Infections associated with long-term prosthetic devices

Rates of periprosthetic infection and surgical revision in Beijing (China) between 2014 and 2016: a retrospective multicenter cross-sectional study

Background

Periprosthetic joint infection (PJI) is a rare but devastating complication after total joint arthroplasty. There is a paucity of data on the incidence and prevalence of periprosthetic infection in mainland China. This study aimed to analyze the rates of surgical revision after arthroplasty due to PJI and the procedures followed in Beijing, China.

Methods

The study involved a retrospective multicenter cross-sectional survey of patients undergoing revisions for periprosthetic infection after hip/knee arthroplasty at nine hospitals in Beijing from 2014 to 2016. Age, gender, body mass index, primary diagnosis, comorbidity, primary surgery, treatment methods, and post-revision complications were analyzed.

Results

A total of 38,319 hip/knee arthroplasties and 366 (0.96%) revisions for PJI were identified. Of these, 161 (161/14,110; 1.14%) revisions involved hip arthroplasty, whereas 205 (205/24,209; 0.85%) revisions were due to knee arthroplasty. Procedures for revisions of infected hip included 7 (4.3%) cases of open debridement and prosthesis retention, 32 (19.9%) cases of one-stage exchange, 121 (75.2%) cases of two-stage exchange, and 1 (0.007%) case of hip dissection. As for the infected knee, the procedures included 45 (22.0%) cases of open debridement and prosthesis retention, 13 (6.3%) cases of one-stage exchange, 143 (69.8%) cases of two-stage exchange, and 4 (0.02%) cases of knee fusion.

Conclusions

The study found the rates of revision due to PJI to be low. Nonetheless, the incidence of PJI in mainland China could be higher and calls for more elaborate studies in geographically and socioeconomically diverse health institutions.

Optimisation of preparation conditions for Ti nanowires and suitability as an antibacterial material

Ultrafine titanium dioxide (TiO₂) nanowires were synthesised using a hydrothermal method with different volumes of ethylene glycol (EG) and annealing temperatures. It shows that sodium titanate nanowires synthesised using 5 and 10 ml EG, which annealed at 400°C produced TiO₂ nanowires that correspond to a photochemically active phase, which is anatase. The influences of annealing temperatures (400-600°C) on the morphological arrangement of TiO₂ nanowires were evident in the field emission scanning electron microscopy. The annealing temperature of 500°C led to agglomeration, which formed a mixture of TiO₂ nanoparticles and nanowires. High thermal stability of TiO₂ nanowires revealed by thermogravimetric analysis and Fourier transform infrared spectroscopy spectrum showed the presence of the Ti-O-Ti vibrations as evidenced due to TiO₂ lattices. An antibacterial study using TiO₂ nanowires toward Escherichia coli and Klebsiella pneumoniae showed large zones of inhibition that indicated susceptibility of the microbe toward TiO₂. Growth kinetic analysis shows that addition of TiO₂ has reduced optical density (OD) suggesting an inhibition of the growth of bacteria. These results indicate TiO₂ nanowires can be effectively used as an antimicrobial agent against gram-bacteria. The TiO₂ nanowires could be exploited in the medical, packaging and detergent formulation industries and wastewater treatment.

Tumor necrosis factor alpha and interleukin-1 beta levels in cerebrospinal fluid examination for the diagnosis of ventriculoperitoneal shunt-related ventriculitis

PURPOSE

Ventriculitis is known to develop after chronic inflammation and bacterial invasion of the ventricular surface with a recurrence of shunt infections. The aim of this study is to evaluate the diagnostic value of elevation in cerebrospinal fluid (CSF) interleukin-1 beta (IL-1β) and tumor necrosis factor alpha (TNF-α) together with CSF culture and laboratory test results in the diagnosis of ventriculoperitoneal (VP) shunt-related ventriculitis, which is known to be more problematic than conventional shunt infection.

METHODS

The study included a total of 34 patients with a VP shunt due to hydrocephalus, who presented with a headache, fever, and shunt infection at the Emergency Department and had a pre-diagnosis of ventriculitis. Nineteen patients were diagnosed with shunt-related infection or ventriculitis using the CSF obtained from the shunt pump. The IL-1β and TNF-α levels from the CSF samples of all patients were measured using the Micro ELISA immunoassay method.

RESULTS

CSF direct microscopic observation revealed that the mean cell count, IL-1β level, CRP level, and blood leukocyte level were higher in patients with ventriculitis compared to those diagnosed with shunt infection (p = 0.02, p = 0.009, p = 0.004, and p = 0.009, respectively). The probability of predicting positive culture outcome was 92.7% with 90.9% sensitivity and 82.6% specificity when IL-1β values exceeded 4.0 pg/ml. TNF-α values did not show a significant, reliable pattern compared to IL-1β.

CONCLUSIONS

IL-1β is a reliable parameter which shall be used in the diagnosis of ventriculitis by predicting positive culture outcome with high sensitivity and specificity.

Methicillin-Resistant Staphylococcus aureus Prosthetic Valve Endocarditis: Pathophysiology, Epidemiology, Clinical Presentation, Diagnosis, and Management

Staphylococcus aureus prosthetic valve endocarditis (PVE) remains among the most morbid bacterial infections, with mortality estimates ranging from 40% to 80%. The proportion of PVE cases due to methicillin-resistant Staphylococcus aureus (MRSA) has grown in recent decades, to account for more than 15% of cases of S. aureus PVE and 6% of all cases of PVE. Because no large studies or clinical trials for PVE have been published, most guidelines on the diagnosis and management of MRSA PVE rely upon expert opinion and data from animal models or related conditions (e.g., coagulase-negative Staphylococcus infection). We performed a review of the literature on MRSA PVE to summarize data on pathogenic mechanisms and updates in epidemiology and therapeutic management and to inform diagnostic strategies and priority areas where additional clinical and laboratory data will be particularly useful to guide therapy. Major updates discussed in this review include novel diagnostics, indications for surgical management, the utility of aminoglycosides in medical therapy, and a review of newer antistaphylococcal agents used for the management of MRSA PVE.

Photobactericidal Activity of Dual Dyes Encapsulated in Silicone Enhanced by Silver Nanoparticles

Crystal violet (CV) and methylene blue (MB) dyes with silver (Ag) nanoparticles (NPs) were encapsulated into silicone to produce light-activated antimicrobial surfaces. Optical microscopy and X-ray photoelectron spectroscopy showed that CV and MB were diffused throughout the silicone samples and that Ag NPs were successfully encapsulated by the swell-encapsulation-shrink process. Antimicrobial tests on Staphylococcus aureus and Escherichia coli showed that CV/MB-encapsulated silicone samples have stronger photobactericidal activity than CV or MB samples and the addition of Ag NPs significantly enhanced the antimicrobial activity under white light. The number of viable bacteria decreased below the detection limit (below <103 CFU) on the silicone-incorporating CV/MB/Ag NPs within 3 h for S. aureus and within 5 h for E. coli. In leaching tests over 216 h, the amount of dye leaching from the samples was barely detectable (<0.02 ppm). These surfaces have a potential for use in healthcare settings to decrease hospital-associated infections.

Biomodification Strategies for the Development of Antimicrobial Urinary Catheters: Overview and Advances

Microbial burden associated with medical devices poses serious health challenges and is accountable for an increased number of deaths leading to enormous medical costs. Catheter-associated urinary tract infections are the most common hospital-acquired infections with enhanced patient morbidity. Quite often, catheter-associated bacteriuria produces apparent adverse outcomes such as urosepsis and even death. Taking this into account, the methods to modify urinary catheters to control microbial infections with relevance to clinical drug resistance are systematically evaluated in this review. Technologies to restrict biofilm formation at initial stages by using functional nanomaterials are elucidated. The conventional methodology of using single therapeutic intervention for developing an antimicrobial catheter lacks clinically meaningful benefit. Therefore, catheter modification using naturally derived antimicrobials such as essential oils, curcumin, enzymes, and antimicrobial peptides in combination with synthetic antibiotics/nanoantibiotics is likely to exert sufficient inhibitory effect on uropathogens and is extensively discussed. Futuristic efforts in this area are projected here that demand clinical studies to address areas of uncertainty to avoid development of bacterial resistance to the new generation therapy with minimum discomfort to the patients.

Photoinitiating Systems Based on Anthraquinone Derivatives: Synthesis of Antifouling and Biocide Coatings

Photoinitiating systems combining 2,6-diaminoanthraquinone (AQD), iodonium salt (Iod), and benzyl alcohol derivatives have been developed to efficiently initiate the cationic polymerization of epoxy monomers upon light exposure. Electron spin resonance spin-trapping (ESR ST) experiments, fluorescence investigations, and steady-state photolysis have demonstrated that a dye-sensitized reaction occurs between AQD and the benzyl alcohol derivatives through a hydrogen abstraction mechanism upon light illumination, followed by reduction of Iod. The in situ liberation of protic acids promotes the cationic photopolymerization of epoxy monomers concomitantly with hydrolysis and condensation of the reactive methoxysilanes of an organic-inorganic precursor, for example, 3-glycidyloxypropyltrimethoxysilane (GPTMS). Nanoindentation experiments and scratch resistance tests proved that the resulting GPTMS coatings exhibit very good resistance to brittle fracture and excellent adherence to stainless-steel substrates. Interestingly, antibacterial tests of the GPTMS coatings showed efficient antifouling and biocide properties against E. coli and S. aureus.

Development of photoactivable glycerol-based coatings containing quercetin for antibacterial applications

Synthesis of antibacterial coatings derived from glycerol and quercetin for the inhibition of bacteria proliferation.

Photoinduced curcumin derivative-coatings with antibacterial properties

Synthesis of antibacterial coatings derived from epoxidized soybean oil and curcumin for the efficient inhibition of bacteria proliferation.

Clinical characteristics of infections in humans due to Staphylococcus epidermidis

Staphylococcus epidermidis is the most common cause of primary bacteremia and infections of indwelling medical devices. The ability to cause disease is linked to its natural niche on human skin and ability to attach and form biofilm on foreign bodies. This review focuses on the S. epidermidis clinical syndromes most commonly encountered by clinicians and future potential treatment modalities.

Functional features of TonB energy transduction systems of Acinetobacter baumannii

Acinetobacter baumannii is an opportunistic pathogen that causes severe nosocomial infections. Strain ATCC 19606(T) utilizes the siderophore acinetobactin to acquire iron under iron-limiting conditions encountered in the host. Accordingly, the genome of this strain has three tonB genes encoding proteins for energy transduction functions needed for the active transport of nutrients, including iron, through the outer membrane. Phylogenetic analysis indicates that these tonB genes, which are present in the genomes of all sequenced A. baumannii strains, were acquired from different sources. Two of these genes occur as components of tonB-exbB-exbD operons and one as a monocistronic copy; all are actively transcribed in ATCC 19606(T). The abilities of components of these TonB systems to complement the growth defect of Escherichia coli W3110 mutants KP1344 (tonB) and RA1051 (exbBD) under iron-chelated conditions further support the roles of these TonB systems in iron acquisition. Mutagenesis analysis of ATCC 19606(T) tonB1 (subscripted numbers represent different copies of genes or proteins) and tonB2 supports this hypothesis: their inactivation results in growth defects in iron-chelated media, without affecting acinetobactin biosynthesis or the production of the acinetobactin outer membrane receptor protein BauA. In vivo assays using Galleria mellonella show that each TonB protein is involved in, but not essential for, bacterial virulence in this infection model. Furthermore, we observed that TonB2 plays a role in the ability of bacteria to bind to fibronectin and to adhere to A549 cells by uncharacterized mechanisms. Taken together, these results indicate that A. baumannii ATCC 19606(T) produces three independent TonB proteins, which appear to provide the energy-transducing functions needed for iron acquisition and cellular processes that play a role in the virulence of this pathogen.

Versatile photochemical surface modification of biopolyester microfibrous scaffolds with photogenerated silver nanoparticles for antibacterial activity

A straightforward and versatile method for immobilizing macromolecules and silver nanoparticles on the surface of poly(3-hydroxybutyrate-co-3-hydroxyvalerate) (PHBHV) electrospun fibers is developed with the objective of designing a new functional material having significant antibacterial activity. The approach relies on a two-step procedure: UV photografting of poly(methacrylic acid) (PMAA) on the surface of PHBHV fibers according to a "grafting from" method, and complexation of in situ photogenerated silver nanoparticles (Ag NPs) by carboxyl groups from tethered PMAA chains. The photografting process is conducted through a photoinduced free-radical process employing a ketone-based photoinitiator in aqueous medium. Under appropriate conditions, the photogenerated radicals abstract hydrogen atoms from the PHBHV backbone, thus initiating the UV-mediated photopolymerization of MAA from the PHBHV microfibrous surface. The photochemical mechanism of the ketone photolysis is entirely described by the electron spin resonance/spin-trapping technique, and the modified PHBHV microfibrous scaffold is extensively characterized by ATR-FTIR spectroscopy, water contact-angle measurements, and mercury intrusion porosimetry. In a second step, the in situ synthesis of Ag NPs within the microfibrous scaffold is implemented by photoreduction reaction in the presence of both a silver precursor and a photosensitizer. The photoinduced formation of Ag NPs is confirmed by UV spectrophotometry and XPS analysis. SEM and TEM experiments confirm the formation and dispersion of Ag NPs on the surface of the modified fibers. Finally, a primary investigation is conducted to support the antibacterial activity of the new functionalized biomaterial against Staphylococcus aureus and Escherichia coli.

Reducing Staphylococcus aureus biofilm formation on stainless steel 316L using functionalized self-assembled monolayers

Stainless steel 316L (SS316L) is a common material used in orthopedic implants. Bacterial colonization of the surface and subsequent biofilm development can lead to refractory infection of the implant. Since the greatest risk of infection occurs perioperatively, strategies that reduce bacterial adhesion during this time are important. As a strategy to limit bacterial adhesion and biofilm formation on SS316L, self-assembled monolayers (SAMs) were used to modify the SS316L surface. SAMs with long alkyl chains terminated with hydrophobic (-CH3) or hydrophilic (oligoethylene glycol) tail groups were used to form coatings and in an orthogonal approach, SAMs were used to immobilize gentamicin or vancomycin on SS316L for the first time to form an "active" antimicrobial coating to inhibit early biofilm development. Modified SS316L surfaces were characterized using surface infrared spectroscopy, contact angles, MALDI-TOF mass spectrometry and atomic force microscopy. The ability of SAM-modified SS316L to retard biofilm development by Staphylococcus aureus was functionally tested using confocal scanning laser microscopy with COMSTAT image analysis, scanning electron microscopy and colony forming unit analysis. Neither hydrophobic nor hydrophilic SAMs reduced biofilm development. However, gentamicin-linked and vancomycin-linked SAMs significantly reduced S. aureus biofilm formation for up to 24 and 48 h, respectively.

Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America

These guidelines are intended for use by infectious disease specialists, orthopedists, and other healthcare professionals who care for patients with prosthetic joint infection (PJI). They include evidence-based and opinion-based recommendations for the diagnosis and management of patients with PJI treated with debridement and retention of the prosthesis, resection arthroplasty with or without subsequent staged reimplantation, 1-stage reimplantation, and amputation.

Infective endocarditis at autopsy: a review of pathologic manifestations and clinical correlates

The frequency of autopsies appears to be declining, and the usefulness has been challenged. We reviewed cases of autopsied active infective endocarditis (IE) during 2 periods based on the availability of high-tech 2-dimensional echocardiograms: Period 1 (P1) included 40 cases studied from 1970 to 1985, and Period 2 (P2) included 28 cases seen from 1986 to 2008--that is, before and after the introduction of echocardiograms in our institution. We conducted the study to reassess the pathology of IE and to determine how frequently diagnosis is not made during life.The age of patients increased 10 years on average between the 2 periods, and comorbidities were significantly more frequent in P2. While the frequency of rheumatic valve disease and prosthetic valve endocarditis (PVE) decreased, degenerative valve disease increased. Isolated mitral or aortic valve IE was most common. Right-sided IE was observed in patients with Staphylococcus aureus bacteremia from infected venous lines. In most cases IE involved only the cusps of cardiac valves. "Virulent" microorganisms caused ulcerations, rupture, and perforation of the cusps and necrosis of chordae tendiniae and perivalvular apparatus. In PVE the lesions were located behind the site of attachment, and vegetations were seen on the sewing ring in both metallic and biologic prostheses. Infection spread to adjacent structures and myocardium with ring abscess observed in 88% of cases. Prosthetic detachment causing valve regurgitation was associated with abscesses in 76% of cases; these patients developed persistent sepsis and severe cardiac failure. Obstruction occurred in patients with PVE of the mitral valve. Acute purulent pericarditis was observed in 22% of cases, mainly in patients with aortic valve IE and myocardial abscesses.Gross infarcts were seen in 63% of cases but were asymptomatic in most instances. The spleen, kidneys, and mesentery were the sites most frequently involved. Myocardial infarctions were found in less than 10% of cases. Abscesses were also frequently found and were a common source of persistent fever and bacteremia. Glomerulonephritis was more common in the first period. Brain pathology consisted of ischemic and hemorrhagic infarcts and abscesses. Cerebral bleeding was more frequent in patients with PVE on anticoagulant therapy. Neutrophilic meningitis was observed in S. aureus IE.Diagnosis of IE was not made during life in 14 (35%) cases during P1 and 12 (42.8%) cases in P2. Overall, diagnosis was missed until autopsy in 38.2% of cases. IE was hospital acquired in 28 instances. While a clinical diagnosis was made in all but 4 cases of early-onset PVE (23.5%), the diagnosis was not made during life in 22 of 51 patients with native-valve IE (43.1%). Of these 22 patients, IE was hospital acquired in 11 (50%). The absence of fever, cardiac murmurs, and many of the typical stigmata of endocarditis may have led to the diagnosis being overlooked clinically.Brain bleeding, cardiac failure and less frequently acute myocardial infarct were the most common causes of death.IE continues to be missed frequently until autopsy. Postmortem examination is an important tool for evaluating the quality of care, and for guiding teaching and research related to cardiovascular infections.

Bioconjugation of protein-repellent zwitterionic polymer brushes grafted from silicon nitride

A new method for attaching antibodies to protein-repellent zwitterionic polymer brushes aimed at recognizing microorganisms while preventing the nonspecific adsorption of proteins is presented. The poly(sulfobetaine methacrylate) (SBMA) brushes were grafted from α-bromo isobutyryl initiator-functionalized silicon nitride (Si(x)N(4), x ≥ 3) surfaces via controlled atom-transfer radical polymerization (ATRP). A trifunctional tris(2-aminoethyl)amine linker was reacted with the terminal alkylbromide of polySBMA chains. N-Hydroxysuccinimide (NHS) functionalization was achieved by reacting the resultant amine-terminated polySBMA brush with bifunctional suberic acid bis(N-hydroxysuccinimide ester). Anti-Salmonella antibodies were subsequently immobilized onto polySBMA-grafted Si(x)N(4) surfaces through these NHS linkers. The protein-repellent properties of the polySBMA-grafted surface after antibody attachment were evaluated by exposing the surfaces to Alexa Fluor 488-labeled fibrinogen (FIB) solution (0.1 g·L(-1)) for 1 h at room temperature. Confocal laser scanning microscopy (CLSM) images revealed the minimal adsorption of FIB onto the antibody-coated polySBMA in comparison with that of antibody-coated epoxide monolayers and also bare Si(x)N(4) surfaces. Subsequently, the interaction of antibodies immobilized onto polySBMA with SYTO9-stained Salmonella solution without using blocking solution was examined by CLSM. The fluorescent images showed that antibody-coated polySBMA efficiently captured Salmonella with only low background noise as compared to antibody-coated monolayers lacking the polymer brush. Finally, the antibody-coated polySBMA surfaces were exposed to a mixture of Alexa Fluor 647-labeled FIB and Salmonella without the prior use of a blocking solution to evaluate the ability of the surfaces to capture bacteria while simultaneously repelling proteins. The fluorescent images showed the capture of Salmonella with no adsorption of FIB as compared to antibody-coated epoxide surfaces, demonstrating the potential of the zwitterionic layer in preventing the nonspecific adsorption of the proteins during the detection of bacteria in complex matrices.

Stable protein-repellent zwitterionic polymer brushes grafted from silicon nitride

Zwitterionic poly(sulfobetaine acrylamide) (SBMAA) brushes were grafted from silicon-rich silicon nitride (SixN4, x > 3) surfaces by atom transfer radical polymerization (ATRP) and studied in protein adsorption experiments. To this aim ATRP initiators were immobilized onto SixN4 through stable Si-C linkages via three consecutive reactions. A UV-induced reaction of 1,2-epoxy-9-decene with hydrogen-terminated SixN4 surfaces was followed by conversion of the epoxide with 1,2-ethylenediamine resulting in primary and secondary amine-terminated surfaces. A reaction with 2-bromoisobutyryl bromide led to ATRP initiator-covered surfaces. Zwitterionic polymer brushes of SBMAA were grown from these initiator-coated surfaces (thickness ∼30 nm), and the polymer-coated surfaces were characterized in detail by static water contact angle measurements, X-ray photoelectron spectroscopy (XPS), and an atomic force microscope (AFM). The adsorption of proteins onto zwitterionic polymer coated surfaces was evaluated by in situ reflectometry, using a fibrinogen (FIB) solution of 0.1 g·L(-1), and compared to hexadecyl-coated SixN4 surfaces (C16-SixN4), uncoated air-based plasma oxidized SixN4 surfaces (SiOy-SixN4), and hexa(ethylene oxide)-coated SixN4 surfaces (EO6-SixN4). Excellent protein repellence (>99%) was observed for these zwitterionic polymer-coated SixN4 surfaces during exposure to FIB solution as compared to C16-SixN4 surfaces. Furthermore, the stability of these zwitterionic polymer-coated SixN4 surfaces was surveyed by exposing the surfaces for 1 week to phosphate buffered saline (PBS) solution at room temperature. The zwitterionic polymer-coated SixN4 surfaces before and after exposure to PBS solution were characterized by XPS, AFM, and water contact angle measurements, and their protein-repelling properties were evaluated by reflectometry. After exposure to PBS solution, the zwitterionic polymer coating remained intact, and its thickness was unchanged within experimental error. No hydrolysis was observed for the zwitterionic polymer after 1 week exposure to PBS solution, and the surfaces still repelled 98% FIB as compared to C16-SixN4 surfaces, demonstrating the long-term efficiency of these easily prepared surface coatings.

Acute infective endocarditis

Acute infective endocarditis is a complex disease with changing epidemiology and a rapidly evolving knowledge base. To consistently achieve optimal outcomes in the management of infective endocarditis, the clinical team must have an understanding of the epidemiology, microbiology, and natural history of infective endocarditis, as well as a grasp of guiding principles of diagnosis and medical and surgical management. The focus of this review is acute infective endocarditis, though many studies of diagnosis and treatment do not differentiate between acute and subacute disease, and indeed many principles of diagnosis and management of infective endocarditis for acute and subacute disease are identical.