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Suardi V, Baroni D, Shahein AHA, Morena V, Logoluso N, Mangiavini L, Pellegrini AV. Microbiology of Prosthetic Joint Infections: A Retrospective Study of an Italian Orthopaedic Hospital. Antibiotics (Basel) 2024; 13:399. [PMID: 38786128 PMCID: PMC11117340 DOI: 10.3390/antibiotics13050399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/22/2024] [Accepted: 04/25/2024] [Indexed: 05/25/2024] Open
Abstract
The most frequent cause of periprosthetic infections (PJIs) is intraoperative contamination; hence, antibiotic prophylaxis plays a crucial role in prevention. Modifications to standard prophylaxis can be considered if there is a high incidence of microorganisms resistant to current protocols. To date, very few studies regarding microbial etiology have been published in Italy. In this single-center, retrospective study conducted at IRCCS Ospedale Galeazzi-Sant'Ambrogio in Milan, we analyzed hip, knee, and shoulder PJIs in patients undergoing first implantation between 1 January 17 and 31 December 2021. The primary aim was to derive a local microbiological case history. The secondary aim was to evaluate the adequacy of preoperative antibiotic prophylaxis in relation to the identified bacteria. A total of 57 PJIs and 65 pathogens were identified: 16 S. aureus, 15 S. epidermidis, and 10 other coagulase-negative staphylococci (CoNS), which accounted for 63% of the isolations. A total of 86.7% of S. epidermidis were methicillin-resistant (MRSE). In line with other case reports, we found a predominance of staphylococcal infections, with a lower percentage of MRSA than the Italian average, while we found a high percentage of MRSE. We estimated that 44.6% of the bacteria isolated were resistant to cefazolin, our standard prophylaxis. These PJIs could be prevented by using glycopeptide alone or in combination with cefazolin, but the literature reports conflicting results regarding the adequacy of such prophylaxis. In conclusion, our study showed that in our local hospital, our standard antibiotic prophylaxis is ineffective for almost half of the cases, highlighting the importance of defining specific antibiotic guidelines based on the local bacterial prevalence of each institution.
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Affiliation(s)
- Virginia Suardi
- IRCCS Ospedale Galeazzi–Sant’Ambrogio, 20157 Milan, Italy; (V.S.); (N.L.); (A.V.P.)
| | - Daniele Baroni
- Department of Orthopedics and Traumatology, Alessandro Manzoni Hospital, 23900 Lecco, Italy;
| | | | - Valentina Morena
- Infectious Disease Unit, Alessandro Manzoni Hospital, 23900 Lecco, Italy;
| | - Nicola Logoluso
- IRCCS Ospedale Galeazzi–Sant’Ambrogio, 20157 Milan, Italy; (V.S.); (N.L.); (A.V.P.)
| | - Laura Mangiavini
- IRCCS Ospedale Galeazzi–Sant’Ambrogio, 20157 Milan, Italy; (V.S.); (N.L.); (A.V.P.)
- Department of Biomedical Sciences for Health, University of Milan, 20133 Milan, Italy
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MacConnell AE, Levack AE, Brown NM. Biofilm and How It Relates to Prosthetic Joint Infection. Orthop Clin North Am 2024; 55:161-169. [PMID: 38403363 DOI: 10.1016/j.ocl.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Prosthetic joint infection following total joint arthroplasty is a devastating complication, resulting in increased morbidity and mortality for the patient. The formation of a biofilm on implanted hardware contributes to the difficulty in successful identification and eradication of the infection. Antibiotic therapy and surgical intervention are necessary for addressing this condition; we present a discussion on different treatment options, including those that are not yet routinely utilized in the clinical setting or are under investigation, to highlight the present and future of PJI management.
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Affiliation(s)
- Ashley E MacConnell
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, 2160 South First Avenue, Suite 1700, Maywood, IL 60153, USA.
| | - Ashley E Levack
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, 2160 South First Avenue, Suite 1700, Maywood, IL 60153, USA
| | - Nicholas M Brown
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, 2160 South First Avenue, Suite 1700, Maywood, IL 60153, USA
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Drago L, Romanò D, Fidanza A, Giannetti A, Erasmo R, Mavrogenis AF, Romanò CL. Dithiotreitol pre-treatment of synovial fluid samples improves microbiological counts in peri-prosthetic joint infection. INTERNATIONAL ORTHOPAEDICS 2023; 47:1147-1152. [PMID: 36810966 PMCID: PMC10079734 DOI: 10.1007/s00264-023-05714-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/30/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE Synovial fluid cultures of periprosthetic joint infections (PJI) may be limited by bacteria living in the fluids as biofilm-aggregates. The antibiofilm pre-treatment of synovial fluids with dithiotreitol (DTT) could improve bacterial counts and microbiological early stage diagnosis in patients with suspected PJI. METHODS Synovial fluids collected from 57 subjects, affected by painful total hip or knee replacement, were divided into two aliquots, one pre-treated with DTT and one with normal saline. All samples were plated for microbial counts. Sensitivity of cultural examination and bacterial counts of pre-treated and control samples were then calculated and statistically compared. RESULTS Dithiothreitol pre-treatment led to a higher number of positive samples, compared to controls (27 vs 19), leading to a statistically significant increase in the sensitivity of the microbiological count examination from 54.3 to 77.1% and in colony-forming units count from 1884 ± 2.129 CFU/mL with saline pre-treatment to 20.442 ± 19.270 with DTT pre-treatment (P = 0.02). CONCLUSIONS To our knowledge, this is the first report showing the ability of a chemical antibiofilm pre-treatment to increase the sensitivity of microbiological examination in the synovial fluid of patients with peri-prosthetic joint infection. If confirmed by larger studies, this finding may have a significant impact on routine microbiological procedures applied to synovial fluids and brings further support to the key role of bacteria living in biofilm-formed aggregates in joint infections.
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Affiliation(s)
- Lorenzo Drago
- Clinical Microbiology, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Delia Romanò
- Operative Unit of Osteoarticular Infection and Reconstructive Surgery, IRCCS Galeazzi S Ambrogio, Milan, Italy
| | - Andrea Fidanza
- Department of Life, Health & Environmental Sciences-Mininvasive Orthopaedic Surgery, University of L’Aquila, L’Aquila, Italy
- Unit of Orthopaedics and Traumatology, Santo Spirito Hospital, Pescara, Italy
| | - Alessio Giannetti
- Department of Life, Health & Environmental Sciences-Mininvasive Orthopaedic Surgery, University of L’Aquila, L’Aquila, Italy
| | - Rocco Erasmo
- Unit of Orthopaedics and Traumatology, Santo Spirito Hospital, Pescara, Italy
| | - Andreas F. Mavrogenis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Carlo Luca Romanò
- Studio Medico Associato Cecca-Romanò, Corso Venezia 2, 20121 Milan, Italy
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Vrancianu CO, Serban B, Gheorghe-Barbu I, Czobor Barbu I, Cristian RE, Chifiriuc MC, Cirstoiu C. The Challenge of Periprosthetic Joint Infection Diagnosis: From Current Methods to Emerging Biomarkers. Int J Mol Sci 2023; 24:ijms24054320. [PMID: 36901750 PMCID: PMC10002145 DOI: 10.3390/ijms24054320] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/18/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023] Open
Abstract
Due to the increase in the life span and mobility at older ages, the number of implanted prosthetic joints is constantly increasing. However, the number of periprosthetic joint infections (PJIs), one of the most severe complications after total joint arthroplasty, also shows an increasing trend. PJI has an incidence of 1-2% in the case of primary arthroplasties and up to 4% in the case of revision operations. The development of efficient protocols for managing periprosthetic infections can lead to the establishment of preventive measures and effective diagnostic methods based on the results obtained after the laboratory tests. In this review, we will briefly present the current methods used in PJI diagnosis and the current and emerging synovial biomarkers used for the prognosis, prophylaxis, and early diagnosis of periprosthetic infections. We will discuss treatment failure that may result from patient factors, microbiological factors, or factors related to errors during diagnosis.
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Affiliation(s)
- Corneliu Ovidiu Vrancianu
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
| | - Bogdan Serban
- University Emergency Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Correspondence: (B.S.); (I.G.-B.)
| | - Irina Gheorghe-Barbu
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
- Correspondence: (B.S.); (I.G.-B.)
| | - Ilda Czobor Barbu
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
| | - Roxana Elena Cristian
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
- Department of Biochemistry and Molecular Biology, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania
| | - Mariana Carmen Chifiriuc
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
- Romanian Academy, 010071 Bucharest, Romania
| | - Catalin Cirstoiu
- University Emergency Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
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Reimplantation after Periprosthetic Joint Infection: The Role of Microbiology. Antibiotics (Basel) 2022; 11:antibiotics11101408. [PMID: 36290065 PMCID: PMC9598703 DOI: 10.3390/antibiotics11101408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/11/2022] [Accepted: 10/11/2022] [Indexed: 11/26/2022] Open
Abstract
Periprosthetic joint infection (PJI) is among the most feared orthopedic complications. Critical questions are whether the infection is completely resolved before reimplantation and what the clinical significance of positive culture is at reimplantation. The aim of this study was to determine whether a correlation exits between culture results at reimplantation after spacer insertion for hip and knee PJI and treatment failure rate. The data of 84 patients who underwent two-stage exchange arthroplasty for hip or knee PJI were reviewed and the results of intraoperative culture at reimplantation were analyzed quantitatively and qualitatively. Correlations were sought between these patterns and treatment outcome. Our data indicate no evidence for a correlation between positive culture at reimplantation and greater risk of treatment failure. Nonetheless, we noted a higher, albeit statistically not significant rate of treatment failure in patients with at least two samples testing positive. The role of microbiology at reimplantation remains unclear, but a positive culture might signal increased risk for subsequent implant failure. Further studies are needed to elucidate the implications of this finding.
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Goh GS, Parvizi J. Diagnosis and Treatment of Culture-Negative Periprosthetic Joint Infection. J Arthroplasty 2022; 37:1488-1493. [PMID: 35101593 DOI: 10.1016/j.arth.2022.01.061] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 01/18/2022] [Indexed: 02/02/2023] Open
Abstract
Identification of the causative organism(s) in periprosthetic joint infection (PJI) is a challenging task. The shortcomings of traditional cultures have been emphasized in recent literature, culminating in a clinical entity known as "culture-negative PJI." Amidst the growing burden of biofilm infections that are inherently difficult to culture, the field of clinical microbiology has seen a paradigm shift from culture-based to molecular-based methods. These novel techniques hold much promise in the demystification of culture-negative PJI and revolutionization of the microbiology laboratory. This article outlines the clinical implications of culture-negative PJI, common causes of this diagnostic conundrum, established strategies to improve culture yield, and newer molecular techniques to detect infectious organisms.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Balato M, Petrarca C, Arpaia P, Moccaldi N, Mancino F, Carleo G, Minucci S, Mariconda M, Balato G. Detecting and Monitoring Periprosthetic Joint Infection by Using Electrical Bioimpedance Spectroscopy: A Preliminary Case Study. Diagnostics (Basel) 2022; 12:diagnostics12071680. [PMID: 35885583 PMCID: PMC9323083 DOI: 10.3390/diagnostics12071680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/30/2022] [Accepted: 07/08/2022] [Indexed: 12/03/2022] Open
Abstract
A method to detect the presence of infection after Total Joint Arthroplasty is presented. The method is based on Electrical Bioimpedance Spectroscopy and guarantees low latency, non-invasiveness, and cheapness with respect to the state of art. Experimental measurements were carried out on a singular patient who had already undergone bilateral Total Knee Arthroplasty. He was affected by a hematogenous Periprosthetic Joint Infections on the left knee. The right knee was adopted as the reference. Measurements were acquired once before the surgical procedure (Diagnosis Phase) and twice in the postoperative phases (Monitoring Phase). The most relevant frequency range, for diagnosis and monitoring phases, was found to be between 10 kHz to 50 kHz. The healing trend predicted by the decrease of impedance magnitude spectrum was reflected in clinical and laboratory results. In addition, one month after the last acquisition (two months after the surgery), the patient fully recovered, confirming the prediction of the Electrical Bioimpedance Spectroscopy technique.
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Affiliation(s)
- Marco Balato
- Department of Electrical Engineering and Information Technologies (DIETI), University of Naples “Federico II”, 80125 Napoli, Italy; (C.P.); (P.A.); (N.M.); (F.M.)
- Correspondence:
| | - Carlo Petrarca
- Department of Electrical Engineering and Information Technologies (DIETI), University of Naples “Federico II”, 80125 Napoli, Italy; (C.P.); (P.A.); (N.M.); (F.M.)
| | - Pasquale Arpaia
- Department of Electrical Engineering and Information Technologies (DIETI), University of Naples “Federico II”, 80125 Napoli, Italy; (C.P.); (P.A.); (N.M.); (F.M.)
- Interdepartmental Research Center on Management and Innovation in Healthcare, (CIRMIS), University of Naples “Federico II”, 80131 Napoli, Italy;
| | - Nicola Moccaldi
- Department of Electrical Engineering and Information Technologies (DIETI), University of Naples “Federico II”, 80125 Napoli, Italy; (C.P.); (P.A.); (N.M.); (F.M.)
| | - Francesca Mancino
- Department of Electrical Engineering and Information Technologies (DIETI), University of Naples “Federico II”, 80125 Napoli, Italy; (C.P.); (P.A.); (N.M.); (F.M.)
| | - Giusy Carleo
- Department of Neuroscience and Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80131 Napoli, Italy;
| | - Simone Minucci
- Department of Economics, Engineering, Society and Business Organization (DEIM), University of Tuscia, 01100 Viterbo, Italy;
| | - Massimo Mariconda
- Interdepartmental Research Center on Management and Innovation in Healthcare, (CIRMIS), University of Naples “Federico II”, 80131 Napoli, Italy;
- Department of Public Health, University of Naples “Federico II”, 80131 Napoli, Italy;
| | - Giovanni Balato
- Department of Public Health, University of Naples “Federico II”, 80131 Napoli, Italy;
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Fritsche T, Schnetz M, Klug A, Fischer S, Ruckes C, Hunfeld KP, Hoffmann R, Gramlich Y. Tissue sampling is non-inferior in comparison to sonication in orthopedic revision surgery. Arch Orthop Trauma Surg 2022; 143:2901-2911. [PMID: 35612616 DOI: 10.1007/s00402-022-04469-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/24/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to assess the role of sonication fluid cultures in detecting musculoskeletal infections in orthopedic revision surgery in patients suspected of having peri-prosthetic joint infection (PJI), fracture-related infections (FRI), or postoperative spinal implant infections (PSII). METHODS Between 2016 and 2019, 149 cases with a data set including sonication fluid cultures and tissue specimen and histological analysis were included. Accuracy of each diagnostic tool as well as the influence of antibiotic therapy was analyzed. Pathogens identified in the sonication cultures and in the associated tissue samples were compared based on the matching of the antibiograms. Therapeutic benefits were then assessed. RESULTS Of 149 cases, 43.6% (n = 65) were identified as PJI, 2.7% (n = 4) as FRI, 12.8% (n = 19) as PSII, 6.7% (n = 10) as aseptic non-union, and 34.2% (n = 51) as aseptic implant loosening. The sensitivity and specificity of tissue and synovial specimens showed no significant difference with respect to sonication fluid cultures (sensitivity/specificity: tissue: 68.2%/96.7%; sonication fluid cultures: 60.2%/98.4%). The administration of antibiotics over 14 days prior to microbiological sampling (n = 40) resulted in a lower sensitivity of 42.9% each. Histological analysis showed a sensitivity 86.3% and specificity of 97.4%. In 83.9% (n = 125) of the cases, the results of sonication fluid cultures and tissue specimens were identical. Different microorganisms were found in only four cases. In 17 cases, tissue samples (n = 5) or sonication (n = 12) were false-negatives. CONCLUSION Sonication fluid culture showed no additional benefit compared to conventional microbiological diagnostics of tissue and synovial fluid cultures. Preoperative administration of antibiotics had a clearly negative effect on microbiologic test accuracy. In over 83.9% of the cases, sonication fluid and tissue cultures showed identical results. In the other cases, sonication fluid culture did not further contribute to the therapy decision, whereas other factors, such as fistulas, cell counts, or histological analysis, were decisive in determining therapy.
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Affiliation(s)
- Theresa Fritsche
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - Matthias Schnetz
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - Alexander Klug
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - Sebastian Fischer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - Christian Ruckes
- Interdisciplinary Center for Clinical Studies, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, Mainz, Germany
| | - K P Hunfeld
- Institute of Laboratory Medicine, Microbiology and Infection Control, Northwest Medical Center, Medical Faculty Goethe University Frankfurt, Steinbacher Hohl 2-26, 60488, Frankfurt am Main, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - Yves Gramlich
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany.
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Drago L, Romanò CL. Commentary: Dithiothreitol (DTT), When Used as Biofilm Detaching Method to Diagnose Implant-Associated Infections, Does Not Affect Microorganisms' Viability, According to the Current Literature. Front Microbiol 2022; 12:814945. [PMID: 35345543 PMCID: PMC8957080 DOI: 10.3389/fmicb.2021.814945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/27/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lorenzo Drago
- Clinical Microbiology Unit, Department of Biomedical Sciences for Health, Faculty of Medicine and Surgery, University of Milan, Milan, Italy
| | - Carlo Luca Romanò
- Orthopaedic Department, Monza Polyclinic-San Gaudenzio Hospital, Novara, Italy
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10
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Karbysheva S, Cabric S, Koliszak A, Bervar M, Kirschbaum S, Hardt S, Perka C, Trampuz A. Clinical evaluation of dithiothreitol in comparison with sonication for biofilm dislodgement in the microbiological diagnosis of periprosthetic joint infection. Diagn Microbiol Infect Dis 2022; 103:115679. [DOI: 10.1016/j.diagmicrobio.2022.115679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 02/26/2022] [Accepted: 03/04/2022] [Indexed: 11/03/2022]
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Logoluso N, Pedrini FA, Morelli I, De Vecchi E, Romanò CL, Pellegrini AV. Megaprostheses for the revision of infected hip arthroplasties with severe bone loss. BMC Surg 2022; 22:68. [PMID: 35216567 PMCID: PMC8876444 DOI: 10.1186/s12893-022-01517-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 02/14/2022] [Indexed: 01/14/2023] Open
Abstract
Background Periprosthetic hip infections with severe proximal femoral bone loss may require the use of limb salvage techniques, but no agreement exists in literature regarding the most effective treatment. Aim of this study is to analyze the infection eradication rate and implant survival at medium-term follow-up in patients treated with megaprostheses for periprosthetic hip infections with severe bone loss. Methods Twenty-one consecutive patients were retrospectively reviewed at a mean 64-month follow-up (24–120). Functional and pain scores, microbiological, radiological and intraoperative findings were registered. Kaplan Meier survival analysis and log rank test were used for infection free survival and implant survival analyses. Results The infection eradication rate was 90.5%, with an infection free survival of 95.2% at 2 years (95%CI 70.7–99.3) and 89.6%(95%CI 64.3–97.3) at 5 years. Only two patients required major implant revisions for aseptic implant loosening. The most frequent complication was dislocation (38.1%). The major revision-free survival of implants was 95.2% (95%CI 70.7–99.3) at 2 years and 89.6% (95%CI 64.3–97.3) at 5 years. The overall implant survival was 83.35% (CI95% 50.7–93.94) at 2 and 5 years. Subgroup analyses (cemented versus cementless MPs, coated versus uncoated MPs) revealed no significant differences at log rank test, but its reliability was limited by the small number of patients included. Conclusions Proximal femoral arthroplasty is useful to treat periprosthetic hip infections with severe bone loss, providing good functional results with high infection eradication rates and rare major revisions at medium-term follow-up. No conclusions can be drawn on the role of cement and coatings.
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Affiliation(s)
- Nicola Logoluso
- IRCCS Istituto Ortopedico Galeazzi, Centre for Reconstructive Surgery and Osteoarticular Infections (C.R.I.O. Unit), via Riccardo Galeazzi 4, 20161, Milan, Italy
| | - Francesca Alice Pedrini
- Residency Program in Orthopaedics and Traumatology, University of Milan, via Festa del Perdono 7, 20122, Milan, Italy
| | - Ilaria Morelli
- ASST Ovest Milanese, Ospedale di Legnano, UOC Ortopedia e Traumatologia, via Papa Giovanni Paolo II, 20025, Legnano, MI, Italy.
| | - Elena De Vecchi
- IRCCS Istituto Ortopedico Galeazzi, Laboratory of Clinical Chemistry and Microbiology, via Riccardo Galeazzi 4, 20161, Milan, Italy
| | | | - Antonio Virgilio Pellegrini
- IRCCS Istituto Ortopedico Galeazzi, Centre for Reconstructive Surgery and Osteoarticular Infections (C.R.I.O. Unit), via Riccardo Galeazzi 4, 20161, Milan, Italy
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12
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Is sonication superior to dithiothreitol in diagnosis of periprosthetic joint infections? A meta-analysis. INTERNATIONAL ORTHOPAEDICS 2022; 46:1215-1224. [PMID: 35199219 DOI: 10.1007/s00264-022-05350-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/13/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Even though effective techniques in diagnosis of periprosthetic joint infections (PJIs) have been developed, the optimal modality has yet to be determined. The present meta-analysis aimed to compare the diagnostic accuracy of dithiothreitol (DTT) and sonication against the Musculoskeletal Infection Society criteria in patients undergoing revision joint surgery. METHODS We searched the PubMed, Scopus, and Central Cochrane register of controlled trials as well as gray literature until the 9th of November, 2021. We included articles considering the comparative diagnostic accuracy of sonication and DTT in adult patients having revision hip and knee arthroplasty for septic or aseptic reasons. We calculated pooled sensitivity, specificity, and diagnostic accuracy of the above diagnostic techniques against the Musculoskeletal Infection Society (MSIS) criteria and created receiver operating characteristics (ROC) curves to enable comparisons between each other. The quality of included papers was evaluated utilizing QUADAS-2 and QUADAS-C tools. RESULTS Data from five comparative studies totaling 726 implants were pooled together. The diagnostic accuracy of DTT and sonication were 86.7% (95% CI 82.7 to 90.1) and 83.9% (95% CI 79.7 to 87.5), respectively. Pooled sensitivity and specificity showed no statistically significant differences between DTT and sonication (0.7 [95% CI 0.62 to 0.77] vs 0.72 [95% CI 0.65 to 0.78], p = 0.14; and 0.99 [95% CI 0.97 to 1] vs 0.97 [95% CI 0.93 to 0.99], p = 5.5, respectively). CONCLUSIONS This meta-analysis did not identify any clinically meaningful difference between the diagnostic potential of sonication and the chemical-based biofilm dislodgment methods. This finding remained robust after adjusting for the administration of antibiotics prophylaxis, implementation of the polymerase chain reaction of sonicated fluid, and study quality.
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13
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Oliva A, Miele MC, Al Ismail D, Di Timoteo F, De Angelis M, Rosa L, Cutone A, Venditti M, Mascellino MT, Valenti P, Mastroianni CM. Challenges in the Microbiological Diagnosis of Implant-Associated Infections: A Summary of the Current Knowledge. Front Microbiol 2021; 12:750460. [PMID: 34777301 PMCID: PMC8586543 DOI: 10.3389/fmicb.2021.750460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/04/2021] [Indexed: 12/14/2022] Open
Abstract
Implant-associated infections are characterized by microbial biofilm formation on implant surface, which renders the microbiological diagnosis challenging and requires, in the majority of cases, a complete device removal along with a prolonged antimicrobial therapy. Traditional cultures have shown unsatisfactory sensitivity and a significant advance in the field has been represented by both the application of the sonication technique for the detachment of live bacteria from biofilm and the implementation of metabolic and molecular assays. However, despite the recent progresses in the microbiological diagnosis have considerably reduced the rate of culture-negative infections, still their reported incidence is not negligible. Overall, several culture- and non-culture based methods have been developed for diagnosis optimization, which mostly relies on pre-operative and intra-operative (i.e., removed implants and surrounding tissues) samples. This review outlines the principal culture- and non-culture based methods for the diagnosis of the causative agents of implant-associated infections and gives an overview on their application in the clinical practice. Furthermore, advantages and disadvantages of each method are described.
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Affiliation(s)
- Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Maria Claudia Miele
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Dania Al Ismail
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Federica Di Timoteo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Massimiliano De Angelis
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Luigi Rosa
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Antimo Cutone
- Department of Biosciences and Territory, University of Molise, Pesche, Italy
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Maria Teresa Mascellino
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Piera Valenti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
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Sconfienza LM, Albano D, Messina C, D'Apolito R, De Vecchi E, Zagra L. Ultrasound-Guided Periprosthetic Biopsy in Failed Total Hip Arthroplasty: A Novel Approach to Test Infection in Patients With Dry Joints. J Arthroplasty 2021; 36:2962-2967. [PMID: 33814266 DOI: 10.1016/j.arth.2021.03.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 03/03/2021] [Accepted: 03/09/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND To diagnose periprosthetic joint infection (PJI) preoperatively, ultrasound-guided joint aspiration (US-JA) may not be performed when effusion is minimal or absent. We aimed to report and investigate the diagnostic performance of ultrasound-guided periprosthetic biopsy (US-PB) of synovial tissue to obtain joint samples in patients without fluid around the implants. METHODS One-hundred nine patients (55 men; mean age: 68 ± 13 years) with failed total hip arthroplasty (THA) who underwent revision surgery performed preoperative US-JA or US-PB to rule out PJI. RESULTS Sixty-nine of 109 patients had joint effusion and underwent US-JA, while the remaining 40 with dry joint required US-PB. Thirty-five of 109 patients (32.1%) had PJI, while 74/109 (67.9%) had aseptic THA failure. No immediate complications were observed in both groups. Technical success of US-PB was 100%, as the procedure was carried on as planned in all cases. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of US-JA were 52.2%, 97.8%, 92.3%, 80.3%, and 82.6%, while for US-PB, they were 41.7%, 100%, 100%, 80%, and 82.5%, respectively, with no significant difference (P = .779). Using the final diagnosis as reference standard, we observed a moderate agreement with both US-JA (k = 0.56) and US-PB (k = 0.50). CONCLUSION We present a novel US-guided technique to biopsy periprosthetic synovial tissue of failed THA to rule out PJI. We found similar diagnostic performance as compared with traditional US-JA. This supports future larger studies on this procedure that might be applied in patients without joint effusion.
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Affiliation(s)
- Luca M Sconfienza
- Unità Operativa di Radiologia Diagnostica ed Interventistica, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - Domenico Albano
- Unità Operativa di Radiologia Diagnostica ed Interventistica, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; Dipartimento di Biomedicina, Sezione di Scienze Radiologiche, Neuroscienze e Diagnostica Avanzata, Università degli Studi di Palermo, Palermo, Italy
| | - Carmelo Messina
- Unità Operativa di Radiologia Diagnostica ed Interventistica, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - Rocco D'Apolito
- Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Elena De Vecchi
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Luigi Zagra
- Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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Kolenda C, Josse J, Batailler C, Faure A, Monteix A, Lustig S, Ferry T, Laurent F, Dupieux C. Experience With the Use of the MicroDTTect Device for the Diagnosis of Low-Grade Chronic Prosthetic Joint Infections in a Routine Setting. Front Med (Lausanne) 2021; 8:565555. [PMID: 33796542 PMCID: PMC8007775 DOI: 10.3389/fmed.2021.565555] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 01/21/2021] [Indexed: 11/13/2022] Open
Abstract
Background: In prosthetic joint infections (PJIs), identification of the causative microorganisms is critical to successfully adapt and optimize treatment. However, microbiological diagnosis of PJIs remains a challenge notably because bacteria are embedded in biofilm adhered to the prosthetic material. Recently, dithiothreitol (DTT) treatment of prosthesis has been proposed as a new strategy to release bacteria from biofilm and to improve the yield of microbiological diagnosis. In this study, we evaluated the interest of a commercial device using DTT, the MicroDTTect system (Heraeus, Hanau, Germany), for the diagnosis of low-grade chronic PJIs, compared to the conventional culture of periprosthetic tissue (PPT) samples. Methods: Twenty patients undergoing a surgery procedure for removal of prosthetic material because of a suspicion of low-grade PJI without pre-operative microbiological documentation were included (NCT04371068). Bacteriological results using the fluid obtained after prosthesis treatment with the MicroDTTect system were compared to results obtained with conventional culture of PPT samples. Results: All the bacteria considered as responsible for PJIs recovered from culture of PPT samples were also detected using the MicroDTTect device. For one patient, an additional bacterial isolate (Staphylococcus haemolyticus) suspected to be involved in a polymicrobial PJI was identified using DTT treatment. Time to positivity of the cultures was also reduced using the MicroDTTect system, notably in case of Cutibacterium acnes infection. However, probable bacterial contaminants were found (MicroDTTect system, n = 5; PPT samples, n = 1). Conclusion: This study showed that DTT treatment of the prosthetic component using the MicroDTTect device could improve the microbiological diagnosis of low-grade PJIs.
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Affiliation(s)
- Camille Kolenda
- CIRI, Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, ENS de Lyon, Lyon, France.,Centre de Référence des Infections Ostéo-Articulaires Complexes de Lyon, Lyon, France.,Laboratoire de Bactériologie, Institut des Agents Infectieux, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Jérôme Josse
- CIRI, Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, ENS de Lyon, Lyon, France.,Centre de Référence des Infections Ostéo-Articulaires Complexes de Lyon, Lyon, France
| | - Cécile Batailler
- Centre de Référence des Infections Ostéo-Articulaires Complexes de Lyon, Lyon, France.,Service de Chirurgie Orthopédique, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Allison Faure
- CIRI, Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, ENS de Lyon, Lyon, France
| | - Alice Monteix
- Laboratoire de Bactériologie, Institut des Agents Infectieux, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Sébastien Lustig
- Centre de Référence des Infections Ostéo-Articulaires Complexes de Lyon, Lyon, France.,Service de Chirurgie Orthopédique, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Tristan Ferry
- CIRI, Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, ENS de Lyon, Lyon, France.,Centre de Référence des Infections Ostéo-Articulaires Complexes de Lyon, Lyon, France.,Service de Maladies Infectieuses et Tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Frédéric Laurent
- CIRI, Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, ENS de Lyon, Lyon, France.,Centre de Référence des Infections Ostéo-Articulaires Complexes de Lyon, Lyon, France.,Laboratoire de Bactériologie, Institut des Agents Infectieux, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Céline Dupieux
- CIRI, Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, ENS de Lyon, Lyon, France.,Centre de Référence des Infections Ostéo-Articulaires Complexes de Lyon, Lyon, France.,Laboratoire de Bactériologie, Institut des Agents Infectieux, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
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16
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Microbial yield from infectious tissues pretreated by various methods: an invitro study. BMC Musculoskelet Disord 2021; 22:209. [PMID: 33612121 PMCID: PMC7898421 DOI: 10.1186/s12891-021-04071-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 02/10/2021] [Indexed: 12/02/2022] Open
Abstract
Background This study aimed to evaluate the effects of different pretreatment methods on the microbial yield from infectious tissues. Methods Strains of Staphylococcus aureus (SA), Escherichia coli (EC) and Candida albicans (CA) were used to construct single-surface, full-surface, and internal infection models in sterile pork tissue. Manual milling (MM), mechanical homogenization (MH), sonificated (SF), dithiothreitol (DTT), and direct culture (DC) were used to pretreat these tissues, the microbial yield from different pretreatment methods were recorded and compared. Moreover, periprosthetic tissues collected intraoperatively from periprosthetic joint infection (PJI) patients were used as a verification. Results The study showed that the microbial yield from MH pretreatment was significantly higher than that of MM (P < 0.01) and SF pretreatment method (P < 0.01). Furthermore, in the internal infection model, the microbial yield from MH group was also significantly higher than that of SF (P < 0.01), DTT (P < 0.01), and DC group (P < 0.01). Moreover, the number of bacterial colonies obtained from periprosthetic tissues pretreated by MH was significantly higher than pretreated by other pretreatment methods (P = 0.004). Conclusions The effects of MH and DTT in microbial yield were significantly higher than that of DC, SF and MM, and these methods can be used to process multiple tissue samples at the same time, which might further improve the diagnostic sensitivity of infectious disease. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04071-5.
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17
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Fang X, Zhang L, Cai Y, Huang Z, Li W, Zhang C, Yang B, Lin J, Wahl P, Zhang W. Effects of different tissue specimen pretreatment methods on microbial culture results in the diagnosis of periprosthetic joint infection. Bone Joint Res 2021; 10:96-104. [PMID: 33517765 PMCID: PMC7937541 DOI: 10.1302/2046-3758.102.bjr-2020-0104.r3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Aims Microbiological culture is a key element in the diagnosis of periprosthetic joint infection (PJI). However, cultures of periprosthetic tissue do not have optimal sensitivity. One of the main reasons for this is that microorganisms are not released from the tissues, either due to biofilm formation or intracellular persistence. This study aimed to optimize tissue pretreatment methods in order to improve detection of microorganisms. Methods From December 2017 to September 2019, patients undergoing revision arthroplasty in a single centre due to PJI and aseptic failure (AF) were included, with demographic data and laboratory test results recorded prospectively. Periprosthetic tissue samples were collected intraoperatively and assigned to tissue-mechanical homogenization (T-MH), tissue-manual milling (T-MM), tissue-dithiothreitol (T-DTT) treatment, tissue-sonication (T-S), and tissue-direct culture (T-D). The yield of the microbial cultures was then analyzed. Results A total of 46 patients were enrolled, including 28 patients in the PJI group and 18 patients in the AF group. In the PJI group, 23 cases had positive culture results via T-MH, 22 cases via T-DTT, 20 cases via T-S, 15 cases via T-MM, and 13 cases via T-D. Three cases under ongoing antibiotic treatment remained culture-negative. Five tissue samples provided the optimal yield. Any ongoing antibiotic treatment had a relevant influence on culture sensitivity, except for T-DTT. Conclusion T-MH had the highest sensitivity. Combining T-MH with T-DTT, which requires no special equipment, may effectively improve bacterial detection in PJI. A total of five periprosthetic tissue biopsies should be sampled in revision arthroplasty for optimal detection of PJI. Cite this article: Bone Joint Res 2021;10(2):96–104.
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Affiliation(s)
- Xinyu Fang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Lvheng Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yuanqing Cai
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zida Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Wenbo Li
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Chaofan Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Bin Yang
- Department of Laboratory Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jianhua Lin
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Peter Wahl
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Wenming Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
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18
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The utility of dithiothreitol treatment of periprosthetic tissues and explanted implants in the diagnosis of prosthetic joint infection. Indian J Med Microbiol 2020; 39:179-183. [PMID: 33966858 DOI: 10.1016/j.ijmmb.2020.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/16/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE The methods used for the processing of periprosthetic tissues and explanted implants to improve culture outcome especially in biofilm mediated prosthetic joint infections (PJIs) are still debated upon. Studies have reported that Dithiothreitol (DTT) pretreatment of infected devices gives similar results as sonication. However, none of them evaluated the DTT treatment of periprosthetic tissues and explanted implants in the same cohort. We evaluated the diagnostic utility of DTT treatment of periprosthetic tissue and explanted implants, as compared to the normal saline treatment of periprosthetic tissues and sonication of explanted implants for the diagnosis of PJI. METHODS Seventy-three revision arthroplasty cases were prospectively included in this study. Three to five tissue specimens and the explanted implants were collected from each patient. Periprosthetic tissue samples were processed by both normal saline and DTT treatments. Explanted implants were subjected to both DTT treatment and sonication. Musculoskeletal Infection Society (MSIS) PJI criteria was used as the reference standard for the diagnosis of PJI. RESULTS Of the 73 cases enrolled, 34 had PJI and 39 were aseptic failures. The sensitivity of DTT treated periprosthetic tissue culture (PTC) and saline treated PTC was similar (66.6% vs 58.8%, P = 0.25). The specificity of both was 100%. Sonication and DTT treatment of explanted implants showed comparable sensitivity (85.3% vs 82.4%) and specificity (100% vs 97.4%), P > 0.99. Compared to DTT treated PTC, culture of DTT treated explanted implants significantly improved the diagnosis of PJI (P = 0.03). CONCLUSIONS We could verify that DTT can be used to improve culture outcome in laboratories where biofilm detaching sonication techniques are not available for infected implants. In addition, we showed that it is possible to use DTT for treating tissue biopsies, but larger studies are required to confirm our findings.
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19
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Albano D, Messina C, Zagra L, Andreata M, De Vecchi E, Gitto S, Sconfienza LM. Failed Total Hip Arthroplasty: Diagnostic Performance of Conventional
MRI
Features and Locoregional Lymphadenopathy to Identify Infected Implants. J Magn Reson Imaging 2020; 53:201-210. [DOI: 10.1002/jmri.27314] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 02/06/2023] Open
Affiliation(s)
- Domenico Albano
- IRCCS Istituto Ortopedico Galeazzi, Unità Operativa di Radiologia Diagnostica ed Interventistica Milan Italy
- Sezione di Scienze Radiologiche, Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata Università degli Studi di Palermo Palermo Italy
| | - Carmelo Messina
- IRCCS Istituto Ortopedico Galeazzi, Unità Operativa di Radiologia Diagnostica ed Interventistica Milan Italy
- Dipartimento di Scienze Biomediche per la Salute Università degli Studi di Milano Milan Italy
| | - Luigi Zagra
- IRCCS Istituto Ortopedico Galeazzi, Hip Department Milan Italy
| | - Mauro Andreata
- IRCCS Istituto Ortopedico Galeazzi, Hip Department Milan Italy
| | - Elena De Vecchi
- IRCCS Istituto Ortopedico Galeazzi Laboratory of Clinical Chemistry and Microbiology Milan Italy
| | - Salvatore Gitto
- Dipartimento di Scienze Biomediche per la Salute Università degli Studi di Milano Milan Italy
| | - Luca M. Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, Unità Operativa di Radiologia Diagnostica ed Interventistica Milan Italy
- Dipartimento di Scienze Biomediche per la Salute Università degli Studi di Milano Milan Italy
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20
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Kalbian I, Park JW, Goswami K, Lee YK, Parvizi J, Koo KH. Culture-negative periprosthetic joint infection: prevalence, aetiology, evaluation, recommendations, and treatment. INTERNATIONAL ORTHOPAEDICS 2020; 44:1255-1261. [DOI: 10.1007/s00264-020-04627-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 05/12/2020] [Indexed: 02/08/2023]
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21
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Hoekstra M, Veltman ES, Nurmohamed RF, van Dijk B, Rentenaar RJ, Vogely HC, van der Wal BC. Sonication Leads to Clinically Relevant Changes in Treatment of Periprosthetic Hip or Knee Joint Infection. J Bone Jt Infect 2020; 5:128-132. [PMID: 32566451 PMCID: PMC7295643 DOI: 10.7150/jbji.45006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/25/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Diagnosis of periprosthetic joint infection (PJI) can be troublesome. Sonication can be a helpful tool in culturing bacteria that are difficult to detect with standard tissue cultures. Aim of this study is to evaluate the clinical importance of our standardized sonication protocol in detecting periprosthetic joint infection. Materials and methods: All patients with revision surgery of a hip or knee prosthesis between 2011 and 2016 were retrospectively reviewed and divided in two groups: clinically suspected of infection or not suspected of infection. For both tissue culture and implant sonication, calculations of sensitivity and specificity were performed. Clinical relevance of sonication was evaluated by calculating in which percentage of patients' sonication influenced clinical treatment. Results: 226 patients with revision of a total hip prosthesis (122 patients) or a total knee prosthesis (104 patients) were included. Sensitivity of perioperatively taken tissue cultures was 94.3% and specificity was 99.3%. For sonication sensitivity was 80.5% and specificity was 97.8%. In the infection group eight patients (9%) with only one positive tissue culture and a positive sonication fluid culture with the same pathogen were found. Interpretation: Although sensitivity and specificity of sonication was lower compared to tissue cultures, periprosthetic joint infection could only be established in 8 patients (9%) suspected of infection because of a positive result of the sonication fluid culture. Sonication leads to clinically relevant changes in treatment and seems therefore to be a helpful diagnostic tool in clinical practice.
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Affiliation(s)
- Marrit Hoekstra
- Department of Orthopaedic Surgery, University Medical Centre Utrecht, the Netherlands
| | - Ewout S. Veltman
- Department of Orthopaedic Surgery, University Medical Centre Utrecht, the Netherlands
| | | | - Bruce van Dijk
- Department of Orthopaedic Surgery, University Medical Centre Utrecht, the Netherlands
| | - Rob J. Rentenaar
- Department of Clinical Microbiology, University Medical Centre Utrecht, the Netherlands
| | - H. Charles Vogely
- Department of Orthopaedic Surgery, University Medical Centre Utrecht, the Netherlands
| | - Bart C.H. van der Wal
- Department of Orthopaedic Surgery, University Medical Centre Utrecht, the Netherlands
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Abstract
Culture-negative periprosthetic joint infections (CN-PJI) pose a significant challenge in terms of diagnosis and management. The reported incidence of CN-PJI is reported to be between 7% and 15%. Fungi and mycobacterium are thought to be responsible for over 85% of such cases with more fastidious bacteria accounting for the rest. With the advent of polymerase chain reaction, mass spectrometry and next generation sequencing, identifying the causative organism(s) may become easier but such techniques are not readily available and are very costly. There are a number of more straightforward and relatively low-cost methods to help surgeons maximize the chances of diagnosing a PJI and identify the organisms responsible. This review article summarizes the main diagnostic tests currently available as well as providing a simple diagnostic clinical algorithm for CN-PJI.
Cite this article: EFORT Open Rev 2019;4:585-594. DOI: 10.1302/2058-5241.4.180067
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Affiliation(s)
- Jeya Palan
- Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
| | - Ciaran Nolan
- Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
| | - Kostas Sarantos
- Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
| | - Richard Westerman
- Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
| | - Richard King
- Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
| | - Pedro Foguet
- Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
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Drago L, Clerici P, Morelli I, Ashok J, Benzakour T, Bozhkova S, Alizadeh C, Del Sel H, Sharma HK, Peel T, Mattina R, Romanò CL. The World Association against Infection in Orthopaedics and Trauma (WAIOT) procedures for Microbiological Sampling and Processing for Periprosthetic Joint Infections (PJIs) and other Implant-Related Infections. J Clin Med 2019; 8:jcm8070933. [PMID: 31261744 PMCID: PMC6678965 DOI: 10.3390/jcm8070933] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 06/18/2019] [Accepted: 06/26/2019] [Indexed: 12/12/2022] Open
Abstract
While implant-related infections continue to play a relevant role in failure of implantable biomaterials in orthopaedic and trauma there is a lack of standardised microbiological procedures to identify the pathogen(s). The microbiological diagnosis of implant-related infections is challenging due to the following factors: the presence of bacterial biofilm(s), often associated with slow-growing microorganisms, low bacterial loads, previous antibiotic treatments and, possible intra-operative contamination. Therefore, diagnosis requires a specific set of procedures. Based on the Guidelines of the Italian Association of the Clinical Microbiologists (AMCLI), the World Association against Infection in Orthopaedics and Trauma has drafted the present document. This document includes guidance on the basic principles for sampling and processing for implant-related infections based on the most relevant literature. These procedures outline the main microbiological approaches, including sampling and processing methodologies for diagnostic assessment and confirmation of implant-related infections. Biofilm dislodgement techniques, incubation time and the role of molecular approaches are addressed in specific sections. The aim of this paper is to ensure a standardised approach to the main microbiological methods for implant-related infections, as well as to promote multidisciplinary collaboration between clinicians and microbiologists.
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Affiliation(s)
- Lorenzo Drago
- Clinical Microbiology, Department of Biomedical Sciences for Health, University of Milan, 20100 Milano, Italy.
| | - Pierangelo Clerici
- Laboratory of Clinical Microbiology, AO Legnano Hospital, AMCLI, 20025 Milano, Italy.
| | - Ilaria Morelli
- Residency Program in Orthopaedics and Traumatology, University of Milan, 20100 Milano, Italy.
| | - Johari Ashok
- Department of Paediatric Orthopaedics and Spine Surgery, Children's Orthopedic Centre, Mumbai 230532, India.
| | | | - Svetlana Bozhkova
- Department of Prevention and Treatment of Wound Infection, R.R. Vreden Russian Research Institute of Traumatology and Orthopaedics, 33701 S. Petersburg, Russia.
| | - Chingiz Alizadeh
- Traumatology & Orthopedics Department, Baku Health Clinic, 1005 Baku, Azerbaijian.
| | - Hernán Del Sel
- Department of Orthopaedics, British Hospital Buenos Aires, Buenos Aires B1675, Argentina.
| | - Hemant K Sharma
- Hull University Teaching Hospitals, Anlaby Road, Hull HU3 2JZ, UK.
| | - Trisha Peel
- Department of Infectious Diseases, Monash University, Melbourne, VIC 3004, Australia.
| | - Roberto Mattina
- Department of Odontoiatric and Surgical Sciences, University of Milan, 20100 Milano, Italy.
| | - Carlo Luca Romanò
- Studio Medico Cecca-Romanò, corso Venezia, 2, 20121 Milano, Italy.
- Romano Institute, Rruga Ibrahim Rugova, 1001 Tirane, Albania.
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Li C, Ojeda-Thies C, Trampuz A. Culture of periprosthetic tissue in blood culture bottles for diagnosing periprosthetic joint infection. BMC Musculoskelet Disord 2019; 20:299. [PMID: 31228938 PMCID: PMC6589180 DOI: 10.1186/s12891-019-2683-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/14/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The purpose of this meta-analysis was to evaluate the diagnostic accuracy of periprosthetic tissue culture in blood culture bottles (BCB) for periprosthetic joint infection (PJI). METHODS PubMed, Web of Science, and Embase were systematically searched for eligible studies evaluating the diagnostic performance of periprosthetic tissue culture in BCB for the diagnosis of PJI. The pooled data were analysed by Meta-Disc software. RESULTS Four studies with a total of 1071 patients were included in this meta-analysis. The summarized estimates showed that periprosthetic tissue culture in BCB may be of great value in PJI diagnosis with a pooled sensitivity of 0.70 (95% confidence interval [CI]; 0.66-0.75), specificity of 0.97 (95% CI: 0.95-0.98); positive likelihood ratio (PLR) of 20.98 (95% CI: 11.52-38.2); negative likelihood ratio (NLR) of 0.28 (95% CI: 0.20-0.40); and diagnostic odds ratio (DOR) of 92.26 (95% CI: 43.93-193.78). CONCLUSIONS The present meta-analysis showed that periprosthetic tissue in BCB improves the results of microorganism cultures, with a sensitivity of 70% and a specificity of 97%. However, more large-scale, well-performed studies are needed to verify our findings.
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Affiliation(s)
- Cheng Li
- Charité - Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | | | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
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Zagra L, Villa F, Cappelletti L, Gallazzi E, Materazzi G, De Vecchi E. Can leucocyte esterase replace frozen sections in the intraoperative diagnosis of prosthetic hip infection? Bone Joint J 2019; 101-B:372-377. [PMID: 30929495 DOI: 10.1302/0301-620x.101b4.bjj-2018-0752.r1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Leucocyte esterase (LE) has been shown to be an accurate marker of prosthetic joint infection (PJI), and has been proposed as an alternative to frozen section (FS) histology for intraoperative diagnosis. In this study, the intraoperative assessment of LE was compared with FS histology for the diagnosis of prosthetic hip infection. PATIENTS AND METHODS A total of 119 patients undergoing revision total hip arthroplasty (THA) between June 2015 and December 2017 were included in the study. There were 56 men and 63 women with a mean age of 66.2 years (27 to 88). Synovial fluid was collected before arthrotomy for the assessment of LE using enzymatic colourimetric strips. Between five and six samples were stained with haematoxylin and eosin for FS histology, and considered suggestive of infection when at least five polymorphonuclear leucocytes were found in five high-power fields. RESULTS The sensitivity and specificity of the LE assay were 100% and 93.8%, respectively; the positive (PPV) and the negative (NPV) predictive values were 79.3% and 100%, respectively. The mean time between the collection of the sample and the result being known was 20.1 minutes (sd 4.4). The sensitivity and specificity of FS histology were 78.3% and 96.9%, respectively; the PPV and the NPV were 85.7% and 94.9%, respectively. The mean time between the collection of the sample and the result being known was 27.2 minutes (sd 6.9). CONCLUSION The sensitivity of LE assay was higher, with similar specificity and diagnostic accuracy, compared with FS histology. The faster turnaround time, its ease of use, and low costs make LE assay a valuable alternative to FS histology. We now use it routinely for the intraoperative diagnosis of PJI. Cite this article: Bone Joint J 2019;101-B:372-377.
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Affiliation(s)
- L Zagra
- Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - F Villa
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - L Cappelletti
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - E Gallazzi
- Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - G Materazzi
- Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - E De Vecchi
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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Abdel MP, Akgün D, Akin G, Akinola B, Alencar P, Amanatullah DF, Babazadeh S, Borens O, Vicente Cabral RM, Cichos KH, Deirmengian C, de Steiger R, Ghanem E, Radtke Gonçalves JR, Goodman S, Hamlin B, Hwang K, Klatt BA, Lee GC, Manrique J, Moon AS, Ogedegbe F, Salib CG, Tian S, Winkler T. Hip and Knee Section, Diagnosis, Pathogen Isolation, Culture: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S361-S367. [PMID: 30343972 DOI: 10.1016/j.arth.2018.09.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Askar M, Ashraf W, Scammell B, Bayston R. Comparison of different human tissue processing methods for maximization of bacterial recovery. Eur J Clin Microbiol Infect Dis 2018; 38:149-155. [PMID: 30357554 PMCID: PMC6314997 DOI: 10.1007/s10096-018-3406-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 10/01/2018] [Indexed: 11/28/2022]
Abstract
Tissues are valuable microbiological samples that have proved superiority over swabs. Culture of tissue samples is used in the diagnosis of a variety of infections. However, as well as factors such as the site of obtaining the sample, the number of samples, and previous antibiotic use, the method of tissue processing may have an important effect on sensitivity. Data from the literature comparing different tissue processing methods is very limited. This study aimed to compare different mechanical and chemical methods of tissue processing in terms of efficacy and retaining the viability of the bacteria in the tissues. Standard suspensions of Staphylococcus aureus and Escherichia coli were prepared and treated differently to test the effect of that treatment on bacterial viability. Artificially inoculated pork tissue and known infected human tissue samples were then processed by different methods prior to culture, and results were compared. Percentages of reduction in the number of viable bacteria compared to the control by homogenization was similar to 5-min dithiothreitol treatment but significantly lower than bead beating. Bacterial recovery from homogenized human tissues was significantly higher than from any other method of treatment. Although bead beating could be the most efficient method in obtaining a homogeneous tissue product, it significantly reduces the number of viable bacteria within tissues. Homogenization offers the most effective easily controllable retrieval of bacteria from tissue and retains their viability. Guidelines for diagnosing infections using tissue samples should include a standardized processing method.
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Affiliation(s)
- Mohamed Askar
- Department of Academic Orthopaedics, Queen's Medical Centre, University of Nottingham, C Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
| | - Waheed Ashraf
- Department of Academic Orthopaedics, Queen's Medical Centre, University of Nottingham, C Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
| | - Brigitte Scammell
- Department of Academic Orthopaedics, Queen's Medical Centre, University of Nottingham, C Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
| | - Roger Bayston
- Department of Academic Orthopaedics, Queen's Medical Centre, University of Nottingham, C Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK.
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Banche G, Bistolfi A, Allizond V, Galletta C, Iannantuoni MR, Marra ES, Merlino C, Massè A, Cuffini AM. Unexpected Listeria monocytogenes detection with a dithiothreitol-based device during an aseptic hip revision. Future Microbiol 2018; 13:1295-1299. [PMID: 29909646 DOI: 10.2217/fmb-2018-0135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Prosthetic joint infection diagnosis is often difficult since biofilm-embedded microorganisms attach well to the prosthetic surfaces and resist their detection by conventional methods. DL-dithiothreitol has been described as a valid method for biofilm detachment on orthopedic devices. We report the case of an occasional detection of Listeria monocytogenes in a non immuno-compromised patient with a preoperative diagnosis of aseptic loosening. The infection diagnosis due to such rare bacteria was made postoperatively, thanks to a DL-dithiothreitol-based device. This may be considered a feasible approach for the microbiological analysis of prosthetic joint infection, considering that a prompt diagnosis of such biofilm-associated infections could bring some advantages, such as an early and appropriate antibiotic therapy administration and a reduction of undiagnosed infections.
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Affiliation(s)
- Giuliana Banche
- Department of Public Health & Pediatrics, University of Torino, via Santena 9, Turin 10126, Italy
| | - Alessandro Bistolfi
- Department of Orthopedics & Traumatology, AOU Città della Scienza e della Salute, CTO Hospital, via Zuretti 29, Turin 10126, Italy
| | - Valeria Allizond
- Department of Public Health & Pediatrics, University of Torino, via Santena 9, Turin 10126, Italy
| | - Claudia Galletta
- Department of Orthopedics & Traumatology, AOU Città della Scienza e della Salute, CTO Hospital, via Zuretti 29, Turin 10126, Italy
| | - Maria Rita Iannantuoni
- Department of Public Health & Pediatrics, University of Torino, via Santena 9, Turin 10126, Italy
| | - Elisa Simona Marra
- Department of Public Health & Pediatrics, University of Torino, via Santena 9, Turin 10126, Italy
| | - Chiara Merlino
- Department of Public Health & Pediatrics, University of Torino, via Santena 9, Turin 10126, Italy
| | - Alessandro Massè
- Department of Orthopedics & Traumatology, AOU Città della Scienza e della Salute, CTO Hospital, via Zuretti 29, Turin 10126, Italy
| | - Anna Maria Cuffini
- Department of Public Health & Pediatrics, University of Torino, via Santena 9, Turin 10126, Italy
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Suren C, Harrasser N, Pohlig F, Banke IJ, Lenze U, Lenze F, Knebel C, VON Eisenhart-Rothe R, Schauwecker J, Mühlhofer HML. Prospective Analysis of a Sterile, Semi-automated Tissue Biopsy Homogenization Method in the Diagnosis of Prosthetic Joint Infections. ACTA ACUST UNITED AC 2018; 31:937-942. [PMID: 28882962 DOI: 10.21873/invivo.11150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 06/09/2017] [Accepted: 06/12/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Prosthetic joint infection (PJI) remains a serious complication of total joint arthroplasty. To effectively treat PJI, it is essential to identify the microorganism causing it and be able to combine correct surgical and anti-infective treatments. This cannot always be achieved with the currently employed diagnostic methods. The aim of this study was to evaluate a semi-automated tissue biopsy bead milling method (Ultra-TurrAX, Axonlab AG; Reichenbach, Germany) based on the hypothesis that the results are more sensitive for microbe detection and less prone to contamination. MATERIALS AND METHODS We included 35 consecutive patients undergoing 38 hip or knee arthroplasty revisions in this study. In addition to manually processed biopsies, we processed tissue specimens harvested intraoperatively using a semi-automated method. The sensitivity and specificity of both methods were calculated using MSIS criteria and sonication results as gold standards. RESULTS For total hip arthroplasty samples were evaluated separately based on MSIS criteria as the reference standard, Ultra-TurrAX processing yielded 81% (62-100%) sensitivity and 100% specificity. Using sonication as the gold standard, a sensitivity of 80% (60-100%) and specificity of 80% (45-100%) were calculated. In total knee arthroplasty, Ultra-TurrAX processing yielded 27% (1-54%) sensitivity and 57% (20-94%) specificity when using MSIS criteria as the gold standard. Using sonication as the gold standard, a sensitivity of 60% (17-100%) and specificity of 77% (54-100%) were calculated. CONCLUSION This is the first study to analyze bead mill processing in total hip and knee arthroplasty revisions in a consecutive patient series. The method's sensitivity was comparable to and its specificity superior to regular sample processing results reported in the literature with respect to hip arthroplasties and to both hip and knee arthroplasties collectively. With respect to total knee arthroplasties, the method fared worse in our collective, most likely due to the small number of patients in the sample. Integrating the method into the clinical workflow allowed for speedier and more efficient sample handling and processing. The theoretical advantage of a lower risk of contamination because of fewer manual processing steps is, in our opinion, valid.
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Affiliation(s)
- Christian Suren
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Norbert Harrasser
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Florian Pohlig
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Ingo J Banke
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Ulrich Lenze
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Florian Lenze
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Carolin Knebel
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | | | - Johannes Schauwecker
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Heinrich M L Mühlhofer
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
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De Vecchi E, George DA, Romanò CL, Pregliasco FE, Mattina R, Drago L. Antibiotic sensitivities of coagulase-negative staphylococci and Staphylococcus aureus in hip and knee periprosthetic joint infections: does this differ if patients meet the International Consensus Meeting Criteria? Infect Drug Resist 2018; 11:539-546. [PMID: 29695923 PMCID: PMC5905490 DOI: 10.2147/idr.s151271] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Introduction Coagulase-negative staphylococci (CoNS) are the main pathogens responsible for prosthetic joint infections (PJIs). As normal inhabitants of human skin, it is often difficult to define if they are contaminants, or if they have an active role in initiating infection. This study aims to evaluate differences in CoNS organisms (Staphylococcus hominis, Staphylococcus capitis, Staphylococcus haemolyticus, Staphylococcus warneri) and Staphylococcus aureus in terms of isolation rate and antimicrobial susceptibility from patients who met the International Consensus Meeting (ICM) criteria for PJIs and those who did not. Methods Staphylococci isolates from January 2014 to December 2015 retrieved from patients undergoing revision joint arthroplasty were classified in accordance with criteria established by the ICM of Philadelphia. Results As per the consensus classification, 50 CoNS and 39 S. aureus infections were recognized as pathogens, while 16 CoNS and four S. aureus were considered as contaminants. Frequency of isolation of S. aureus was significantly higher in infected patients than in those without infection, while no significant differences were observed among CoNS. Resistance to levofloxacin, erythromycin, gentamicin trimethoprim/sulfamethoxazole, and rifampicin was significantly more frequent in S. haemolyticus than in the other species, as well as resistance to erythromycin and gentamicin in S. hominis. In comparison to S. aureus, CoNS were significantly more resistant to daptomycin and gentamicin and more susceptible to rifampicin. Conclusion CoNS, other than Staphylococcus epidermidis, are frequently isolated from PJIs, and their infective role and antimicrobial susceptibility need to be assessed on an individual patient basis. S. haemolyticus seems to emerge as responsible for PJI in a large volume of patients, and its role needs to be further investigated, also considering its pattern of resistance.
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Affiliation(s)
- Elena De Vecchi
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | - David A George
- Department of Trauma and Orthopaedics, University College London Hospitals, London, UK
| | - Carlo L Romanò
- Centre for Reconstructive Surgery and Osteoarticular Infections, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | - Fabrizio E Pregliasco
- Department of Biochemical Sciences for Health, University of Milan, Milan, Italy.,Health Management Unit, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | - Roberto Mattina
- Department of Biomedical, Surgical and Dental Science, University of Milan, Milan, Italy
| | - Lorenzo Drago
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy.,Department of Biochemical Sciences for Health, University of Milan, Milan, Italy
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Romanò CL, Trentinaglia MT, De Vecchi E, Logoluso N, George DA, Morelli I, Drago L. Cost-benefit analysis of antibiofilm microbiological techniques for peri-prosthetic joint infection diagnosis. BMC Infect Dis 2018; 18:154. [PMID: 29609540 PMCID: PMC5879767 DOI: 10.1186/s12879-018-3050-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 03/20/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Implant-related infections, including those of peri-prosthetic joint (PJIs), osteosynthesis and other biomaterials, are biofilm-related. Pathogen identification is considered the diagnostic benchmark; however, the presence of bacterial biofilms makes pathogen detection with traditional microbiological techniques only partially effective. To improve microbiological diagnostic accuracy, some biofilm debonding techniques have been recently proposed. Aim of this health economics assessment study was to evaluate their economic impact on hospital costs. METHODS Direct and indirect hospital costs connected with the routine introduction of sonication and dithiothreitol treatment applied to hip and knee PJIs and of tissue cultures were examined. In particular the consequences of diagnostic inaccuracy, the opportunities, costs, and risks of each technique were calculated. RESULTS Considering an average of five samples per patient, processed separately with traditional tissue culture with or without sonication of prosthetic components, or pooled together using the MicroDTTect device (a close system for sample collection, transport and treatment with Dithiothreitol for microbial release from biofilm), the overall mean direct cost per patient was € 397 and € 393 for sonication or MicroDTTect, respectively, compared to € 308 for traditional tissue cultures. In terms of opportunity costs, MicroDTTect was the most effective technique, allowing for a 35% or 55% reduction in time required for sample treatment, compared to tissue cultures combined or not with sonication, respectively. Pooling together direct and indirect costs associated with false positive and negative results of the different diagnostic techniques, unnecessary medical treatments and possible medical claims, MicroDTTect or sonication become increasingly cost-effective when the extra-costs, generated by diagnostic inaccuracy of traditional tissue culture, took place, respectively, in 2% or 20% or more of the patients. CONCLUSIONS This is the first study specifically focused on the economic impact of the routine clinical use of microbiological antibiofilm sampling and processing techniques in orthopaedics. Although our results may suffer from a potential country and hospital bias, as the data collection process for direct and indirect costs is specific to each institution and country, this analysis highlights the potential economic advantage to hospitals associated with the routine introduction of antibiofilm techniques for microbiological diagnosis of PJI.
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Affiliation(s)
- Carlo L Romanò
- Centre for Reconstructive Surgery and Osteoarticular Infections, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy.
| | | | - Elena De Vecchi
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | - Nicola Logoluso
- Centre for Reconstructive Surgery and Osteoarticular Infections, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | - David A George
- Department of Trauma and Orthopaedics, University College London Hospitals, London, UK
| | - Ilaria Morelli
- Department of Reconstructive Surgery of Osteo-Articular infections C.R.I.O. Unit, IRCCS Galeazzi Institute, University of Milan, Milan, Italy
| | - Lorenzo Drago
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Galeazzi Orthopaedic Institute and Laboratory of Clinical Microbiology, Department of Biochemical Sciences for Health, University of Milan, Milan, Italy
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Drago L. CORR Insights®: Is Treatment With Dithiothreitol More Effective Than Sonication for the Diagnosis of Prosthetic Joint Infection? Clin Orthop Relat Res 2018; 476:439-440. [PMID: 29389799 PMCID: PMC6259690 DOI: 10.1007/s11999.0000000000000135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Epidemiology and Antibiotic Resistance of Late Prosthetic Knee and Hip Infections. J Arthroplasty 2017; 32:2496-2500. [PMID: 28390886 DOI: 10.1016/j.arth.2017.03.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/21/2017] [Accepted: 03/06/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Prosthetic joint infections (PJI) are still a major complication of hip and knee arthroplasties. Identification of the causative pathogens and knowledge of their antibiotic susceptibilities are essential for the management of these infections. The main purpose of the study was to identify and compare the causative bacteria of prosthetic knee and hip joint infections in a reference Italian orthopedic center and to characterize antibiotic resistance profiles of bacteria involved. METHODS Data from 429 patients with diagnosis of PJI were collected from January 2013 to June 2015: 229 presented a hip and 200 a knee prosthesis infection. Prostheses and periprosthetic tissues were treated with dithiothreitol before plating onto different media and broths. Identification and antimicrobial susceptibility testing were carried out by VITEK2 Compact (bioMerieux). RESULTS There was not a substantial difference in the etiology of hip and knee PJI: staphylococci were the most frequently isolated bacteria in both groups, followed by Enterobacteriaceae and Propionibacterium acnes. Staphylococci showed a high rate of methicillin resistance (144 of 341) and a worrying frequency of isolates were resistant to teicoplanin (9%). Only 8.3% of Enterobacteriaceae produced extended-spectrum beta-lactamases, whereas the rate of carbapenemase-producing bacteria was not significant. CONCLUSION We observed similar etiology of hip and knee PJIs. Nevertheless, bacteria isolated from knee showed higher resistance rates to glycopeptides and fluoroquinolones when compared with those isolated from the hip. The reason for this difference remains to be elucidated in future studies.
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Superiority of the sonication method against conventional periprosthetic tissue cultures for diagnosis of prosthetic joint infections. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 28:51-57. [PMID: 28714050 DOI: 10.1007/s00590-017-2012-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 07/02/2017] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Diagnosis of periprosthetic infections is challenging. The aim of this study was to compare the diagnostic accuracy of conventional periprosthetic tissue culture and culture of sonication fluid of the explanted prostheses. METHODS We prospectively enrolled 114 patients undergoing revision hip or knee arthroplasty because of loosening of the prostheses, at our institution, between July 2012 and July 2016. Patients' medical history and demographic characteristics were recorded. The explanted hardware was separated in sterile containers and sonicated under sterile conditions. At least five samples of periprosthetic tissue were sent for culture and histological examination. We compared the culture of samples obtained by sonication of explanted hip and knee prostheses with conventional culture of periprosthetic tissue for the microbiological diagnosis of prosthetic joint infection. RESULTS Infectious Diseases Society of America guidelines were used for the definition of prosthetic joint infection. Sixty-one patients had periprosthetic infection and 53 aseptic loosening (73 hip prostheses and 41 knee prostheses). The sensitivity of sonication fluid culture was 77.04%, and the sensitivity of conventional tissue cultures was 55.73% (p value = 0.012). The specificities of the two methods were 98.11 and 94.34%, respectively. The sensitivity of the histopathological examination of the periprosthetic tissue was 72.10%. There were 17 patients with PJI where the isolated pathogen was detected in SFC but not in PTC, while in five cases the pathogen was detected only in PTC. There were nine patients where no bacteria were detected by any microbiological method and the diagnosis was based on clinical and histological findings, according to the guidelines. CONCLUSIONS The sonication method represents a reliable test for the diagnosis of prosthetic joint infections with a greater sensitivity and specificity than the conventional periprosthetic tissue cultures.
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Drago L, Toscano M, Tacchini L, Banfi G. α-Defensin point-of-care test for diagnosis of prosthetic joint infections: neglected role of laboratory and clinical pathologists. ACTA ACUST UNITED AC 2017; 56:19-24. [DOI: 10.1515/cclm-2017-0041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 05/03/2017] [Indexed: 01/28/2023]
Abstract
Abstract
Periprosthetic joint infection (PJI) is a serious complication that may occur after native joint replacement leading to a severe health and economic burden. Currently, due to several confounding factors, PJI is difficult to diagnose. Today, a multidisciplinary approach is indispensable to correctly define a periprosthetic joint infection; indeed, tissue histology, microbiology cultures and clinical findings are used together to achieve this goal. Analysis of α-defensin is commonly used for PJI diagnosis, as it allows the rapid detection of α-defensin present in the synovial fluid following a microbial infection. Currently, a point-of-care testing (POCT) assay able to detect the presence of human α-defensins 1–3 in synovial fluid of patients is aimed directly at orthopedic surgeons. However, many orthopedic surgeons lack experience and training in quality laboratory practices, often failing to appreciate the significance of quality control and proper documentation when using POCT assays. To guarantee the highest quality diagnostic services, the α-defensin test should be used together with other biochemical and microbiological criteria commonly used for PJI diagnosis. Additionally, the close cooperation and communication between laboratory, pathologists and physicians is of fundamental importance in the correct diagnosis of PJI.
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Affiliation(s)
- Lorenzo Drago
- Department of Biomedical Sciences for Health , University of Milan , Milan , Italy
- Laboratory of Clinical-Chemistry and Microbiology , IRCCS Galeazzi Institute, University of Milan , Milan , Italy , Phone: +390266214839, Fax: +3902662144774
| | - Marco Toscano
- Laboratory of Clinical Microbiology , Department of Biomedical Sciences for Health , University of Milan , Milan , Italy
| | - Lorenza Tacchini
- Board Member of the Italian Commission for Biomedical Lab Technician , Department of Biomedical Sciences for Health , University of Milan , Milan , Italy
| | - Giuseppe Banfi
- Scientific Direction, IRCCS Galeazzi Institute , University of Milan, and Vita e Salute San Raffaele University , Milan , Italy
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Diagnosis of periprosthetic joint infection using alpha-defensin test or multiplex-PCR: ideal diagnostic test still not found. INTERNATIONAL ORTHOPAEDICS 2017; 41:1307-1313. [PMID: 28160020 DOI: 10.1007/s00264-017-3412-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 01/20/2017] [Indexed: 12/28/2022]
Abstract
PURPOSE Diagnosing periprosthetic infection remains a challenge. Multiplex-PCR and biomarkers such as alpha-defensin are potentially useful and fast methods for detecting periprosthetic infection. This study compared these new methods with clinical assessment, conventional microbiological methods and histo-pathological examination. METHODS Twenty-eight consecutive patients with 30 joints and a mean age of 67.7 years (range 39 to 88) with removal of total hip arthroplasty (THA) or total knee replacement (TKR) were included in this study. Patients were classified according to the modified Musculoskeletal Infection Society score (MSIS) for infected joints. Punction fluid and tissue specimens were taken for conventional microbiological examination, alphadefensin test was performed, a synovial membrane specimen was used for multiplex-PCR and histopathological examination was carried out. RESULTS The alpha-defensin test and multiplex-PCR showed a sensitivity of 76.9 vs. 30.8% and a specificity of 82.4 vs. 100%, respectively. We found a significant difference between the positive and negative results (p = 0.0023). The conventional microbiological methods were not significantly different from the alpha-defensin test (p = 0.244) with a sensitivity of 84.6% and a specificity of 100% but did differ significantly from the multiplex PCR (p = 0.0030). There was a significant difference between modified MSIS classification and multiplex PCR (p = 0.0007). CONCLUSIONS Neither alpha-defensin test nor multiplex-PCR could detect periprosthetic infection immediately and reliably. Multiplex-PCR was suitable for detecting the non-infected but not the truly infected. Alpha-defensin test was helpful but showed no satisfactory results. Conventional microbiological methods remain the most reliable for periprosthetic infection diagnosis.
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Saeed K, Dryden M, Bassetti M, Bonnet E, Bouza E, Chan M, Cortes N, Davis JS, Esposito S, Giordano G, Gould I, Hartwright D, Lye D, Marin M, Morgan-Jones R, Lajara-Marco F, Righi E, Romano CL, Segreti J, Unal S, Williams RL, Yalcin AN. Prosthetic joints: shining lights on challenging blind spots. Int J Antimicrob Agents 2017; 49:153-161. [DOI: 10.1016/j.ijantimicag.2016.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/23/2016] [Accepted: 10/01/2016] [Indexed: 12/12/2022]
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Microbiological Diagnosis of Implant-Related Infections: Scientific Evidence and Cost/Benefit Analysis of Routine Antibiofilm Processing. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 971:51-67. [PMID: 27815925 DOI: 10.1007/5584_2016_154] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Prosthetic joint infection is one of the most severe complication following joint arthroplasty, producing a significant worsening of patient's quality of life. Management of PJIs requires extended courses of antimicrobial therapy, multiple surgical interventions and prolonged hospital stay, with a consequent economic burden, which is thought to markedly increase in the next years due to the expected burden in total joint arthroplasties. The present review summarizes the present knowledge on microbiological diagnosis of prosthetic joint infections, focusing on aethiological agents and discussing pros and cons of the available strategies for their diagnosis.Intra-operative clinical diagnosis and pathogen identification is considered the diagnostic benchmark, however the presence of bacterial biofilm makes pathogen detection with traditional microbiological techniques highly ineffective. Diagnosis of PJIs is a rather complex challenge for orthopedics and requires a strict collaboration between different specialists: orthopaedics, infectivologists, microbiologists, pathologists and radiologists. Diagnostic criteria have been described by national and international association and scientific societies. Clinicians should be trained on how to use it, but more importantly they should know potential and limitation of the available tests in order to use them appropriately.
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