1
|
Azad MA, Patel R. Practical Guidance for Clinical Microbiology Laboratories: Microbiologic diagnosis of implant-associated infections. Clin Microbiol Rev 2024; 37:e0010423. [PMID: 38506553 DOI: 10.1128/cmr.00104-23] [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: 03/21/2024] Open
Abstract
SUMMARYImplant-associated infections (IAIs) pose serious threats to patients and can be associated with significant morbidity and mortality. These infections may be difficult to diagnose due, in part, to biofilm formation on device surfaces, and because even when microbes are found, their clinical significance may be unclear. Despite recent advances in laboratory testing, IAIs remain a diagnostic challenge. From a therapeutic standpoint, many IAIs currently require device removal and prolonged courses of antimicrobial therapy to effect a cure. Therefore, making an accurate diagnosis, defining both the presence of infection and the involved microorganisms, is paramount. The sensitivity of standard microbial culture for IAI diagnosis varies depending on the type of IAI, the specimen analyzed, and the culture technique(s) used. Although IAI-specific culture-based diagnostics have been described, the challenge of culture-negative IAIs remains. Given this, molecular assays, including both nucleic acid amplification tests and next-generation sequencing-based assays, have been used. In this review, an overview of these challenging infections is presented, as well as an approach to their diagnosis from a microbiologic perspective.
Collapse
Affiliation(s)
- Marisa Ann Azad
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robin Patel
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
2
|
Egerci OF, Yapar A, Dogruoz F, Selcuk H, Kose O. Preventive strategies to reduce the rate of periprosthetic infections in total joint arthroplasty; a comprehensive review. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05301-w. [PMID: 38635048 DOI: 10.1007/s00402-024-05301-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/24/2024] [Indexed: 04/19/2024]
Abstract
The increasing frequency of total hip (THA) and knee arthroplasties (TKA) is marred by the rise in periprosthetic joint infections (PJIs) and surgical site infections (SSIs), with PJIs incurring costs over $1.62 billion as of 2020 and individual case management averaging $90,000. SSIs additionally burden the U.S. healthcare economy with billions in expenses annually. PJI prevalence in primary THA and TKA ranges from 0.5% to 2.4%, spiking to 20% in revisions and representing 25% of TKA revision causes. Projections estimate up to 270,000 annual PJI cases by 2030. Often caused by gram-positive bacteria, particularly methicillin-resistant staphylococci, these infections demand preventive measures. This review dissects PJI prevention across preoperative, intraoperative, and perioperative phases, aligning with evidence-based CDC and WHO guidelines. Preoperative measures include managing diabetes, obesity, tobacco use, Staphylococcus aureus screening and nasal decolonization, nutritional optimization, and management of inflammatory arthropathies. Intraoperatively, antibiotic prophylaxis, skin preparation, operative room environmental controls, surgical technique precision, and irrigation options are scrutinized. Perioperative concerns focus on anticoagulation, blood management, and infection risk mitigation. Integrating these strategies promotes a patient-centric care model, aiming to reduce PJI incidence, improve patient outcomes, and increase care cost-effectiveness in joint arthroplasty.
Collapse
Affiliation(s)
- Omer Faruk Egerci
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Aliekber Yapar
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Fırat Dogruoz
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Huseyin Selcuk
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Ozkan Kose
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey.
| |
Collapse
|
3
|
De Groot J, Brokelman R, Fransen B, Jiya T, Pakvis D. Antibiotic prophylaxis before tissue biopsy has no effect on culture results in presumed aseptic revision total hip arthroplasty. J Bone Jt Infect 2024; 9:67-74. [PMID: 38601000 PMCID: PMC11004665 DOI: 10.5194/jbji-9-67-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 12/26/2023] [Indexed: 04/12/2024] Open
Abstract
Background: Antibiotic prophylaxis (AP) is considered to be the gold standard for revision total hip arthroplasty (R-THA) due to the high incidence of prosthetic joint infection (PJI). To diagnose PJI, intraoperative tissue biopsies for culture are of particular importance. However, antibiotic interference could theoretically lead to less reliable culture results. Currently, there is no consensus on whether AP should be administered before or after tissue biopsy. In this study, we aimed to investigate the effect of AP timing on culture results and PJI rates in presumed aseptic R-THA. Methods: A retrospective single-center cohort study among 490 patients was performed; 61 patients received AP pre-incision, and 429 patients received AP post-biopsy. At least three intraoperative tissues were sampled for each patient and cultured for a minimum of 2 weeks. Minimum follow-up was 6 months. Epidemiological and clinical data (including culture results and incidence of PJI during follow-up) were gathered and analyzed. Results: Positive (4.9 % vs. 5.4 %, p = 0.89 ) and contaminated culture results (23.0 % vs. 22.6 %, p = 0.95 ) were not significantly different between pre-incisional and post-biopsy AP administration. Post-operative PJI incidence during follow-up was 1.6 % and 3.0 %, respectively. This difference was not statistically significant (p = 0.54 ). Conclusion: Pre-incisional AP administration does not yield fewer culture results compared to post-biopsy AP administration. Although statistically not significant, PJI during follow-up was almost twice as high when AP was withheld until after tissue biopsy. Other literature also supports the additional protective benefit of pre-incisional AP. Therefore, we believe pre-incisional AP administration is preferable for presumed aseptic R-THA.
Collapse
Affiliation(s)
- Jesse D. De Groot
- Department of Orthopedic surgery, OCON Orthopedic Clinic, Geerdinksweg 144, 7555 DL Hengelo, the Netherlands
| | - Roy G. B. Brokelman
- Department of Orthopedic surgery, OCON Orthopedic Clinic, Geerdinksweg 144, 7555 DL Hengelo, the Netherlands
| | - Bas L. Fransen
- Department of Orthopedic surgery, OCON Orthopedic Clinic, Geerdinksweg 144, 7555 DL Hengelo, the Netherlands
| | - Tim U. Jiya
- Department of Orthopedic surgery, OCON Orthopedic Clinic, Geerdinksweg 144, 7555 DL Hengelo, the Netherlands
| | - Dean F. M. Pakvis
- Department of Orthopedic surgery, OCON Orthopedic Clinic, Geerdinksweg 144, 7555 DL Hengelo, the Netherlands
| |
Collapse
|
4
|
Uçkay I, Bomberg H, Risch M, Müller D, Betz M, Farshad M. Broad-spectrum antibiotic prophylaxis in tumor and infected orthopedic surgery-the prospective-randomized, microbiologist-blinded, stratified, superiority trials: BAPTIST Trials. Trials 2024; 25:69. [PMID: 38243311 PMCID: PMC10799415 DOI: 10.1186/s13063-023-07605-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 08/26/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND The perioperative antibiotic prophylaxis with 1st or 2nd generation cephalosporins is evidence-based in orthopedic surgery. There are, however, situations with a high risk of prophylaxis-resistant surgical site infections (SSI). METHODS We perform a superiority randomized controlled trial with a 10% margin and a power of 90% in favor of the broad-spectrum prophylaxis. We will randomize orthopedic interventions with a high risk for SSI due to selection of resistant pathogens (open fractures, surgery under therapeutic antibiotics, orthopedic tumor surgery, spine surgery with American Society of Anesthesiologists (ASA) score ≥ 3 points) in a prospective-alternating scheme (1:1, standard prophylaxis with cefuroxime versus a broad-spectrum prophylaxis of a combined single-shot of vancomycin 1 g and gentamicin 5 mg/kg parenterally). The primary outcome is "remission" at 6 weeks for most orthopedic surgeries or at 1 year for surgeries with implant. Secondary outcomes are the risk for prophylaxis-resistant SSI pathogens, revision surgery for any reason, change of antibiotic therapy during the treatment of infection, adverse events, and the postoperative healthcare-associated infections other than SSI within 6 weeks (e.g., urine infections or pneumonia). With event-free surgeries to 95% in the broad-spectrum versus 85% in the standard prophylaxis arm, we need 2 × 207 orthopedic surgeries. DISCUSSION In selected patients with a high risk for infections due to selection of prophylaxis-resistant SSI, a broad-spectrum combination with vancomycin and gentamycin might prevent SSIs (and other postoperative infections) better than the prophylaxis with cefuroxime. TRIAL REGISTRATION ClinicalTrial.gov NCT05502380. Registered on 12 August 2022. Protocol version: 2 (3 June 2022).
Collapse
Affiliation(s)
- Ilker Uçkay
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
- Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
- Infection Control, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Hagen Bomberg
- Department of Anesthesiology, Intensive Care and Pain Medicine, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Markus Risch
- Department of Anesthesiology, Intensive Care and Pain Medicine, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Daniel Müller
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Michael Betz
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
- Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| |
Collapse
|
5
|
Puzzitiello RN, Lipson SE, Michaud RG, York BR, Finch DJ, Menendez ME, Ryan SP, Wurcel AG, Salzler MJ. Effect of Antibiotic Administration Before Joint Aspiration on Synovial Fluid White Blood Cell Count in Native Joint Septic Arthritis. Open Forum Infect Dis 2024; 11:ofad600. [PMID: 38221984 PMCID: PMC10787370 DOI: 10.1093/ofid/ofad600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Indexed: 01/16/2024] Open
Abstract
Background This study was performed to assess the impact of preaspiration antibiotics on synovial fluid analysis and timing of operative treatment in native-joint septic arthritis. Methods We performed a retrospective record review of adult patients from an urban level 1 trauma center with native joint septic arthritis in 2015-2019, identified by means of codes from the International Classification of Diseases (Ninth Revision and Tenth Revision). Univariate and multivariate analyses were performed to determine whether antibiotics were associated with lower synovial fluid white blood cell counts (WBCs), the percentage of polymorphonuclear neutrophil (PMNs), and rate of culture positivity. Secondary analysis included time elapsed from aspiration to surgery. Results Of the 126 patients with septic joints included, nearly two-thirds (n = 80 [63.5%]) received antibiotics before joint aspiration. The synovial fluid WBC count, percentage of PMNs, and rate of culture positivity were significantly lower in patients who received preaspiration antibiotics than in those who did not (mean WBC count, 51 379.1/μL [standard deviation, 52 576.3/μL] vs 92 162.7/μL [59 330.6/μL], respectively [P < .001]; PMN percentage, 83.6% [20.5%] vs 91.9% [6.0%; P = .01]; and culture positivity, 32.5% vs 59.1% [P = .008]). Multivariable analyses revealed that these associations remained after controlling for potential confounders (change in PMNs, -42 784.60/μL [95% confidence interval, -65 355/μL to -20 213.90/μL [P < .001]; change in PMNs, -7.8% [-13.7% to -1.8%] [P = .01]; odds ratio, 0.39 [.18-.87; P = .02). Patients with a synovial fluid WBC count ≤50 000/μL experienced significant delay in time from joint aspiration to operative intervention (mean [standard deviation], 10.5 [11.3] vs 17.9 [17.2] hours; P = .02). Conclusions The administration of antibiotics before joint aspiration for suspected septic arthritis appears to decrease the synovial fluid WBC count, the percentage of PMNs, and the rate of culture positivity. Efforts to limit antibiotic administration before joint aspiration are important to minimize diagnostic dilemmas and circumvent treatment delays.
Collapse
Affiliation(s)
| | - Sophie E Lipson
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | | | - Benjamin R York
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Daniel J Finch
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Mariano E Menendez
- Department of Orthopedics, Tufts Medical Center, Boston, Massachusetts, USA
| | - Scott P Ryan
- Department of Orthopedics, Tufts Medical Center, Boston, Massachusetts, USA
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Alysse G Wurcel
- Tufts University School of Medicine, Boston, Massachusetts, USA
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - Matthew J Salzler
- Department of Orthopedics, Tufts Medical Center, Boston, Massachusetts, USA
- Tufts University School of Medicine, Boston, Massachusetts, USA
| |
Collapse
|
6
|
Rein S, Sorowka A, Grünewald T, Kremer T. Microbiologic Analysis of Hand Infections: A Prospective Study. Surg Infect (Larchmt) 2023; 24:625-631. [PMID: 37646765 DOI: 10.1089/sur.2023.052] [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: 09/01/2023] Open
Abstract
Background: Hand infections are a common problem in emergency departments. Staphylococcus aureus is the main pathogen of both hand and blood stream infections. Therefore, the aim of the present study was to evaluate the frequency and impact of bacteremia in patients with hand infections to improve the microbiologic diagnostics. Patients and Methods: A prospective study of 90 patients with acute hand infections without antimicrobial pre-treatment was performed. Blood cultures were taken pre-operatively. If positive, transesophageal echocardiography was performed to rule out infectious endocarditis. Tissue samples were microbiologically processed using standardized culture media. If negative, a broad-spectrum bacterial 16S ribosomal RNA (rRNA) gene polymerase chain reaction (PCR) was applied. The etiology and location of the infection, the length of hospital stay, the number of surgical interventions, and the inflammatory parameters were obtained. Results: Six patients with bacteremia (6.6%) were diagnosed, after animal bites (n = 3) and intra-articular empyema (n = 3). Pathogens included Staphylococcus pettenkoferi, Pasteurella multocida, Staphylococcus epidermidis, Staphylococcus aureus, and Bacteroides pyogenes. No case of infective endocarditis was detected. Patients with bacteremia required more surgical interventions (p = 0.002), had a longer hospital stay (p < 0.001), higher plasma C-reactive protein (CRP; p = 0.016), and a higher age (p = 0.002) compared with those without bacteremia. In 14 cases (15.6%) no pathogen was detected by culture, whereas the subsequent broad-spectrum PCR diagnosed three cases (21.4%). Conclusions: Pre-operative blood cultures in patients with hand infections are important to detect bacteremia as an essential marker of clinical severity. Those blood cultures are indicated after deep animal bites and joint empyema. A precise identification of pathogens is fundamental for an effective treatment of hand infections, for which a 16S rRNA gene PCR can contribute in culture-negative tissue samples.
Collapse
Affiliation(s)
- Susanne Rein
- Department of Plastic and Hand Surgery, Burn Unit, Hospital Sankt Georg, Leipzig, Germany
- Martin-Luther-University Halle-Wittenberg, Germany
| | - Anne Sorowka
- Department of Plastic and Hand Surgery, Burn Unit, Hospital Sankt Georg, Leipzig, Germany
| | - Thomas Grünewald
- Department of Infectious Diseases and Tropical Medicine, Hospital Chemnitz, Chemnitz, Germany
| | - Thomas Kremer
- Department of Plastic and Hand Surgery, Burn Unit, Hospital Sankt Georg, Leipzig, Germany
| |
Collapse
|
7
|
Is There a Wound Recontamination by Eluates with High Bacterial Load in Negative-Pressure Wound Therapy with Instillation and Dwell Time? Plast Reconstr Surg 2023; 151:136e-147e. [PMID: 36251856 PMCID: PMC9788932 DOI: 10.1097/prs.0000000000009770] [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] [Indexed: 01/25/2023]
Abstract
BACKGROUND This study investigated bacterial colonization of the foam eluate after negative-pressure wound therapy (NPWT) with instillation and dwell time (NPWTi-d) to obtain an indication of possible recontamination of the wound during NPWTi-d. To detect bacterial colonization and the extent of planktonic and nonplanktonic bioburden as comprehensively as possible, routine culture and molecular biology methods were used. METHODS Before (time point 1) and after (median 3.0 days; time point 2) NPWT ( n = 15) and NPWTi-d with antiseptic installation ( n = 15), wound bed [22 acute, eight chronic wounds; median age, 51 years (range, 24 to 91); 26 men], foam, and eluate were examined by routine culture methods and fluorescence in situ hybridization (FISH), polymerase chain reaction, and FISH sequencing (FISHseq). RESULTS At time point 2, 94.9% (37 of 39) of the pathogens identifiable in the eluate were also detected in the wound bed. Foam and eluate were always bacterially contaminated. NPWTi-d resulted in a significant reduction in the number of pathogen species compared with NPWT (NPWTi-d, time point 1 versus time point 2: P = 0.026; NPWT, time point 1 versus time point 2: not significant). Routine culture of wound bed samples at time point 2 identified only 28 of 52 (53.8%) of the pathogens, whereas examination of wound bed, foam, and eluate and additional FISHseq use detected 50 of 52 (96.2%) of the bacterial species. FISHseq identified biofilm in one and microcolonies in 10 wounds (time point 2). CONCLUSIONS The bacterial load of the foam is flushed back into the wound during NPWTi-d. FISHseq should be used in addition to the routine culture method when pathogen identification and detection of nonplanktonic bacterial growth is particularly important for the patient's therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
Collapse
|
8
|
Xia Y, Deng C, Zhou Y, Wu D, Liu Z, Xie L, E B, Han J, You C. Effects of prophylactic antibiotic administration and antibiotic timing on culture results and clinical outcomes of paediatric musculoskeletal infection: a protocol for a randomised controlled clinical trial. BMJ Open 2022; 12:e053568. [PMID: 35840306 PMCID: PMC9295648 DOI: 10.1136/bmjopen-2021-053568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Musculoskeletal infection (MSI) is a common cause of morbidity among the paediatric population. Some clinicians recommend withholding prophylactic antibiotics until culture collection with an aim to improve the culture sensitivity. However, a recent retrospective study reported that prophylactic antibiotic administration did not affect culture sensitivities in either disseminated or local MSI in paediatric population, which is surprising. The aim of the present study is to investigate the effects of prophylactic antibiotic administration and the timing of antibiotic administration on culture sensitivity and clinical outcomes of paediatric MSI. METHODS AND ANALYSIS A randomised controlled clinical trial will be carried out. Individuals aged 0-18 years with a diagnosis of MSI will be screened and evaluated at the Shenzhen Children's Hospital. The participants will be randomly allocated into four groups, and they will receive the antibiotic treatment at different time points, that is, 1 week, 3 days, 1 day prior to tissue culture collection and 1 day after tissue culture collection, respectively. The primary outcome will be culture sensitivity. In addition, the disease-related markers including white blood cell count, C reactive protein, erythrocyte sedimentation rate, vital signs as well as the length of hospital stay will be measured or recorded accordingly. Using χ2 tests, the rates of positive cultures will be compared between different groups. Statistical comparisons between the different patient groups regarding the confounding and outcome variables will be conducted using independent t-tests, Mann-Whitney U tests, χ2 tests and Fisher's exact tests as appropriate with the significance level set to 5% (p<0.05). ETHICS AND DISSEMINATION This study has received ethical approval. The findings will be disseminated both in scientific conferences and peer-reviewed journal. TRIAL REGISTRATION NUMBER ChiCTR2100041631.
Collapse
Affiliation(s)
- Yongjie Xia
- Department of Orthopedic, Shenzhen Children's Hospital, Shenzhen, China
| | - Chao Deng
- Department of Orthopedic, Shenzhen Children's Hospital, Shenzhen, China
| | - Yibiao Zhou
- Department of Orthopedic, Shenzhen Children's Hospital, Shenzhen, China
| | - Dechao Wu
- Department of Orthopedic, Shenzhen Children's Hospital, Shenzhen, China
| | - Zhiyong Liu
- Department of Orthopedic, Shenzhen Children's Hospital, Shenzhen, China
| | - Liangfu Xie
- Department of Orthopedic, Shenzhen Children's Hospital, Shenzhen, China
| | - Bing E
- Department of Orthopedic, Shenzhen Children's Hospital, Shenzhen, China
| | - Jingming Han
- Department of Orthopedic, Shenzhen Children's Hospital, Shenzhen, China
| | - Chao You
- Department of Orthopedic, Shenzhen Children's Hospital, Shenzhen, China
| |
Collapse
|
9
|
Muscat J, Manton R, Ahmed R, Johnson O, Ridha H, Goon P. A Five-Year Retrospective Analysis of Diagnostic and Treatment Data of Flexor Sheath Infections: Can We Accurately Predict the Presence and Severity of Infection Prior to Surgical Washout? Cureus 2021; 13:e19715. [PMID: 34900496 PMCID: PMC8650629 DOI: 10.7759/cureus.19715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 11/05/2022] Open
Abstract
Flexor sheath infections (FSIs) are soft tissue infections affecting the hand, which, if mismanaged, can have devastating consequences. Clinical assessment is key to diagnosis, with many relying on Kanavel cardinal signs as an aid. To prevent unnecessary operative intervention and the associated post-operative combined patient and healthcare burden, it is key that patients with FSIs are correctly identified. It would also be useful to stratify severity of FSIs without surgical exploration. To date, there is no accepted method to assist clinicians in doing so. We retrospectively analysed data from a five-year period to see if we could identify pre-operatively (a) accurate predictors of FSIs and (b) severity of the FSIs. We established that only the presence of all four Kanavel cardinal signs significantly predicted the presence of an FSI. No other variable that was available prior to surgery could predict either presence or severity of infection.
Collapse
Affiliation(s)
- Joseph Muscat
- Trauma and Orthopaedics, East and North Hertfordshire NHS Trust, Stevenage, GBR
| | - Robert Manton
- Plastic Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, GBR
| | - Rowaa Ahmed
- Plastic Surgery, Leeds General Infirmary, Leeds, GBR
| | - Oscar Johnson
- Orthopaedics and Trauma, Peterborough City Hospital, Peterborough, GBR
| | - Hyder Ridha
- Plastic and Reconstructive Surgery, East and North Hertfordshire NHS Trust, Stevenage, GBR
| | - Patrick Goon
- Plastic and Reconstructive Surgery, East and North Hertfordshire NHS Trust, Stevenage, GBR
| |
Collapse
|
10
|
Viezens L, Dreimann M, Strahl A, Heuer A, Koepke LG, Bay B, Waldeyer C, Stangenberg M. Spontaneous spondylodiscitis and endocarditis: interdisciplinary experience from a tertiary institutional case series and proposal of a treatment algorithm. Neurosurg Rev 2021; 45:1335-1342. [PMID: 34510310 PMCID: PMC8976816 DOI: 10.1007/s10143-021-01640-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/01/2021] [Accepted: 09/02/2021] [Indexed: 12/19/2022]
Abstract
Previously, the simultaneous presence of endocarditis (IE) has been reported in 3–30% of spondylodiscitis cases. The specific implications on therapy and outcome of a simultaneous presence of both diseases are not yet fully evaluated. Therefore, the aim of this study was to investigate the influence of a simultaneously present endocarditis on the course of therapy and outcome of spondylodiscitis. A prospective database analysis of 328 patients diagnosed with spontaneous spondylodiscitis (S) using statistical analysis with propensity score matching was conducted. Thirty-six patients (11.0%) were diagnosed with concurrent endocarditis (SIE) by means of transoesophageal echocardiography. In our cohort, the average age was 65.82 ± 4.12 years and 64.9% of patients were male. The incidence of prior cardiac or renal disease was significantly higher in the SIE group (coronary heart disease SIE n = 13/36 vs. S n = 57/292, p < 0.05 and chronic heart failure n = 11/36 vs. S n = 41/292, p < 0.05, chronic renal failure SIE n = 14/36 vs. S n = 55/292, p < 0.05). Complex interdisciplinary coordination and diagnostics lead to a significant delay in surgical intervention (S = 4.5 ± 4.5 days vs. SIE = 8.9 ± 9.5 days, p < 0.05). Mortality did not show statistically significant differences: S (13.4%) and SIE (19.1%). Time to diagnosis and treatment is a key to efficient treatment and patient safety. In order to counteract delayed therapy, we developed a novel therapy algorithm based on the analysis of treatment processes of the SIE group. We propose a clear therapy pathway to avoid frequently observed pitfalls and delays in diagnosis to improve patient care and outcome.
Collapse
Affiliation(s)
- Lennart Viezens
- Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany.
| | - Marc Dreimann
- Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | - André Strahl
- Division of Orthopedics, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Annika Heuer
- Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | - Leon-Gordian Koepke
- Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | - Benjamin Bay
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Waldeyer
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Stangenberg
- Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| |
Collapse
|
11
|
Rupp M, Baertl S, Walter N, Hitzenbichler F, Ehrenschwender M, Alt V. Is There a Difference in Microbiological Epidemiology and Effective Empiric Antimicrobial Therapy Comparing Fracture-Related Infection and Periprosthetic Joint Infection? A Retrospective Comparative Study. Antibiotics (Basel) 2021; 10:antibiotics10080921. [PMID: 34438971 PMCID: PMC8388716 DOI: 10.3390/antibiotics10080921] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/14/2021] [Accepted: 07/27/2021] [Indexed: 11/16/2022] Open
Abstract
This study aims to investigate (1) microbial patterns in fracture-related infections (FRIs) in comparison to microbiological patterns of periprosthetic joint infections (PJIs), (2) the identification of effective empiric antibiotic therapy for FRIs and PJIs and (3) analysis of difficult-to-treat (DTT) pathogens. Patients treated for FRIs or PJIs from 2017 to 2020 were evaluated for pathogens detected during treatment. Antibiotic susceptibility profiles were examined with respect to broadly used antibiotics and antibiotic combinations. Resistance rates to rifampicin or fluoroquinolone were determined. A total of 81 patients with PJI and 86 with FRI were included in the study. For FRIs Staphylococcus aureus was the most common infection-causing pathogen (37.4% vs. 27.9% for PJI). Overall, there was no statistical difference in pathogen distribution (p = 0.254). For FRIs, combinations of gentamicin + vancomycin (93.2%), co-amoxiclav + glycopeptide and meropenem + vancomycin (91.9% each) would have been effective for empiric therapy, similar to PJIs. Difficult to treat pathogens were more frequently detectable in PJIs (11.6% vs. 2.3%). Empiric therapy combinations such as gentamicin + vancomycin, co-amoxiclav + glycopeptide or meropenem + vancomycin, are effective antibiotic strategies for both FRI and PJI patients. More DTT pathogens were detectable in PJIs compared to FRIs.
Collapse
Affiliation(s)
- Markus Rupp
- Department for Trauma Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany; (S.B.); (N.W.); (V.A.)
- Correspondence: ; Tel.: +49-941944-6799
| | - Susanne Baertl
- Department for Trauma Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany; (S.B.); (N.W.); (V.A.)
| | - Nike Walter
- Department for Trauma Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany; (S.B.); (N.W.); (V.A.)
| | - Florian Hitzenbichler
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, 93053 Regensburg, Germany;
| | - Martin Ehrenschwender
- Institute of Clinical Microbiology and Hygiene, University Medical Center Regensburg, 93053 Regensburg, Germany;
| | - Volker Alt
- Department for Trauma Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany; (S.B.); (N.W.); (V.A.)
| |
Collapse
|
12
|
DNA Microarray-based Detection of Bacteria in Samples Containing Antibiotics: Effect of Antibiotics on the Performance of Pathogen Detection Assays. BIOTECHNOL BIOPROC E 2021. [DOI: 10.1007/s12257-020-0342-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
13
|
Bickert B, Müller CT, Harhaus L. [Hand Infections - A Review Article]. HANDCHIR MIKROCHIR P 2021; 53:214-218. [PMID: 34134152 DOI: 10.1055/a-1382-8186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
This review article addresses the incidence, types, and causes of hand infections, as well as risk factors and differential diagnosis.
Collapse
Affiliation(s)
- Berthold Bickert
- BG Unfallklinik Ludwigshafen; Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie der Universität Heidelberg
| | - Camillo T Müller
- BG Unfallklinik Ludwigshafen; Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie der Universität Heidelberg
| | - Leila Harhaus
- BG Unfallklinik Ludwigshafen; Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie der Universität Heidelberg
| |
Collapse
|
14
|
Dudareva M, Barrett LK, Morgenstern M, Atkins BL, Brent AJ, McNally MA. Providing an Evidence Base for Tissue Sampling and Culture Interpretation in Suspected Fracture-Related Infection. J Bone Joint Surg Am 2021; 103:977-983. [PMID: 33764925 DOI: 10.2106/jbjs.20.00409] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The recent consensus definition for the diagnosis of fracture-related infection (FRI) includes the identification of indistinguishable microorganisms in at least 2 surgical deep-tissue specimens as a confirmatory criterion. However, this cut-off, and the total number of specimens from a patient with suspected FRI that should be sent for microbiological testing, have not been validated. We endeavored to estimate the accuracy of different numbers of specimens and diagnostic cut-offs for microbiological testing of deep-tissue specimens in patients undergoing surgical treatment for possible FRI. METHODS A total of 513 surgical procedures in 385 patients with suspected FRI were included. A minimum of 2 surgical deep-tissue specimens were submitted for microbiological testing; 5 or more specimens were analyzed in 345 procedures (67%). FRI was defined by the presence of any confirmatory criteria other than microbiology. Resampling was utilized to model the sensitivity and specificity of diagnostic cut-offs for the number of surgical specimens yielding indistinguishable microorganisms and for the total number of specimens. The likelihood of detecting all clinically relevant microorganisms was also assessed. RESULTS A diagnostic cut-off of at least 2 of 5 specimens with indistinguishable microorganisms identified by culture was 68% sensitive (95% confidence interval [CI], 62% to 74%) and 87% specific (95% CI, 81% to 94%) for the diagnosis of FRI. Two out of 3 specimens were 60% sensitive (95% CI, 55% to 66%) and 92% specific (95% CI, 88% to 96%). Submitting only 3 deep-tissue specimens risked missing clinically relevant microorganisms in at least 1 in 10 cases. CONCLUSIONS The present study was the first to validate microbiological criteria for the diagnosis of FRI, supporting the current confirmatory diagnostic criteria for FRI. Analysis of at least 5 deep-tissue specimens in patients with possible FRI is recommended. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- M Dudareva
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals , Oxford , United Kingdom
| | - L K Barrett
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals , Oxford , United Kingdom
| | - M Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel , Basel , Switzerland
| | - B L Atkins
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals , Oxford , United Kingdom
| | - A J Brent
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals , Oxford , United Kingdom
| | - M A McNally
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals , Oxford , United Kingdom
| |
Collapse
|
15
|
Dartus J, Martinot P, Leclerc JT, Senneville E, Wallet F, Putman S, Migaud H, Loiez C. Diagnostic accuracy of the BJI InoPlex™ (Diaxonhit) immunoassay on blood samples for periprosthetic joint infection in complex microbiological situations. Preliminary results of 24 cases in a French Reference Center for Complex Bone and Joint Infection (CRIOAC). Orthop Traumatol Surg Res 2021; 107:102909. [PMID: 33789198 DOI: 10.1016/j.otsr.2021.102909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/22/2020] [Accepted: 06/29/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND While joint aspiration is the benchmark for diagnosing periprosthetic joint infections (PJI), the results can be flawed because certain bacteria are difficult to culture, the patient is on concurrent antibiotic therapy or in some cases, repeated joint aspirations confer conflicting results. The BJI InoPlex™ (Diaxonhit) is a multiplex ELISA (Enzyme Linked Immunosorbent Assay) that measures the immune response (presence of specific IgG) to certain bacterial species from three families: Staphylococcus (8 antigens) epidermidis, aureus and lugdunensis, Streptococcus B (4 antigens) and Cutibacterium acnes (4 antigens). This assay is done with peripherally collected blood. However, there are few published studies about this assay, especially if the microbiological diagnosis is in doubt in cases of suspected chronic PJI. This led us to conduct a retrospective study in a French tertiary care center to determine 1) the sensitivity and specificity of the BJI InoPlex™, 2) its positive (PPV) and negative predictive value (NPV) and 3) what causes diagnostic errors. HYPOTHESIS The BJI InoPlex has a sensitivity/specificity and PPV/NPV above 75%. MATERIALS AND METHODS The BJI InoPlex was used 24 times on 24 patients between January 2016 and January 2017 in scenarios where the microbiological diagnosis was difficult: 1 with on-going antibiotic therapy, 13 conflicting repeat joint aspirations, 10 negative cultures with history of infection and/or clinical evidence of a PJI. The series consisted of 11 hip arthroplasty and 13 knee arthroplasty cases. The results of the BJI InoPlex test were compared to the MusculoSkeletal Infection Society (MSIS) the criteria for a joint infection. RESULTS For the bacterial species covered by the test, the sensitivity of the BJI InoPlex for diagnosing a chronic PJI based on the 2018 MSIS criteria was 50%, the specificity was 56%, the PPV was 36% and the NPV was 69%. DISCUSSION While innovative, minimally invasive, and rapid (results in a few hours), the BJI InoPlex does not provide an effective diagnosis of chronic PJI in complex microbiological situations. In this study, we used the test in the most difficult situations possible and on a small number of patients, which may explain why the results were not as good as in other studies. Its current performance and cost mean there is no role for it in our algorithm for treating patients with a suspected PJI, contrary to other biomarkers. Its spectrum must include other bacterial strains involved in chronic PJI. Knowledge of the specific infectious agent increases its diagnostic value, it could be used to monitor the outcome of a PJI, although other studies would be needed to support this use. LEVEL OF EVIDENCE IV-Retrospective diagnostic study.
Collapse
Affiliation(s)
- Julien Dartus
- University Lille, CHU de Lille, ULR 4490, département universitaire de chirurgie orthopédique et traumatologique, 59000 Lille, France; CRIOAC, centre de référence pour le traitement des infections ostéo-articulaires complexes Lille-Tourcoing, rue Emile-Laine, 59037 Lille, France; CHU de Lille, service de chirurgie orthopédique, hôpital Roger-Salengro, 2, avenue Oscar-Lambret, 59000 Lille, France.
| | - Pierre Martinot
- University Lille, CHU de Lille, ULR 4490, département universitaire de chirurgie orthopédique et traumatologique, 59000 Lille, France; CRIOAC, centre de référence pour le traitement des infections ostéo-articulaires complexes Lille-Tourcoing, rue Emile-Laine, 59037 Lille, France; CHU de Lille, service de chirurgie orthopédique, hôpital Roger-Salengro, 2, avenue Oscar-Lambret, 59000 Lille, France
| | - Jean-Thomas Leclerc
- CRIOAC, centre de référence pour le traitement des infections ostéo-articulaires complexes Lille-Tourcoing, rue Emile-Laine, 59037 Lille, France; CHU de Lille, service de chirurgie orthopédique, hôpital Roger-Salengro, 2, avenue Oscar-Lambret, 59000 Lille, France; Service de chirurgie orthopédique, CHU de Québec-université Laval, 2325, rue de l'Université, Québec, QC G1V 0A6, Canada
| | - Eric Senneville
- University Lille, CHU de Lille, ULR 4490, département universitaire de chirurgie orthopédique et traumatologique, 59000 Lille, France; CRIOAC, centre de référence pour le traitement des infections ostéo-articulaires complexes Lille-Tourcoing, rue Emile-Laine, 59037 Lille, France; Service de maladie infectieuses et du voyageur, CH Dron, rue du Président-Coty, 59208 Tourcoing, France
| | - Frédéric Wallet
- University Lille, CHU de Lille, ULR 4490, département universitaire de chirurgie orthopédique et traumatologique, 59000 Lille, France; CRIOAC, centre de référence pour le traitement des infections ostéo-articulaires complexes Lille-Tourcoing, rue Emile-Laine, 59037 Lille, France; CHU de Lille, service de bactériologie-hygiène, centre de biologie-pathologie, 59000 Lille, France
| | - Sophie Putman
- University Lille, CHU de Lille, ULR 4490, département universitaire de chirurgie orthopédique et traumatologique, 59000 Lille, France; CRIOAC, centre de référence pour le traitement des infections ostéo-articulaires complexes Lille-Tourcoing, rue Emile-Laine, 59037 Lille, France; CHU de Lille, service de chirurgie orthopédique, hôpital Roger-Salengro, 2, avenue Oscar-Lambret, 59000 Lille, France
| | - Henri Migaud
- University Lille, CHU de Lille, ULR 4490, département universitaire de chirurgie orthopédique et traumatologique, 59000 Lille, France; CRIOAC, centre de référence pour le traitement des infections ostéo-articulaires complexes Lille-Tourcoing, rue Emile-Laine, 59037 Lille, France; CHU de Lille, service de chirurgie orthopédique, hôpital Roger-Salengro, 2, avenue Oscar-Lambret, 59000 Lille, France
| | - Caroline Loiez
- University Lille, CHU de Lille, ULR 4490, département universitaire de chirurgie orthopédique et traumatologique, 59000 Lille, France; CRIOAC, centre de référence pour le traitement des infections ostéo-articulaires complexes Lille-Tourcoing, rue Emile-Laine, 59037 Lille, France; CHU de Lille, service de bactériologie-hygiène, centre de biologie-pathologie, 59000 Lille, France
| |
Collapse
|
16
|
Low prevalence of tissue detection of cefepime and daptomycin used as empirical treatment during revision for periprosthetic joint infections: results of a prospective multicenter study. Eur J Clin Microbiol Infect Dis 2021; 40:2285-2294. [PMID: 34014434 DOI: 10.1007/s10096-021-04277-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/10/2021] [Indexed: 10/21/2022]
Abstract
Data demonstrating that antibiotics administered intraoperatively in patients with surgical revision for periprosthetic joint infection achieve concentrations exceeding minimal inhibitory concentrations of the identified bacteria at the surgical site when the new implant is inserted are lacking. We prospectively included patients with periprosthetic joint infection operated with one- or two-stage replacement during which cefepime (2g)-daptomycin (10mg/kg) combination was administered intravenously as intraoperative empirical antibiotic treatment. Three biopsies (two bones and one synovial membrane) were taken from each patient just before the insertion of the new implant. Eighteen adults of median age 68 years were included. Knee was involved in 10 patients (55.6%) and surgery consisted in one-/two-stage replacement in 11/7 patients. A tourniquet was used during the intervention in the 10 patients with knee prosthesis. Among 54 tissue samples, cefepime and daptomycin were detected respectively in 35 (64.8%) and 21 (38.9%) cases (P=0.01). A total of 17 bacteria dominated by staphylococci (n=14) were identified in 10 patients; tissue inhibitory quotient calculated in 51 samples was >1 in 22 cases (43.1%) for cefepime and in 16 cases (31.4%) for daptomycin. The proportion of tissue samples with detectable antibiotic was significantly higher in hip versus knee prosthesis (P=0.03). The present study suggests that intraoperative empirical administration of cefepime-daptomycin combination during septic prosthetic joint replacement results in a high proportion of tissue samples in which at least one of the two antibiotics was not detected or at a low concentration despite satisfactory concomitant blood serum concentrations.
Collapse
|
17
|
Lipsky BA, Uçkay İ. Treating Diabetic Foot Osteomyelitis: A Practical State-of-the-Art Update. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:339. [PMID: 33916055 PMCID: PMC8066570 DOI: 10.3390/medicina57040339] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/17/2022]
Abstract
Background and Objectives: Diabetic foot osteomyelitis (DFO) can be difficult to treat and securing optimal clinical outcomes requires a multidisciplinary approach involving a wide variety of medical, surgical and other health care professionals, as well as the patient. Results of studies conducted in the past few years have allowed experts to formulate guidelines that can improve clinical outcomes. Material and Methods: We conducted a narrative review of the literature on treat- ment of DFO, with an emphasis on studies published in the last two years, especially regarding antimicrobial therapies and surgical approached to treatment of DFO, supplemented by our own extensive clinical and research experience in this field. Results: Major amputations were once com- mon for DFO but, with improved diagnostic and surgical techniques, "conservative" surgery (foot- sparing, resecting only the infected and necrotic bone) is becoming commonplace, especially for forefoot infections. Traditional antibiotic therapy, which has been administered predominantly in- travenously and frequently for several months, can often be replaced by appropriately selected oral antibiotic regimens following only a brief (or even no) parenteral therapy, and given for no more than 6 weeks. Based on ongoing studies, the recommended duration of treatment may soon be even shorter, especially for cases in which a substantial portion of the infected bone has been resected. Using the results of cultures (preferably of bone specimens) and antimicrobial stewardship princi- ples allows clinicians to select evidence-based antibiotic regimens, often of a limited pathogen spec- trum. Intra-osseous antimicrobial and surgical approaches to treatment are also evolving in light of ongoing research. Conclusions: In this narrative, evidenced-based review, taking consideration of principles of antimicrobial stewardship and good surgical practice, we have highlighted the recent literature and offered practical, state-of-the-art advice on the antibiotic and surgical management of DFO.
Collapse
Affiliation(s)
- Benjamin A. Lipsky
- Department of Medicine, University of Washington, Seattle, WA 98116, USA
| | - İlker Uçkay
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland;
| |
Collapse
|
18
|
Occult infection in pseudarthrosis revision after spinal fusion. Spine J 2021; 21:370-376. [PMID: 33080375 DOI: 10.1016/j.spinee.2020.10.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/22/2020] [Accepted: 10/13/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Pseudarthrosis after attempted spinal fusion is yet not sufficiently understood and presents a surgical challenge. Occult infections are sometimes observed in patients with pseudarthrosis and no inflammatory signs of infection. The prevalence of such occult infection and its association with patient demographics and inflammatory markers are largely unknown. PURPOSE To determine the prevalence of unexpected low-grade infection in spinal pseudarthrosis revision surgery, and to evaluate whether such infection is associated with patient demographics and inflammatory markers. STUDY DESIGN Retrospective observational study. PATIENT SAMPLE One-hundred-and-twenty-eight patients who underwent thoracolumbar revision surgery due to presumed aseptic pseudarthrosis after spinal instrumentation. OUTCOME MEASURES Culture-positive infections or noninfectious pseudarthrosis. METHODS Samples were routinely taken for microbiological examination from all adults (n=152) who underwent revision surgery for presumed aseptic thoracolumbar pseudarthrosis between 2014 and 2019. A full intraoperative microbiological workup (at least three intraoperative tissue samples) was done for 128 (84%) patients, and these patients were included in further analyses. Patient characteristics, medical history, inflammatory markers, and perioperative data were compared between those with and without microbiologically-confirmed infection based on samples obtained during pseudarthrosis revision. RESULTS The microbiological workup confirmed infection in 13 of 128 cases (10.2%). The predominant pathogen was Cutibacterium acnes (46.2%), followed by coagulase-negative staphylococci (38.5%). The presence of infection was associated with the body mass index (30.9±4.7 kg/m2 [infected] vs. 28.2±5.6 kg/m2 [controls], p=.049), surgery in the thoracolumbar region (46% vs. 18%, p=.019), and a slightly higher serum C-reactive protein level on admission (9.4±8.0 mg/L vs. 5.7±7.1 mg/L, p=.031). Occult infection was not associated with age, sex, prior lumbar surgeries, number of fused lumbar levels, American Society of Anesthesiologist score, Charlson Comorbidity Index, presence of diabetes mellitus, and smoking status. CONCLUSIONS Occult infections were found in 10% of patients undergoing pseudarthrosis revision after spinal fusion, even without preoperative clinical suspicion. Occult infection was associated with higher body mass index, fusions including the thoracolumbar junction, and slightly higher C-reactive protein levels. Intraoperative microbiological samples should be routinely obtained to exclude or identify occult infection in all revision surgeries for symptomatic pseudarthrosis of the spine, as this information can be used to guide postoperative antibiotic treatment.
Collapse
|
19
|
Brinker MR, Macek J, Laughlin M, Dunn WR. Utility of Common Biomarkers for Diagnosing Infection in Nonunion. J Orthop Trauma 2021; 35:121-127. [PMID: 33105452 DOI: 10.1097/bot.0000000000001925] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the diagnostic utility of leukocyte count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) for distinguishing between septic and aseptic nonunions. DESIGN A single-gate (cohort) design was used, using 1 set of eligibility criteria applied to a consecutive sample of nonunions. SETTING Private quaternary referral center. PATIENTS/PARTICIPANTS Inclusion criteria were consecutive patients (≥18 years) with a nonunion requiring surgery that allowed for direct or medullary canal tissue sampling from the nonunion site. The cohort included 204 subjects with 211 nonunions. INTERVENTION Blood samples were drawn for laboratory analysis of WBC, ESR, and CRP before surgery. MAIN OUTCOME MEASUREMENTS The reference standard used to define infection was the fracture-related infection confirmatory criteria. Measures of diagnostic accuracy were calculated. To assess the additional diagnostic gain of each index lab test while simultaneously considering the others, logistic regression models were fit. RESULTS The prevalence of infection was 19% (40 of 211 nonunion sites). The positive likelihood ratios (95% confidence interval) for WBC, ESR, and CRP were 1.07 (0.38-3.02), 1.27 (0.88-1.82) and 1.57 (0.94-2.60), respectively. Multivariable modeling adjusted for the effect of preoperative antibiotics showed that WBC (P = 0.42), ESR (P = 0.48), and CRP (P = 0.23) were not significant predictors of infection. CONCLUSIONS In this consecutive sample of 211 nonunions in whom standard clinical practice would be to obtain index lab tests, our findings showed that WBC, ESR, and CRP were not significant predictors of infection. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Mark R Brinker
- Fondren Orthopedic Research Institute, Houston, TX
- Fondren Orthopedic Group, Houston, TX; and
- Texas Orthopedic Hospital, Houston, TX
| | - Jenny Macek
- Fondren Orthopedic Group, Houston, TX; and
- Texas Orthopedic Hospital, Houston, TX
| | | | | |
Collapse
|
20
|
Uçkay I, Holy D, Betz M, Sauer R, Huber T, Burkhard J. Osteoarticular infections: a specific program for older patients? Aging Clin Exp Res 2021; 33:703-710. [PMID: 31494913 DOI: 10.1007/s40520-019-01329-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/16/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND With the increasing number of elderly patients, arthroplasties, fractures and diabetic foot infections, the worldwide number of osteoarticular infections (OAI) among the elderly is concomitantly expected to rise. AIMS We explore existing scientific knowledge about OAI in the frail elderly population. METHODS We performed a literature search linking OAIs to geriatric patients and comparing elderly patients (> 65 years) with average adults (range 18-65 years). RESULTS In this literature, financial aspects, comparison of diverse therapies on quality of life, reimbursement policies, or specific guidelines or nursing recommendations are missing. Age itself was not an independent factor related to particular pathogens, prevention of OAI, nursing care, and outcomes of OAI. However, geriatric patients were significantly more exposed to adverse events of therapy. They had more co-morbidities and more conservative surgery for OAI. CONCLUSION Available literature regarding OAI management among elderly patients is sparse. In recent evaluations, age itself does not seem an independent factor related to particular epidemiology, pathogens, prevention, nursing care, rehabilitation and therapeutic outcomes of OAI. Future clinical research will concern more conservative surgical indications, but certainly reduce inappropriate antibiotic use.
Collapse
Affiliation(s)
- Ilker Uçkay
- Infectiology, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.
- Infection Control, Balgrist University Hospital, Zurich, Switzerland.
| | - Dominique Holy
- Internal Medicine, Balgrist University Hospital, Zurich, Switzerland
| | - Michael Betz
- Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Regina Sauer
- Nursing Care, Balgrist University Hospital, Zurich, Switzerland
| | - Tanja Huber
- Pharmacy, Balgrist University Hospital, Zurich, Switzerland
| | - Jan Burkhard
- Infection Control, Balgrist University Hospital, Zurich, Switzerland
- Internal Medicine, Balgrist University Hospital, Zurich, Switzerland
| |
Collapse
|
21
|
McGuire A, Krysa N, Mann S. Hair of the Dog? Periprosthetic Joint Infection with Streptococcus can is. Arthroplast Today 2021; 8:53-56. [PMID: 33718556 PMCID: PMC7921709 DOI: 10.1016/j.artd.2021.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/17/2021] [Accepted: 01/21/2021] [Indexed: 11/27/2022] Open
Abstract
A 61-year-old man underwent elective primary total hip arthroplasty at an academic center and presented to the emergency department 2 weeks later with a periprosthetic infection. Intraoperative cultures were positive for Streptococcus canis. He was successfully treated with one-stage revision and 6 weeks of intravenous cefazolin. It was later determined that the patient has a pet dog who frequently licks his legs. We hypothesize that patients with pets are more likely to carry this pathogen as part of their skin microbiome, and further research is required to establish whether S. canis poses an infectious risk beyond that of normal group B Streptococcus skin flora and if preoperative decolonization strategies are warranted.
Collapse
Affiliation(s)
- Andrew McGuire
- Division of Orthopaedic Surgery, Queen's University and Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Nicole Krysa
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Steve Mann
- Division of Orthopaedic Surgery, Queen's University and Kingston Health Sciences Centre, Kingston, Ontario, Canada
| |
Collapse
|
22
|
Oenning S, Moellenbeck B, Gosheger G, Schmidt-Bräkling T, Schwarze J, Ackmann T, Schneider KN, Theil C. Fungal Periprosthetic Knee Joint Infection in a Patient with Metamizole-Induced Agranulocytosis. Arthroplast Today 2020; 6:726-730. [PMID: 32923558 PMCID: PMC7475080 DOI: 10.1016/j.artd.2020.07.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/17/2020] [Accepted: 07/25/2020] [Indexed: 12/25/2022] Open
Abstract
We present the case of a 55-year-old female patient with metamizole-induced agranulocytosis after total knee arthroplasty, leading to septic periprosthetic joint infections (PJIs). Owing to metamizole-induced agranulocytosis, the synovial leukocyte count was negative. Here, we discuss the diagnostic challenges evolving from sepsis and neutropenia in patients with suspected PJIs. We suggest an urgent surgical approach, mainly focusing on the clinical presentation preoperatively. Later, our patient developed candidemia and periprosthetic tissue samples were positive for Candida albicans. For fungal PJIs, long-term follow-up studies are lacking and therapeutic recommendations differ. Here, we present our therapeutic approach, including staged revision and 12 weeks of systemic antifungal therapy, and discuss recent findings regarding the therapy of fungal PJIs.
Collapse
Affiliation(s)
- Sebastian Oenning
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Burkhard Moellenbeck
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Georg Gosheger
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Tom Schmidt-Bräkling
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Jan Schwarze
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Thomas Ackmann
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Kristian Nikolaus Schneider
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Christoph Theil
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| |
Collapse
|
23
|
Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining. J Clin Med 2020; 9:jcm9072190. [PMID: 32664491 PMCID: PMC7408657 DOI: 10.3390/jcm9072190] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 02/06/2023] Open
Abstract
A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting.
Collapse
|
24
|
Principles and practice of antibiotic stewardship in the management of diabetic foot infections. Curr Opin Infect Dis 2020; 32:95-101. [PMID: 30664029 DOI: 10.1097/qco.0000000000000530] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Systemic antibiotic therapy in persons with a diabetic foot infection (DFI) is frequent, increasing the risk of promoting resistance to common pathogens. Applying principles of antibiotic stewardship may help avoid this problem. RECENT FINDINGS We performed a systematic review of the literature, especially seeking recently published studies, for data on the role and value of antibiotic stewardship (especially reducing the spectrum and duration of antibiotic therapy) in community and hospital populations of persons with a DFI. SUMMARY We found very few publications specifically concerning antibiotic stewardship in persons with a DFI. The case-mix of these patients is substantial and infection plays only one part among several chronic problems. As with other types of infections, attempting to prevent infections and avoiding or reducing the spectrum and duration of antibiotic therapy are perhaps the best ways to reduce antibiotic prescribing in the DFI population. The field is complex and necessitates knowledge over the current scientific literature and clinical experience. On a larger scale, clinical pathways, guidelines, and recommendations are additionally supportive.
Collapse
|
25
|
Longo UG, Candela V, Facchinetti G, Marchetti A, Dsoke S, Mazzella C, Risi Ambrogioni L, De Marinis MG, Denaro V. Antibiotic prophylaxis in primary and revision shoulder replacement: a systematic review. BMC Musculoskelet Disord 2020; 21:292. [PMID: 32393217 PMCID: PMC7216509 DOI: 10.1186/s12891-020-03332-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/06/2020] [Indexed: 01/05/2023] Open
Abstract
Background One of the most common bacteria responsible for most Periprosthetic joint infection (PJI) is Propionibacterium acnes. Even though the rate of infections in patients undergoing total shoulder arthroplasty is increasing, effective diagnostic tests and the precautions taken during the surgery are not yet adequate. This systematic review aims to evaluate the effectiveness of antimicrobial prophylaxis in PJI in shoulder replacement and to provide health workers with the best approach to the use of antimicrobial agents based on currently available clinical evidence. Methods a systematic review of the literature was carried out in accordance with the PRISMA Statement. Studies concerning the effectiveness of antimicrobial prophylaxis in the prevention of PJI in patients undergoing shoulder replacement were included. Results Seven studies were included in the final analysis because they were considered valid. A total of 3272 patients underwent a surgical procedure, most of which were males. The male population has a greater presence of hair, therefore a greater risk of P. acnes. in surface cultures. Patients were assessed at an average follow-up period of 20 months ranging from 9 weeks to 53 months. Conclusion The optimal perioperative antimicrobial regimen is controversial. The clinical guidelines recommend the use of only one antibiotic as prophylaxis but considering the increase in the rates of antibiotic-resistant infections, the question arises whether antibiotic prophylaxis should be extended for adequate coverage. Shoulder arthroplasty performed on the male population must be carefully checked after surgery for the possible presence of P. Acnes.
Collapse
Affiliation(s)
- Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy.
| | - Vincenzo Candela
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy
| | | | - Anna Marchetti
- Research Unit Nursing Science, Campus Bio-Medico di Roma University, Rome, Italy
| | - Silvia Dsoke
- Research Unit Nursing Science, Campus Bio-Medico di Roma University, Rome, Italy
| | - Claudia Mazzella
- Research Unit Nursing Science, Campus Bio-Medico di Roma University, Rome, Italy
| | - Laura Risi Ambrogioni
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy
| | | | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy
| |
Collapse
|
26
|
Ammann E, Uçkay I, Bouaicha S, Wieser K, Meyer DC. Little benefit of surgical anchor and suture removal and of antibiotic therapy beyond 6 weeks in infected rotator cuff repair. J Shoulder Elbow Surg 2020; 29:830-837. [PMID: 31668502 DOI: 10.1016/j.jse.2019.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/18/2019] [Accepted: 07/28/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to investigate the benefit of surgical anchor and/or suture removal and prolonged antibiotic therapy in acute and chronic infections of rotator cuff repair (RCIs). METHODS A single-center cohort and case-control study (Cox regression) was performed. Outcome variables were remission of infection and postinfection reoperations due to failed tendon healing for mechanical causes. All analyses were performed with an emphasis on anchor and suture retention or removal. RESULTS We identified 54 primary RCIs (44 men; median age 54 years) that were surgically revised (10 by open débridement and 44 by arthroscopy). Twenty-eight (52%) were not intact on revision surgery (débridement) - 10 were partially and 18 totally re-ruptured. The median number of surgical revisions was 1 (range, 1-3), and the median duration of postsurgical antibiotic therapy was 75 days. After a minimal follow-up of 2 years, 8 infections (8/54, 15%) recurred. Twenty patients needed a revision surgery; in all of those 20 patients, intraoperative samples were negative for infection. By multivariate analysis, anchor removal at the first revision influenced neither remission (hazard ratio [HR] 0.9, 95% confidence interval [CI] 0.4-2.0) nor the need for later revision surgery due to mechanical sequelae (HR 0.6, 95% CI 0.1-1.4). The corresponding HRs for suture removal were 0.9 (95% CI 0.4-1.7) and 0.4 (95% CI 0.1-1.2). Likewise, the numbers of revision surgery (HR 0.5, 95% CI 0.2-1.3) and antibiotics beyond 6 weeks failed to influence remission (HR 1.1, 95% CI 0.4-3.1). CONCLUSIONS In our RCI cohort, the removal of anchors or sutures, repeated revision surgery, or an antibiotic therapy beyond 6 weeks failed to improve remission or to reduce sequelae.
Collapse
Affiliation(s)
- Elias Ammann
- Department of Orthopedics, Shoulder and Elbow Team, Applied Research, Balgrist University Hospital, Zürich, Switzerland
| | - Ilker Uçkay
- Infectiology, Applied Research, Balgrist University Hospital, Zürich, Switzerland; Unit for Clinical and Applied Research, Balgrist University Hospital, Zürich, Switzerland.
| | - Samy Bouaicha
- Department of Orthopedics, Shoulder and Elbow Team, Applied Research, Balgrist University Hospital, Zürich, Switzerland
| | - Karl Wieser
- Department of Orthopedics, Shoulder and Elbow Team, Applied Research, Balgrist University Hospital, Zürich, Switzerland
| | - Dominik C Meyer
- Department of Orthopedics, Shoulder and Elbow Team, Applied Research, Balgrist University Hospital, Zürich, Switzerland
| |
Collapse
|
27
|
Ertuğrul B, Uçkay I, Schöni M, Peter-Riesch B, Lipsky BA. Management of diabetic foot infections in the light of recent literature and new international guidelines. Expert Rev Anti Infect Ther 2020; 18:293-305. [PMID: 32052672 DOI: 10.1080/14787210.2020.1730177] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: In May 2019 the International Working Group on the Diabetic Foot (IWGDF) launched their quadrennially updated guidelines on the management of diabetic foot infections (DFIs). Concomitantly, the number of new publications regarding DFI increased.Areas covered: The IWGDF committee developed and addressed key questions and produced evidence-based recommendations related to diagnosing and treating DFIs. This narrative review provides an overview of this new guideline and also of other recently published literature in the field of DFIs.Expert opinion: The 2019 IWGDF guidelines provide an authoritative, international, evidence-based approach to diagnosing and treating DFIs. The 27 recommendations are supported by systematic reviews of both diagnosis and interventions. Our review of this guideline, along with other recent publications in the field, allows us to offer state-of-the-art guidance for caring for these difficult infections. As the evidence base for management of DFIs remains suboptimal, we need further research to improve the management of DFIs.
Collapse
Affiliation(s)
- Bülent Ertuğrul
- Infectious Diseases and Clinical Microbiology, Adnan Menderes University, Aydın, Turkey
| | - Ilker Uçkay
- Infectiology, Balgrist University Hospital, Zurich, Switzerland
| | - Madlaina Schöni
- Orthopedic Department, Balgrist University Hospital, Zurich, Switzerland
| | | | | |
Collapse
|
28
|
Jenny JY. Specificities of total hip and knee arthroplasty revision for infection. Orthop Traumatol Surg Res 2020; 106:S27-S34. [PMID: 31813779 DOI: 10.1016/j.otsr.2019.05.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 05/06/2019] [Accepted: 05/24/2019] [Indexed: 02/02/2023]
Abstract
Hip or knee revision for infection requires careful planning of the debridement phase. Bacteriological sample management needs to be planned. Multidisciplinary decisions have to be taken as to 1- or 2-stage strategy, reconstruction technique and soft-tissue management. Surgical resection should be complete while economical. There must be no shortcomings in the technical procedure. Implant removal and surgical debridement are the keys to curing the infection, and planning is essential to optimize this phase. Bacteriological techniques are well codified. Wide-spectrum curative antibiotic therapy should be initiated immediately after intraoperative sampling and secondarily adapted to culture findings. A high-level microbiology laboratory is indispensable to good quality treatment. Prophylactic antibiotic therapy is controversial, but probably contributive. Two-stage exchange has not demonstrated superiority in curing infection. A 1-stage procedure may be preferred if all prerequisites are met. In the knee, any need for flap coverage should be planned for rather than encountered intraoperatively. The principles of reconstruction are unchanged by infection, but extended resection may require a larger revision implant. The temptation to oversimplify has to be resisted, and non-escalation or indeed "de-escalation" in implant size should be sought. Bone defect management is unaffected by infection. Fixation technique is at the surgeon's discretion. Pain relief and functional results are probably less good than after exchange without infectious context. The creation of regional complex bone and joint infection centers in France (CRIOACs) constitutes a considerable advance in periprosthetic infection management, and an opinion should be systematically requested; transfer is to be considered on a case-by-case basis.
Collapse
Affiliation(s)
- Jean-Yves Jenny
- Pôle Locomax, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France.
| |
Collapse
|
29
|
Li L, Xu L, Zhu R, Song J, Wang X. Effect of prior receipt of antibiotics on the pathogen distribution: a retrospective observational cohort study on 27,792 patients. BMC Infect Dis 2020; 20:8. [PMID: 31906848 PMCID: PMC6945440 DOI: 10.1186/s12879-019-4724-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 12/22/2019] [Indexed: 01/09/2023] Open
Abstract
Background There have been no systematic studies of microbiological differences before and after antibiotics treatment. The aim of this study was to evaluate the effect of prior receipt of antibiotics on the microorganism distribution. Methods A retrospective, observational cohort study was conducted in a 3200-bed tertiary, referral, teaching hospital in eastern China. During a 2-year period, all hospitalized patients treated with antimicrobial agents were enrolled in this study. Among 48,692 patients evaluated, the 27,792 (57.1%) who were sampled within 2 days before or after administration of the first dose of antimicrobial agents were included. Distribution of clinical specimens and the microorganism were compared between before and after antibiotic drug treatment groups. Results Compared to specimens taken after antibiotics exposure, specimens taken before antibiotics exposure had a higher proportion of blood and urine specimens and a higher culture positive rate (all P < 0.001). Higher percentages of Staphylococcus aureus (9.9% vs. 8.5%, P = 0.041), non-fermenting bacteria (27.7% vs. 19.9%, P < 0.001), and fungi (8.4% vs. 4.0%, P < 0.001) were isolated from the group after antibiotics exposure, while the percentages of Streptococcus spp. (4.8% vs. 2.7%, P < 0.001), Haemophilus influenzae (2.3% vs. 0.8%, P < 0.001), and Moraxella catarrhalis (0.7% vs. 0.1%, P < 0.001) were higher in the group before antibiotics exposure. Further analysis found significant differences of microbes derived from respiratory secretions, blood or urine samples. We found, after antibiotics exposure, the separation rate of non-fermenting bacteria was significantly increased (all P < 0.05), and the separation rate of Candida spp. was higher, with statistical significance in airway secretion and urine samples (both P < 0.05), but the separation rate of Staphylococcus aureus among the three groups was not affected by antibiotics. In addition, the isolation rate of Streptococcus spp. in blood and urine samples decreased significantly (both P < 0.05) after antibiotics exposure. Interestingly, no statistical difference was found for microbes isolated from body fluid specimens between the two groups. Conclusions The outcome revealed that antibiotic-insensitive organisms such as non-fermentative bacteria and fungi were more frequently isolated after antibiotics exposure. However, this trend might be specimen dependent and was not obvious in body fluid specimens.
Collapse
Affiliation(s)
- Leiqing Li
- Department of Critical Care Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Lingcheng Xu
- Department of Infection Prevention and Control, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Rongsheng Zhu
- Department of Infection Prevention and Control, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Jiaojiao Song
- Department of Infection Prevention and Control, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Xuanding Wang
- Department of Infection Prevention and Control, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, China.
| |
Collapse
|
30
|
Wuarin L, Abbas M, Harbarth S, Waibel F, Holy D, Burkhard J, Uçkay I. Changing perioperative prophylaxis during antibiotic therapy and iterative debridement for orthopedic infections? PLoS One 2019; 14:e0226674. [PMID: 31851708 PMCID: PMC6919616 DOI: 10.1371/journal.pone.0226674] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/02/2019] [Indexed: 12/03/2022] Open
Abstract
Background Perioperative antibiotic prophylaxis in non-infected orthopedic surgery is evident, in contrast to prophylaxis during surgery for infection. Epidemiological data are lacking for this particular situation. Methods and findings It is a single-center cohort on iterative surgical site infections (SSIs) in infected orthopedic patients. We included 2480 first episodes of orthopedic infections (median age 56 years and 833 immune-suppressed): implant-related infections (n = 648), osteoarticular infections (1153), and 1327 soft tissue infections. The median number of debridement was 1 (range, 1–15 interventions). Overall, 1617 infections (65%) were debrided once compared to 862 cases that were operated multiple times (35%). Upon iterative intraoperative tissue sampling, we detected pathogens in 507 cases (507/862; 59%), of which 241 (242/507; 48%) corresponded to the initial species at the first debridement. We witnessed 265 new SSIs (11% of the cohort) that were resistant to current antibiotic therapy in 174 cases (7% of the cohort). In multivariate analysis, iterative surgical debridements that were performed under current antibiotic administration were associated with new SSIs (odds ratio 1.6, 95%CI 1.2–2.2); mostly occurring after the 2nd debridement. However, we failed to define an ideal hypothetic prophylaxis during antibiotic therapy to prevent further SSIs. Conclusions Selection of new pathogens resistant to ongoing antibiotic therapy occurs frequently during iterative debridement in orthopedic infections, especially after the 2nd debridement. The new pathogens are however unpredictable. The prevention, if feasible, probably relies on surgical performance and wise indications for re-debridement instead of new maximal prophylactic antibiotic coverage in addition to current therapeutic regimens.
Collapse
Affiliation(s)
- Lydia Wuarin
- Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
| | - Mohamed Abbas
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
| | - Felix Waibel
- Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Dominique Holy
- Internal Medicine, Balgrist University Hospital, Zurich, Switzerland
- Infectiology and Infection Control, Balgrist University Hospital, Zurich, Switzerland
| | - Jan Burkhard
- Internal Medicine, Balgrist University Hospital, Zurich, Switzerland
- Infectiology and Infection Control, Balgrist University Hospital, Zurich, Switzerland
| | - Ilker Uçkay
- Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
- Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland
- Internal Medicine, Balgrist University Hospital, Zurich, Switzerland
- Infectiology and Infection Control, Balgrist University Hospital, Zurich, Switzerland
- Unit for Clinical and Applied Research, Balgrist University Hospital, Zurich, Switzerland
- * E-mail:
| |
Collapse
|
31
|
Ye J, Deng J, Chen Y, Yang T, Zhu Y, Wu C, Wu T, Jia J, Cheng X, Wang X. Cicada and catkin inspired dual biomimetic antibacterial structure for the surface modification of implant material. Biomater Sci 2019; 7:2826-2832. [PMID: 31065627 DOI: 10.1039/c9bm00082h] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Implant infections frequently occur in various kinds of surgery. Apart from antibiotics, the surface modification of implant material is a promising avenue to resolve this global problem. An ideal implant interface is expected to possess good biocompatibility, as well as broad-spectrum and long-term bacterial inhibition capabilities. Here, a delicate cicada and catkin inspired dual biomimetic structure was proposed, for the first time, to improve the antibacterial properties of implant material. By using poly(ether-ether-ketone) (PEEK) as a model implant, the relative in vitro and in vivo evaluations demonstrated that this dual biomimetic structure could simultaneously provide less bacterial adhesion, wider antimicrobial range and longer antibacterial durability. Meanwhile, the modified implant also retained ideal biocompatibility. Most importantly, the relative dual biomimetic structure engineering process could be accomplished through a simple, economic and fast hydrothermal chemical reaction, which might have an impact on the development of future biomedical materials.
Collapse
Affiliation(s)
- Jing Ye
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Nanchang University, NanChang, 330006, P.R. China.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Hellebrekers P, Rentenaar RJ, McNally MA, Hietbrink F, Houwert RM, Leenen LPH, Govaert GAM. Getting it right first time: The importance of a structured tissue sampling protocol for diagnosing fracture-related infections. Injury 2019; 50:1649-1655. [PMID: 31208777 DOI: 10.1016/j.injury.2019.05.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 05/18/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Fracture-related infection (FRI) is an important complication following surgical fracture management. Key to successful treatment is an accurate diagnosis. To this end, microbiological identification remains the gold standard. Although a structured approach towards sampling specimens for microbiology seems logical, there is no consensus on a culture protocol for FRI. The aim of this study is to evaluate the effect of a structured microbiology sampling protocol for fracture-related infections compared to ad-hoc culture sampling. METHODS We conducted a pre-/post-implementation cohort study that compared the effects of implementation of a structured FRI sampling protocol. The protocol included strict criteria for sampling and interpretation of tissue cultures for microbiology. All intraoperative samples from suspected or confirmed FRI were compared for culture results. Adherence to the protocol was described for the post-implementation cohort. RESULTS In total 101 patients were included, 49 pre-implementation and 52 post-implementation. From these patients 175 intraoperative culture sets were obtained, 96 and 79 pre- and post-implementation respectively. Cultures from the pre-implementation cohort showed significantly more antibiotic use during culture sampling (P = 0.002). The post-implementation cohort showed a tendency more positive culture sets (69% vs. 63%), with a significant difference in open wounds (86% vs. 67%, P = 0.034). In all post-implementation culture sets causative pathogens were cultured more than once per set, in contrast to pre-implementation. Despite stricter tissue sampling and culture interpretation criteria, the number of polymicrobial infections was similar in both cohorts, approximately 29% of all culture sets and 44% of all positive culture sets. Significantly more polymicrobial cultures were found in early infections in the post-implementation cohort (P = 0.048). This indicates a better yield in the new protocol. CONCLUSION A standardised protocol for intraoperative sampling for bacterial identification in FRI is superior than an ad-hoc approach. It has a positive effect on both surgeon and microbiologist by increasing awareness about the problem at hand. This resulted in more microbiologically confirmed infections and more certainty when identifying causative pathogens.
Collapse
Affiliation(s)
- P Hellebrekers
- Department of Traumasurgery, University Medical Center Utrecht, the Netherlands
| | - R J Rentenaar
- Department of Medical Microbiology, University Medical Center Utrecht, the Netherlands
| | - M A McNally
- Department of Orthopaedic Surgery, Oxford University Hospitals, United Kingdom
| | - F Hietbrink
- Department of Traumasurgery, University Medical Center Utrecht, the Netherlands
| | - R M Houwert
- Department of Traumasurgery, University Medical Center Utrecht, the Netherlands
| | - L P H Leenen
- Department of Traumasurgery, University Medical Center Utrecht, the Netherlands
| | - G A M Govaert
- Department of Traumasurgery, University Medical Center Utrecht, the Netherlands.
| |
Collapse
|
33
|
Rossel A, Lebowitz D, Gariani K, Abbas M, Kressmann B, Assal M, Tscholl P, Stafylakis D, Uçkay I. Stopping antibiotics after surgical amputation in diabetic foot and ankle infections-A daily practice cohort. Endocrinol Diabetes Metab 2019; 2:e00059. [PMID: 31008367 PMCID: PMC6458464 DOI: 10.1002/edm2.59] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/28/2018] [Accepted: 12/30/2018] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE The appropriate duration of antibiotic therapy for diabetic foot infections (DFI) after surgical amputations in toto is debated. There are discrepancies worldwide. METHODS Using a clinical pathway for adult DFI patients (retrospective cohort analysis), we conducted a cluster-controlled Cox regression analysis. Minimum follow-up was 2 months. RESULTS We followed 482 amputated DFI episodes for a median of 2.1 years after the index episode. The DFIs predominately affected the forefoot (n = 433; 90%). We diagnosed osteomyelitis in 239 cases (239/482; 50%). In total, 47 cases (10%) were complicated by bacteremia, 86 (18%) by abscesses and 139 (29%) presented with cellulitis. Surgical amputation involved the toes (n = 155), midfoot (280) and hindfoot (47). Overall, 178 cases (37%) required revascularization. After amputation, the median duration of antibiotic administration was 7 days (interquartile range, 1-16 days). In 109 cases (25%), antibiotics were discontinued immediately after surgery. Overall, clinical failure occurred in 90 DFIs (17%), due to the same pathogens in only 38 cases. In multivariate analysis, neither duration of total postsurgical antibiotic administration (HR 1.0, 95% CI 0.99-1.01) nor immediate postoperative discontinuation altered failure rate (HR 0.9, 0.5-1.5). CONCLUSION According to our clinical pathway, we found no benefit in continuing postsurgical antibiotic administration in routine amputation for DFI. In the absence of residual infection (ie, resection at clear margins), antibiotics should be discontinued.
Collapse
Affiliation(s)
- Anne Rossel
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
| | - Dan Lebowitz
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
| | - Karim Gariani
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Service of Diabetology and EndocrinologyGeneva University HospitalsGenevaSwitzerland
| | - Mohamed Abbas
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Infection Control ProgramGeneva University HospitalsGenevaSwitzerland
| | - Benjamin Kressmann
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
| | - Mathieu Assal
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- La Colline Hirslanden ClinicGenevaSwitzerland
| | - Philippe Tscholl
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
- Balgrist University HospitalZurichSwitzerland
| | - Dimitrios Stafylakis
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
| | - Ilker Uçkay
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Infection Control ProgramGeneva University HospitalsGenevaSwitzerland
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
- Balgrist University HospitalZurichSwitzerland
| |
Collapse
|
34
|
Effects of Antibiotic Timing on Culture Results and Clinical Outcomes in Pediatric Musculoskeletal Infection. J Pediatr Orthop 2019; 39:158-162. [PMID: 30730421 DOI: 10.1097/bpo.0000000000000884] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Musculoskeletal infection (MSI) is a common cause of morbidity and hospital resource utilization in the pediatric population. Many physicians prefer to withhold antibiotics until tissue cultures can be taken in an effort to improve culture yields. However, there is little evidence that this practice improves culture results or outcomes in pediatric MSI. Therefore, investigating the effects of antibiotic timing may lead to improved clinical practice guidelines for treating children with MSI. METHODS An IRB-approved retrospective review was conducted that identified 113 patients aged 0 to 18 who presented to the pediatric emergency room at a tertiary care children's hospital with MSI from 2008 to 2013. Demographic data, culture results, severity markers, and intervention timing were obtained from the medical record. Logistic regression and Cox survival analysis were performed to determine the relationship of antibiotic timing with culture sensitivity and time to discharge. RESULTS No difference was seen in culture sensitivity antibiotic administration in either the local (55% culture before antibiotics vs. 89% after antibiotics) or disseminated group (76% before vs. 79% after), which persisted when further accounting for disease severity with C-reactive protein. However, later administration of antibiotics in the local infection group correlated with a decreased likelihood of discharge (3.91 d when cultured before antibiotics vs. 2.93 d when cultured after antibiotics; hazard ratio, 0.53; P<0.05). In patients with disseminated infection, antibiotic administration was not shown to correlate with any difference in time to discharge (hazard ratio, 1.08). CONCLUSIONS The authors were surprised to find that tissue culture sensitivities were not decreased by antibiotic administration in either local or disseminated MSI, suggesting that antibiotic administration should not be delayed to obtain tissue cultures. The correlation of earlier antibiotic administration with shorter length of stay in children with local MSI led the authors to conclude that antibiotics should be initiated as quickly as possible. Further study is necessary to confirm these findings and establish clinical practice guidelines. LEVEL OF EVIDENCE Level III-retrospective cohort.
Collapse
|
35
|
New diagnostic tools for prosthetic joint infection. Orthop Traumatol Surg Res 2019; 105:S23-S30. [PMID: 30056239 DOI: 10.1016/j.otsr.2018.04.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/20/2018] [Accepted: 04/26/2018] [Indexed: 02/02/2023]
Abstract
The diagnosis of peri-prosthetic bone and joint infections relies on converging information from clinical, laboratory and imaging assessments. Clinical findings alone may suffice: a sinus tract is a major criterion that establishes the diagnosis of infection. Identifying the causative organism is crucial and requires the early collection of high-quality samples from sites in contact with the prosthetic material. The bacteriological samples may be obtained by aspiration or open surgery. Imaging techniques have undergone remarkable improvements over the last two decades. Ultrasonography can be performed early and can be used to guide a needle biopsy if appropriate. Computed tomography or magnetic resonance imaging shows the extent of bone and/or soft-tissue involvement, provided effective artefact-suppression techniques are applied. Nuclear medicine methods have an undefined place in the diagnostic strategy and their possible role must be evaluated during a multidisciplinary discussion. The array of new laboratory methods introduced in recent years includes microbiological culture techniques, molecular biology tests, antigen and antibody assays and tests for immune markers in blood and/or joint fluid. When the first-line investigations fail to provide a definitive diagnosis, a multidisciplinary discussion at a referral centre for complex osteo-articular infections makes a major contribution to defining the subsequent diagnostic strategy. This lecture focusses on the following six questions: does the clinical assessment still have diagnostic relevance? What is the diagnostic contribution of imaging studies? Must the infection be documented pre-operatively and if so, how? Which microbiological techniques should be used? Which non-microbiological investigations help to diagnosis peri-prosthetic bone and joint infections? What role do referral centres for complex bone and joint infections play in the diagnostic strategy?
Collapse
|
36
|
van der Merwe M, Rooks K, Crawford H, Frampton CMA, Boyle MJ. The effect of antibiotic timing on culture yield in paediatric osteoarticular infection. J Child Orthop 2019; 13:114-119. [PMID: 30838084 PMCID: PMC6376441 DOI: 10.1302/1863-2548.13.180077] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To assess the influence of antibiotic timing on surgical culture yield in paediatric patients with haematogenous osteoarticular infection. METHODS All patients aged 0 to 15 years admitted to a National Children's Hospital with the diagnosis of acute, haematogenous, osteoarticular infection (osteomyelitis and/or septic arthritis) between June 1997 and December 2016 were retrospectively analyzed. Only patients with positive blood cultures undergoing surgery for culture and debridement were included. Patients were allocated into pre-treatment and post-treatment groups, according to whether they received antibiotics before or after surgical cultures were obtained. Outcomes measured included baseline variables, treatment characteristics and surgical culture yield. RESULTS A total of 131 patients were included; 107 patients in the pre-treatment group and 24 patients in the post-treatment group. There was no significant difference with respect to patient age (p = 0.870), white blood cell count (p = 0.197), ethnicity (p = 0.203) or infection multi-focality (p = 0.883) between the two groups.The administration of systemic antibiotics prior to obtaining surgical cultures had no clinically significant effect on surgical culture yield (rate of positive surgical cultures, 85% (pre-treatment) versus 54.2% (post-treatment); p = 0.002). Within the pre-treatment group, there was no significant difference in duration of pre-surgical antibiotic treatment between patients who had positive or negative surgical cultures (mean duration, 45.9 hours (positive cultures) versus 47.9 hours (negative cultures); p = 0.743). CONCLUSION In paediatric patients with acute, haematogenous, osteoarticular infection, antibiotic administration before surgery does not decrease surgical culture yield. Our results suggest that paediatric patients presenting with suspected osteoarticular infection should receive appropriate systemic antibiotics promptly after blood cultures are obtained. LEVEL OF EVIDENCE Level III - retrospective case-control study.
Collapse
Affiliation(s)
- M. van der Merwe
- Department of Paediatric Orthopaedics, Starship Children’s Hospital, Auckland, New Zealand, Correspondence should be sent to M. van der Merwe, MBChB, Department of Paediatric Orthopaedics, Starship Children’s Hospital, Auckland, New Zealand. E-mail:
| | - K. Rooks
- Department of Paediatric Orthopaedics, Starship Children’s Hospital, Auckland, New Zealand
| | - H. Crawford
- Department of Paediatric Orthopaedics, Starship Children’s Hospital, Auckland, New Zealand
| | - C. M. A. Frampton
- Department of Medicine, The University of Otago, Christchurch, New Zealand
| | - M. J. Boyle
- Department of Paediatric Orthopaedics, Starship Children’s Hospital, Auckland, New Zealand
| |
Collapse
|
37
|
Davat M, Wuarin L, Stafylakis D, Abbas M, Harbarth S, Hannouche D, Uçkay I. Should antibiotic prophylaxis before orthopedic implant surgery depend on the duration of pre-surgical hospital stay? Antimicrob Resist Infect Control 2018; 7:131. [PMID: 30455869 PMCID: PMC6223050 DOI: 10.1186/s13756-018-0421-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 10/11/2018] [Indexed: 11/19/2022] Open
Abstract
Background Prolonged hospital stay before surgery is a risk for colonization with antibiotic-resistant microorganisms and possible antibiotic-resistant surgical site infections (SSI), which lacks acknowledgement in international guidelines for perioperative antibiotic prophylaxis. Method Retrospective cohort study focusing on prophylaxis-resistant SSI in adult orthopedic implant patients; with emphasis on length of hospital stay prior to the index surgery. Results We enrolled 611 cases of SSI (median age, 65 years; 241 females and 161 immune-suppressed) in four large implant groups: arthroplasties (n = 309), plates (n = 127), spondylodeses (n = 31), and nails (n = 46). The causative pathogen was resistant to the perioperative antibiotic prophylaxis regimen in 307 cases (307/611; 50%), but the length of pre-surgical hospitalization did not influence the incidences of prophylaxis-resistant SSIs. These incidences were (107/211;51%) for the admission day, (170/345;49%) within 10 days of delay, (19/35;54%) between 10 and 20 days, and (11/20; 55%) beyond 20 days of hospital stay before surgery. The corresponding incidences of methicillin-resistant staphylococci were 13%, 14%, 17%, and 5%, respectively. In adjusted group comparisons, the length of prior hospital stay was equally unrelated to future prophylaxis-resistant SSI (odds ratio 1.0, 95% confidence interval 0.99-1.01). Conclusions In our retrospective cohort of orthopedic implant SSI, the length of pre-surgical hospital stay was unrelated to the incidence of prophylaxis-resistant pathogens.
Collapse
Affiliation(s)
- Marie Davat
- Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
| | - Lydia Wuarin
- Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
| | | | - Mohamed Abbas
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
| | - Didier Hannouche
- Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
| | - Ilker Uçkay
- Infectiology, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland
| |
Collapse
|
38
|
Lauper N, Davat M, Gjika E, Müller C, Belaieff W, Pittet D, Lipsky BA, Hannouche D, Uçkay I. Native septic arthritis is not an immediate surgical emergency. J Infect 2018; 77:47-53. [PMID: 29742468 DOI: 10.1016/j.jinf.2018.02.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 01/21/2018] [Accepted: 02/07/2018] [Indexed: 12/23/2022]
Abstract
Acute native joint septic arthritis is generally considered a surgical emergency, requiring drainage within hours, including during night, weekend or holiday shifts. However, there are few data supporting the need for the disruption caused by this degree of urgency. METHODS We performed a retrospective review of all adult patients seen in our medical center from 1997-2015 with culture-proven septic arthritis and noted the epidemiology of sequelae, and their possible association with a delay in surgical drainage. RESULTS Of 204 septic arthritis episodes, 46 (23%) involved interdigital hand and foot joints. Large joints involved included the knee (n = 67), shoulder (48), hip (22), ankle (8), acromio-clavicular (5), elbow (4), wrist (3), and sterno-clavicular (1) regions. All patients underwent surgical drainage of the joint and received targeted systemic antibiotic therapy. Sequelae of varying severity occurred in 83 patients (41%): recurrences (n = 15); secondary arthrosis (30); persistent pain (9); Girdlestone procedure (9); arthrodesis (9); amputation (8); stiffness (8); and Chronic Regional Pain Syndrome (2). By multivariate Cox regression analysis factors did not predict sequelae included: age; treatment with systemic corticosteroids; pre-existing clinical or radiological arthropathy; total duration of antibiotic therapy; type of joint; and, number of surgical interventions. Similarly, there was no association of sequelae with the number of days of pre-hospitalization joint symptoms (hazard ratio 1.0, 95% confidence interval 0.99-1.01) or hours spent in the emergency department (HR 1.0, 0.9-1.2). Notably, patients who had joint lavage within 6 h of presentation had similar functional outcomes as those with lavage done at 6-12 h, 12-24 h, or > 24 h after presentation. CONCLUSIONS Our data suggest that for native septic arthritis, in the absence of clinical sepsis immediate joint drainage does not appear to reduce the risk of sequelae compared with delayed drainage.
Collapse
Affiliation(s)
- Nicolas Lauper
- Orthopaedic Surgery Service, Geneva University Hospitals
| | - Marie Davat
- Orthopaedic Surgery Service, Geneva University Hospitals
| | - Ergys Gjika
- Orthopaedic Surgery Service, Geneva University Hospitals; Hand Surgery Unit, Geneva University Hospitals
| | - Camillo Müller
- Orthopaedic Surgery Service, Geneva University Hospitals; Hand Surgery Unit, Geneva University Hospitals
| | | | - Didier Pittet
- Service of Infectious Diseases, Geneva University Hospitals; Infection Control Program, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals; Division of Medical Sciences, University of Oxford, UK
| | | | - Ilker Uçkay
- Orthopaedic Surgery Service, Geneva University Hospitals; Service of Infectious Diseases, Geneva University Hospitals; Infection Control Program, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| |
Collapse
|
39
|
Perioperative Antibiotic Prophylaxis Has No Effect on Time to Positivity and Proportion of Positive Samples: a Cohort Study of 64 Cutibacterium acnes Bone and Joint Infections. J Clin Microbiol 2018; 56:JCM.01576-17. [PMID: 29167293 DOI: 10.1128/jcm.01576-17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 11/20/2017] [Indexed: 12/12/2022] Open
Abstract
If a bone or joint infection is suspected, perioperative antibiotic prophylaxis is frequently withheld until intraoperative microbiological sampling has been performed. This practice builds upon the hypothesis that perioperative antibiotics could render culture results negative and thus impede tailored antibiotic treatment of infections. We aimed to assess the influence of antibiotic prophylaxis within 30 to 60 min before surgery on time to positivity of microbiological samples and on proportion of positive samples in Cutibacterium acnes bone and joint infections. Patients with at least one sample positive for C. acnes between January 2005 and December 2015 were included and classified as having an "infection" if at least 2 samples were positive; otherwise they were considered to have a sample "contamination." Kaplan-Meier curves were used to illustrate time to culture positivity. We found 64 cases with a C. acnes infection and 46 classified as having a C. acnes contamination. Application of perioperative prophylaxis significantly differed between the infection and contamination groups (72.8% versus 55.8%; P < 0.001). Within the infection group, we found no difference in time to positivity between those who had or had not received a perioperative prophylaxis (7.07 days; 95% confidence interval [CI], 6.4 to 7.7, versus 7.11 days; 95% CI, 6.8 to 7.5; P = 0.3). Also, there was no association between the proportion of sample positivity and the application of perioperative prophylaxis (71.6% versus 65.9%; P = 0.39). Since perioperative prophylaxis did not negatively influence the microbiological yield in C. acnes infections, antibiotic prophylaxis can be routinely given to avoid surgical site infections.
Collapse
|
40
|
Wouthuyzen-Bakker M, Benito N, Soriano A. The Effect of Preoperative Antimicrobial Prophylaxis on Intraoperative Culture Results in Patients with a Suspected or Confirmed Prosthetic Joint Infection: a Systematic Review. J Clin Microbiol 2017; 55:2765-2774. [PMID: 28659322 PMCID: PMC5648712 DOI: 10.1128/jcm.00640-17] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 06/23/2017] [Indexed: 02/08/2023] Open
Abstract
Obtaining reliable cultures during revision arthroplasty is important to adequately diagnose and treat a prosthetic joint infection (PJI). The influence of antimicrobial prophylaxis on culture results remains unclear. Since withholding prophylaxis increases the risk for surgical site infections, clarification on this topic is critical. A systematic review was performed with the following research question: in patients who undergo revision surgery of a prosthetic joint, does preoperative antimicrobial prophylaxis affect the culture yield of intraoperative samples in comparison with nonpreoperative antimicrobial prophylaxis? Seven articles were included in the final analysis. In most studies, standard diagnostic culture techniques were used. In patients with a PJI, pooled analysis showed a culture yield of 88% (145/165) in the prophylaxis group versus 95% (344/362) in the nonprophylaxis group (P = 0.004). Subanalysis of patients with chronic PJIs showed positive cultures in 88% (78/89) versus 91% (52/57), respectively (P = 0.59). In patients with a suspected chronic infection, a maximum difference of 4% in culture yield between the prophylaxis and nonprophylaxis groups was observed. With the use of standard culture techniques, antimicrobial prophylaxis seems to affect cultures in a minority of patients. Along with the known risk of surgical site infections due to inadequate timing of antimicrobial prophylaxis, we discourage the postponement of prophylaxis until tissue samples are obtained in revision surgery. Future studies are necessary to conclude whether the small percentage of false-negative cultures after prophylaxis can be further reduced with the use of more-sensitive culture techniques, like sonication.
Collapse
Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Natividad Benito
- Infectious Diseases Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alex Soriano
- Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| |
Collapse
|
41
|
Tumminello A, Dominguez D, Lebowitz D, Bartolone P, Betz M, Hannouche D, Uçkay I. Staphylococcus aureus versus streptococci in orthopaedic infections. Infect Dis (Lond) 2017; 49:716-718. [DOI: 10.1080/23744235.2017.1318219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Antonio Tumminello
- Orthopedic Surgery Service, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Dennis Dominguez
- Orthopedic Surgery Service, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Dan Lebowitz
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Placido Bartolone
- Orthopedic Surgery Service, Faculty of Medicine, University of Geneva, Switzerland
| | - Michael Betz
- Orthopedic Surgery Service, Faculty of Medicine, University of Geneva, Switzerland
| | - Didier Hannouche
- Orthopedic Surgery Service, Faculty of Medicine, University of Geneva, Switzerland
| | - Ilker Uçkay
- Orthopedic Surgery Service, Faculty of Medicine, University of Geneva, Switzerland
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| |
Collapse
|
42
|
Lebowitz D, Gariani K, Kressmann B, Dach EV, Huttner B, Bartolone P, Lê N, Mohamad M, Lipsky BA, Uçkay I. Are antibiotic-resistant pathogens more common in subsequent episodes of diabetic foot infection? Int J Infect Dis 2017; 59:61-64. [PMID: 28450198 DOI: 10.1016/j.ijid.2017.04.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 04/08/2017] [Accepted: 04/13/2017] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND After antibiotic therapy of an initial diabetic foot infection (DFI), pathogens isolated from subsequent episodes might become more resistant to commonly prescribed antibiotics. If so, this might require a modification of the current recommendations for the selection of empiric antibiotic therapy. This study investigated whether the Infectious Diseases Society of America (IDSA) DFI guideline recommendations should be modified based on the number of past DFI episodes. METHODS This was a single-centre retrospective cohort survey of DFI patients seen during the years 2010 to 2016. RESULTS A total 1018 episodes of DFI in 482 adult patients were identified. These patients were followed-up for a median of 3.3 years after the first DFI episode. The total number of episodes was 2257 and the median interval between recurrent episodes was 7.6 months. Among the recurrent DFIs, the causative pathogens were the same as in the previous episode in only 43% of cases (158/365). Staphylococcus aureus was the predominant pathogen in all episodes (range 1 to 13 episodes) and was not more prevalent with the increasing number of episodes. DFIs were treated with systemic antibiotics for a median duration of 20 days (interquartile range 11-35 days). Overall, there was no significant increase in the incidence of antibiotic resistance to methicillin, rifampicin, clindamycin, or ciprofloxacin over the episodes (Pearson's Chi-square test p-values of 0.76, 1.00, 0.06, and 0.46, respectively; corresponding p-values for trend of 0.21, 0.27, 0.38, and 0.08, respectively). CONCLUSIONS After the successful treatment of a DFI, recurrent episodes are frequent. A history of a previous DFI episode did not predict a greater likelihood of any antibiotic-resistant isolate in subsequent episodes. Thus, broadening the spectrum of empiric antibiotic therapy for recurrent episodes of DFI does not appear necessary.
Collapse
Affiliation(s)
- Dan Lebowitz
- Service of General Internal Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4, rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland
| | - Karim Gariani
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4, rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland; Service of Diabetology and Endocrinology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin Kressmann
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4, rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland; Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elodie von Dach
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benedikt Huttner
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4, rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland; Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Placido Bartolone
- Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nam Lê
- Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Morad Mohamad
- Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4, rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland; University of Oxford, Oxford, UK
| | - Ilker Uçkay
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4, rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland; Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| |
Collapse
|
43
|
Liao H, Miao X, Ye J, Wu T, Deng Z, Li C, Jia J, Cheng X, Wang X. Falling Leaves Inspired ZnO Nanorods-Nanoslices Hierarchical Structure for Implant Surface Modification with Two Stage Releasing Features. ACS APPLIED MATERIALS & INTERFACES 2017; 9:13009-13015. [PMID: 28371577 DOI: 10.1021/acsami.7b00666] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Inspired from falling leaves, ZnO nanorods-nanoslices hierarchical structure (NHS) was constructed to modify the surfaces of two widely used implant materials: titanium (Ti) and tantalum (Ta), respectively. By which means, two-stage release of antibacterial active substances were realized to address the clinical importance of long-term broad-spectrum antibacterial activity. At early stages (within 48 h), the NHS exhibited a rapid releasing to kill the bacteria around the implant immediately. At a second stage (over 2 weeks), the NHS exhibited a slow releasing to realize long-term inhibition. The excellent antibacterial activity of ZnO NHS was confirmed once again by animal test in vivo. According to the subsequent experiments, the ZnO NHS coating exhibited the great advantage of high efficiency, low toxicity, and long-term durability, which could be a feasible manner to prevent the abuse of antibiotics on implant-related surgery.
Collapse
Affiliation(s)
- Hang Liao
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nanchang University , Nanchang, Jiangxi 330006, China
| | - Xinxin Miao
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nanchang University , Nanchang, Jiangxi 330006, China
| | - Jing Ye
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nanchang University , Nanchang, Jiangxi 330006, China
| | - Tianlong Wu
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nanchang University , Nanchang, Jiangxi 330006, China
| | - Zhongbo Deng
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nanchang University , Nanchang, Jiangxi 330006, China
| | - Chen Li
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nanchang University , Nanchang, Jiangxi 330006, China
| | - Jingyu Jia
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nanchang University , Nanchang, Jiangxi 330006, China
| | - Xigao Cheng
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nanchang University , Nanchang, Jiangxi 330006, China
| | - Xiaolei Wang
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nanchang University , Nanchang, Jiangxi 330006, China
- Institute of Translational Medicine, NanChang University , NanChang, Jiangxi 330031, China
| |
Collapse
|
44
|
Meier R, Wirth T, Hahn F, Vögelin E, Sendi P. Pyogenic Arthritis of the Fingers and the Wrist: Can We Shorten Antimicrobial Treatment Duration? Open Forum Infect Dis 2017; 4:ofx058. [PMID: 28491895 PMCID: PMC5419293 DOI: 10.1093/ofid/ofx058] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 03/21/2017] [Indexed: 12/13/2022] Open
Abstract
Background Pyogenic arthritis of the small joints of the hand and wrist is a known but poorly described entity. The objective of this work was to characterize the clinical presentation, antimicrobial treatment, and surgical interventions of native small joint arthritis (SJA) treated in our tertiary center. Methods According to predefined variables, medical records of adult patients with SJA treated in a Swiss university hospital between 2005 and 2013 were retrospectively analyzed. Results The median age of 97 patients (101 joints) was 52 years (interquartile range [IQR], 38–68 years); 52% had no comorbidity. Small joint arthritis of the second and third fingers accounted for 53% of infections, with metacarpal-phalangeal and proximal interphalangeal joints most commonly involved. Of 86 (89%) episodes with an exogenous source, 63 (65%) followed a trauma. The most commonly isolated microorganism was Staphylococcus aureus (38%), followed by β-hemolytic streptococci (13%) and Pasteurella spp (11%). Eighty-seven episodes (89 joints) in patients with follow-up examinations were included in treatment and outcome analyses. Up to 2 surgical interventions were required to cure infection in 74 (83%) joints. Median antimicrobial treatment duration was 14 days (IQR, 12–28 days), with amoxicillin/clavulanate administered in 74 (85%) episodes. At follow up, cure of infection was noted in all episodes and good functional outcome in 79% of episodes. Conclusions Small joint arthritis shows considerable differences from clinical patterns reported for larger joints. In our series, the outcome was good with no more than 2 surgical interventions and median treatment duration of 14 days in 79% of episodes.
Collapse
Affiliation(s)
| | - Thomas Wirth
- Department of General Surgery, Inselgruppe Aarberg, Switzerland
| | - Frederik Hahn
- Division of Hand Surgery, Department of Orthopedics, University of Zurich, Switzerland
| | | | - Parham Sendi
- Infectious Diseases, Inselspital, Bern University Hospital and.,Institute of Infectious Diseases, University of Bern, Switzerland
| |
Collapse
|
45
|
Young H, Miller W, Burnham R, Heard S, Berg C, Jenkins TC. How Do Preoperative Antibiotics Affect Culture Yield in Diabetic Foot Infections? Open Forum Infect Dis 2017; 4:ofx016. [PMID: 28480287 PMCID: PMC5414107 DOI: 10.1093/ofid/ofx016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 02/06/2017] [Indexed: 11/15/2022] Open
Abstract
The impact of preoperative antibiotics on culture of diabetic foot infection samples has not been studied. We found that increasing exposure to preoperative antibiotics was associated with less frequent growth of streptococci and anaerobes and more culture-negative results. In contrast, the yield of Staphylococcus aureus and Gram-negative bacilli was unaffected.
Collapse
Affiliation(s)
| | - Whitney Miller
- Division of Infectious Diseases, Denver Health Medical Center, Colorado
| | - Randy Burnham
- Research and Consulting Services, Rocky Mountain Poison and Drug Center, Denver, Colorado
| | - Susan Heard
- Research and Consulting Services, Rocky Mountain Poison and Drug Center, Denver, Colorado
| | - Chrystal Berg
- Department of Orthopedic Surgery, Denver Health Medical Center and University of Colorado Hospital
| | | |
Collapse
|
46
|
Jentzsch T, Osterhoff G, Zwolak P, Seifert B, Neuhaus V, Simmen HP, Jukema GN. Bacterial reduction and shift with NPWT after surgical debridements: a retrospective cohort study. Arch Orthop Trauma Surg 2017; 137:55-62. [PMID: 27988849 DOI: 10.1007/s00402-016-2600-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Surgical debridement, negative-pressure wound therapy (NPWT) and antibiotics are used for the treatment of open wounds. However, it remains unclear whether this treatment regimen is successful in the reduction and shift of the bacterial load. METHODS After debridement in the operating room, NPWT, and antibiotic treatment, primary and secondary consecutive microbiological samples of 115 patients with 120 open wounds with bacterial or yeast growth in ≥1 swab or tissue microbiological sample(s) were compared for bacterial growth, Gram staining and oxygen use at a level one trauma center in 2011. RESULTS Secondary samples had significantly less bacterial growth (32 vs. 89%, p < .001, OR 17), Gram-positive bacteria (56 vs. 78%, p = .013), facultative anaerobic bacteria (64 vs. 85%, p = .011) and Staphylococcus aureus (10 vs. 46%, p = .002). They also tended to include relatively more Coagulase-negative Staphylococci (CoNS) (44 vs. 18%) and Pseudomonas species (spp.) (31 vs. 7%). Most (98%) wounds were successfully closed within 11 days, while wound revision was needed in 4%. CONCLUSIONS The treatment regimen of combined use of repetitive debridement, irrigation and NPWT in an operating room with antibiotics significantly reduced the bacterial load and led to a shift away from Gram-positive bacteria, facultative anaerobic bacteria, and S. aureus, as well as questionably toward CoNS and Pseudomonas spp. in this patient cohort. High rates of wound closure were achieved in a relatively short time with low revision rates. Whether each modality played a role for these findings remains unknown.
Collapse
Affiliation(s)
- Thorsten Jentzsch
- Division of Trauma Surgery, Department of Surgery, University Hospital Zürich, University of Zürich, Rämistrasse 100, 8091, Zürich, Switzerland.
| | - Georg Osterhoff
- Division of Trauma Surgery, Department of Surgery, University Hospital Zürich, University of Zürich, Rämistrasse 100, 8091, Zürich, Switzerland
| | - Pawel Zwolak
- Division of Trauma Surgery, Department of Surgery, University Hospital Zürich, University of Zürich, Rämistrasse 100, 8091, Zürich, Switzerland
| | - Burkhardt Seifert
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Zürich, Switzerland
| | - Valentin Neuhaus
- Division of Trauma Surgery, Department of Surgery, University Hospital Zürich, University of Zürich, Rämistrasse 100, 8091, Zürich, Switzerland
| | - Hans-Peter Simmen
- Division of Trauma Surgery, Department of Surgery, University Hospital Zürich, University of Zürich, Rämistrasse 100, 8091, Zürich, Switzerland
| | - Gerrolt N Jukema
- Division of Trauma Surgery, Department of Surgery, University Hospital Zürich, University of Zürich, Rämistrasse 100, 8091, Zürich, Switzerland
| |
Collapse
|
47
|
Lebowitz D, Kressmann B, Gjoni S, Zenelaj B, Grosgurin O, Marti C, Zingg M, Uçkay I. Clinical features of anaerobic orthopaedic infections. Infect Dis (Lond) 2016; 49:137-140. [PMID: 27581503 DOI: 10.1080/23744235.2016.1225979] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Some patient populations and types of orthopaedic surgery could be at particular risk for anaerobic infections. In this retrospective cohort study of operated adult patients with infections from 2004 to 2014, we assessed obligate anaerobes and considered first clinical infection episodes. Anaerobes, isolated from intra-operative samples, were identified in 2.4% of 2740 surgical procedures, of which half (33/65; 51%) were anaerobic monomicrobial infections. Propionibacterium acnes, a penicillin and vancomycin susceptible pathogen, was the predominantly isolated anaerobe. By multivariate analysis, the presence of fracture fixation plates was the variable most strongly associated with anaerobic infection (odds ratio: 2.1, 95% CI: 1.3-3.5). Anaerobes were also associated with spondylodesis and polymicrobial infections. In contrast, it revealed less likely in native bone or prosthetic joint infections and was not related to prior antibiotic use. In conclusion, obligate anaerobes in our case series of orthopaedic infections were rare, and mostly encountered in infections related to trauma with open-fracture fixation devices rather than clean surgical site infection. Anaerobes were often co-pathogens, and cultures most frequently recovered P. acnes. These observations thus do not support changes in current practices such as broader anaerobe coverage for perioperative prophylaxis.
Collapse
Affiliation(s)
- Dan Lebowitz
- a Division of General Internal Medicine , Geneva University Hospitals and Faculty of Medicine , Geneva , Switzerland
| | - Benjamin Kressmann
- b Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine , Geneva , Switzerland.,c Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine , Geneva , Switzerland
| | - Shpresa Gjoni
- d Division of General Medical Rehabilitation , Geneva University Hospitals and Faculty of Medicine , Geneva , Switzerland
| | - Besa Zenelaj
- c Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine , Geneva , Switzerland
| | - Olivier Grosgurin
- a Division of General Internal Medicine , Geneva University Hospitals and Faculty of Medicine , Geneva , Switzerland
| | - Christophe Marti
- a Division of General Internal Medicine , Geneva University Hospitals and Faculty of Medicine , Geneva , Switzerland
| | - Matthieu Zingg
- c Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine , Geneva , Switzerland
| | - Ilker Uçkay
- b Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine , Geneva , Switzerland.,c Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine , Geneva , Switzerland
| |
Collapse
|
48
|
|