgical interventions, the absolute number of complications of these surgical treatments will inevitably rise. Implant-related infection and compromised fracture healing remain the most challenging and prevalent complications in operative fracture care. Any strategy that can help to reduce these complications will not only lead to a faster and more complete resumption of activities, but will also help to reduce the socio-economic impact. In this review we describe the influence of implant design and material choice on complication rates in trauma patients. Furthermore, we discuss the importance of local delivery systems, such as implant coatings and bone cement, and how these systems may have an impact on the prevalence, prevention and treatment outcome of these complications.
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