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Zelmer AR, Yang D, Gunn NJ, Solomon LB, Nelson R, Kidd SP, Richter K, Atkins GJ. Osteomyelitis-relevant antibiotics at clinical concentrations show limited effectivity against acute and chronic intracellular S. aureus infections in osteocytes. Antimicrob Agents Chemother 2024; 68:e0080824. [PMID: 39194210 PMCID: PMC11459924 DOI: 10.1128/aac.00808-24] [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: 06/02/2024] [Accepted: 08/09/2024] [Indexed: 08/29/2024] Open
Abstract
Osteomyelitis caused by Staphylococcus aureus can involve the persistent infection of osteocytes. We sought to determine if current clinically utilized antibiotics were capable of clearing an intracellular osteocyte S. aureus infection. Rifampicin, vancomycin, levofloxacin, ofloxacin, amoxicillin, oxacillin, doxycycline, linezolid, gentamicin, and tigecycline were assessed for their minimum inhibitory concentration (MIC) and minimum bactericidal concentrations against 12 S. aureus strains, at pH 5.0 and 7.2 to mimic lysosomal and cytoplasmic environments, respectively. Those antibiotics whose bone estimated achievable concentration was commonly above their respective MIC for the strains tested were further assayed in a human osteocyte infection model under acute and chronic conditions. Osteocyte-like cells were treated at 1×, 4×, and 10× the MIC for 1 and 7 days following infection (acute model), or at 15 and 21 days of infection (chronic model). The intracellular effectivity of each antibiotic was measured in terms of CFU reduction, small colony variant formation, and bacterial mRNA expression change. Only rifampicin, levofloxacin, and linezolid reduced intracellular CFU numbers significantly in the acute model. Consistent with the transition to a non-culturable state, few if any CFU could be recovered from the chronic model. However, no treatment in either model reduced the quantity of bacterial mRNA or prevented non-culturable bacteria from returning to a culturable state. These findings indicate that S. aureus adapts phenotypically during intracellular infection of osteocytes, adopting a reversible quiescent state that is protected against antibiotics, even at 10× their MIC. Thus, new therapeutic approaches are necessary to cure S. aureus intracellular infections in osteomyelitis.
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Affiliation(s)
- Anja R. Zelmer
- Center for Orthopedic and Trauma Research, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Dongqing Yang
- Center for Orthopedic and Trauma Research, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Nicholas J. Gunn
- Center for Orthopedic and Trauma Research, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - L. Bogdan Solomon
- Center for Orthopedic and Trauma Research, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
- Department of Orthopedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia
| | - Renjy Nelson
- Department of Infectious Diseases, Central Adelaide Local Health Network, Adelaide, Australia
| | - Stephen P. Kidd
- Australian Center for Antimicrobial Resistance Ecology, University of Adelaide, Adelaide, Australia
- Research Center for Infectious Disease, School of Biological Science, University of Adelaide, Adelaide, Australia
| | - Katharina Richter
- Department of Surgery, Richter Lab, Basil Hetzel Institute for Translational Health Research, University of Adelaide, Adelaide, Australia
- Institute for Photonics and Advanced Sensing, University of Adelaide, Adelaide, Australia
| | - Gerald J. Atkins
- Center for Orthopedic and Trauma Research, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
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Hammat AS, Nelson R, Davis JS, Manning L, Campbell D, Solomon LB, Gnanamanickam ES, Callary SA. Estimation of two-year hospital costs of hip and knee periprosthetic joint infection treatments using activity-based costing. Bone Joint J 2024; 106-B:1084-1092. [PMID: 39348903 DOI: 10.1302/0301-620x.106b10.bjj-2024-0106.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2024]
Abstract
Aims Our aim was to estimate the total costs of all hospitalizations for treating periprosthetic joint infection (PJI) by main management strategy within 24 months post-diagnosis using activity-based costing. Additionally, we investigated the influence of individual PJI treatment pathways on hospital costs within the first 24 months. Methods Using admission and procedure data from a prospective observational cohort in Australia and New Zealand, Australian Refined Diagnosis Related Groups were assigned to each admitted patient episode of care for activity-based costing estimates of 273 hip PJI patients and 377 knee PJI patients. Costs were aggregated at 24 months post-diagnosis, and are presented in Australian dollars. Results The mean cost per hip and knee PJI patient was $64,585 (SD $53,550). Single-stage revision mean costs were $67,029 (SD $47,116) and $80,063 (SD $42,438) for hip and knee, respectively. Two-stage revision costs were $113,226 (SD $66,724) and $122,425 (SD $60,874) for hip and knee, respectively. Debridement, antibiotics, and implant retention in hips and knees mean costs were $53,537 (SD$ 39,342) and $48,463 (SD $33,179), respectively. Suppressive antibiotic therapy without surgical management mean costs were $20,296 (SD $8,875) for hip patients and $16,481 (SD $6,712) for knee patients. Hip patients had 16 different treatment pathways and knee patients had 18 treatment pathways. Additional treatment, episodes of care, and length of stay contributed to substantially increased costs up to a maximum of $369,948. Conclusion Treating PJI incurs a substantial cost burden, which is substantially influenced by management strategy. With an annual PJI incidence of 3,900, the cost burden would be in excess of $250 million to the Australian healthcare system. Treatment pathways with additional surgery, more episodes of care, and a longer length of stay substantially increase the associated hospital costs. Prospectively monitoring individual patient treatment pathways beyond initial management is important when quantifying PJI treatment cost. Our study highlights the importance of optimizing initial surgical treatment, and informs treating hospitals of the resources required to provide care for PJI patients.
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Affiliation(s)
- Aaron S Hammat
- Centre of Orthopaedics and Trauma Research, The University of Adelaide, Adelaide, Australia
| | - Renjy Nelson
- Department of Infectious Diseases, Royal Adelaide Hospital, Adelaide, Australia
- Faculty of Health and Medical Science, The University of Adelaide, Adelaide, Australia
| | - Joshua S Davis
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
- Infection Research Program, Hunter Medical Research Institute, Newcastle, Australia
| | - Laurens Manning
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia
- Medical School, University of Western Australia, Perth, Australia
| | - David Campbell
- Centre of Orthopaedics and Trauma Research, The University of Adelaide, Adelaide, Australia
- Wakefield Orthopaedic Clinic, Calvary Adelaide Hospital, Adelaide, Australia
| | - Lucian B Solomon
- Centre of Orthopaedics and Trauma Research, The University of Adelaide, Adelaide, Australia
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia
| | - Emmanuel S Gnanamanickam
- Department of Infectious Diseases, Royal Adelaide Hospital, Adelaide, Australia
- Adelaide Centre for Clinical Epidemiology, The University of Adelaide, Adelaide, Australia
| | - Stuart A Callary
- Centre of Orthopaedics and Trauma Research, The University of Adelaide, Adelaide, Australia
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia
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Pérez M, Vicente M, Amat C, Lahoz B, Carrera L, Corona PS. Outcomes of a cemented modular rotational-hinge design as the final implant in a two-stage replacement due to chronic knee periprosthetic joint infection. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05516-x. [PMID: 39287785 DOI: 10.1007/s00402-024-05516-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 08/21/2024] [Indexed: 09/19/2024]
Affiliation(s)
- Marta Pérez
- Universitat Autònoma de Barcelona (UAB), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Universitat Autònoma de Barcelona (UAB), Bellaterra, Barcelona, Spain.
| | - Matías Vicente
- Universitat Autònoma de Barcelona (UAB), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Carles Amat
- Universitat Autònoma de Barcelona (UAB), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Berta Lahoz
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Lluís Carrera
- Universitat Autònoma de Barcelona (UAB), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Bellaterra, Barcelona, Spain
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Pablo S Corona
- Universitat Autònoma de Barcelona (UAB), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Bellaterra, Barcelona, Spain
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Barcelona, Spain
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Kristensen NK, Manning L, Lange J, Davis JS. External Validation of the Joint-Specific Bone Involvement, Antimicrobial Options, Coverage of the Soft Tissues, and Host Status (JS-BACH) Classification for Predicting Outcome in Periprosthetic Joint Infections: A Cohort of 653 Patients. J Arthroplasty 2024; 39:2352-2356.e2. [PMID: 38599531 DOI: 10.1016/j.arth.2024.03.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is a devastating complication in hip and knee joint arthroplasty. The "Joint-Specific Bone Involvement, Antimicrobial Options, Coverage of the Soft Tissues, and Host Status (JS-BACH)" classification system was developed in 2021 to stratify the complexity of PJI, and more importantly, to act as a tool to guide referrals to specialist centers. The "JS-BACH" classification has not been validated in an external cohort. This study aimed to do so using a large prospective cohort from Australia and New Zealand. METHODS We applied the JS-BACH classification to the Prosthetic Joint Infection in Australia and New Zealand Observational (PIANO) cohort. This prospective study of newly diagnosed PJI collected 2-year outcome data from 653 participants enrolled in 27 hospitals. The definition of PJI treatment failure at 24 months was any of the following: death, clinical or microbiological signs of infection, destination prosthesis removed, or ongoing antibiotic use. Individual cases were classified as per JS-BACH into "1: uncomplicated" (n = 268), "2: complex" (n = 330), and "3: limited options" (n = 55). This cohort was similar to the original JS-BACH population in terms of baseline characteristics. However, there was a difference in complexity, with more debridement, antibiotics, and implant retention procedures, fewer revision procedures, and a higher proportion of uncomplicated patients in the PIANO cohort. RESULTS The risk of treatment failure correlated strongly with the JS-BACH category, with odds ratios (95% confidence interval) for category 2 versus 1 of 1.75 (1.24 to 2.47) and for category 3 versus 1 of 7.12 (3.42 to 16.02). CONCLUSIONS Despite the PIANO study population being less complicated than the original derivation cohort, the JS-BACH classification showed a clear association with treatment failure in this large external cohort.
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Affiliation(s)
- Nicolai K Kristensen
- Department of Orthopedics, Regional Hospital of Horsens, Horsens, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Center for Planned Surgery, Regional Hospital of Silkeborg, Silkeborg, Denmark
| | - Laurens Manning
- Medical School, University of Western Australia, Perth, Western Australia, Australia; Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jeppe Lange
- Department of Orthopedics, Regional Hospital of Horsens, Horsens, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Joshua S Davis
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia; Infection Research Program, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
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Perdomo-Lizarraga JC, Combalia A, Fernández-Valencia JA, Alías A, Aponcio J, Morata L, Soriano A, Muñoz-Mahamud E. Successful prophylactic measures for the eradication of Staphylococcus aureus infections in elective hip primary and revision arthroplasty. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024:S1888-4415(24)00136-X. [PMID: 39121942 DOI: 10.1016/j.recot.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 07/25/2024] [Accepted: 08/04/2024] [Indexed: 08/12/2024] Open
Abstract
INTRODUCTION Staphylococcus aureus stands as the predominant etiological agent in postoperative acute prosthetic joint infections (PJI), contributing to 35-50% of reported cases. This study aimed to evaluate the efficacy of dual prophylaxis incorporating cefuroxime and teicoplanin, in combination with nasal decolonization utilizing 70% alcohol, and oral and body lavage with chlorhexidine. MATERIAL AND METHODS We conducted a retrospective review of electronic health records regarding primary and revision arthroplasties conducted at our institution from 2020 to 2021. Relevant variables linked to prosthetic joint infections (PJI) were documented until the latest follow-up. RESULTS A total of 539 operations (447 primary arthroplasties and 92 revision arthroplasties) were performed on 519 patients. There were 11 cases of postoperative acute PJI, resulting in infection rates of 1.6% for primary arthroplasties and 4.3% for revision surgeries. Infections were more prevalent in male patients, individuals with an ASA classification>II, and those undergoing longer operations (>90min). S. aureus was not isolated in any of the cases. CONCLUSION The prophylactic measures implemented in our institution have exhibited a high efficacy in preventing postoperative acute PJI caused by S. aureus.
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Affiliation(s)
- J C Perdomo-Lizarraga
- Department of Orthopaedics and Trauma Surgery, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - A Combalia
- Department of Orthopaedics and Trauma Surgery, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - J A Fernández-Valencia
- Department of Orthopaedics and Trauma Surgery, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - A Alías
- Department of Orthopaedics and Trauma Surgery, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - J Aponcio
- Department of Orthopaedics and Trauma Surgery, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - L Morata
- Department of Infectious Diseases, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - A Soriano
- Department of Infectious Diseases, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - E Muñoz-Mahamud
- Department of Orthopaedics and Trauma Surgery, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain.
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Tarabichi S, Lizcano JD, Abe EA, Goh GS, Baker CM, Parvizi J. Finding the Optimal Screening Test for Periprosthetic Joint Infection: A Prospective Study. J Arthroplasty 2024; 39:1919-1925.e2. [PMID: 38452860 DOI: 10.1016/j.arth.2024.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND No single test has demonstrated absolute accuracy in the diagnosis of periprosthetic joint infection (PJI). Serological markers are often used as screening tools to avoid unnecessary joint aspiration in cases with a low probability of infection. This study aimed to determine the utility of standard-of-care serological tests as a screening tool for PJI in patients undergoing revision arthroplasty. METHODS This prospective study enrolled 502 patients undergoing revision hip or knee arthroplasty between May 2017 and August 2021. A PJI was defined using a modified definition of the 2018 International Consensus Meeting criteria. Plasma D-dimer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen were measured preoperatively. There were 82 patients undergoing reimplantation who were excluded. Additionally, 8 patients who had an inconclusive International Consensus Meeting score were also excluded. Of the 412 included patients, 317 (76.9%) underwent revision for aseptic failure, and 95 (23.1%) had PJI. Receiver operating characteristic curves were used to assess the diagnostic utility of each serological test. A pairwise comparison with Bonferroni correction was performed to determine whether the differences in areas under the curve (AUCs) between the tests were significant. Additional analyses were performed to find the threshold for each test that offered 100% sensitivity, allowing it to be the optimal screening test. RESULTS All 4 serological markers, D-dimer (AUC 0.860, sensitivity 81.3%, specificity 81.7%), CRP (AUC 0.862, sensitivity 90.4%, specificity 70.0%), ESR (AUC 0.833, sensitivity 73.9%, specificity 85.2%), and fibrinogen (AUC 0.798, sensitivity 74.7%, specificity 75.4%), demonstrated comparable accuracy for the diagnosis of PJI (all P > .05). When maximizing sensitivity to 100%, D-dimer demonstrated the highest specificity (AUC 0.860, specificity 40.2%), outperforming ESR (AUC 0.833, specificity 3.3%), fibrinogen (AUC 0.798, specificity 2.3%), and CRP (AUC 0.862, specificity 0%). A plasma D-dimer level of ≥ 244 ng/mL was identified as the optimal cutoff for use as a screening test. CONCLUSIONS Although plasma D-dimer demonstrated similar diagnostic accuracy as CRP, ESR, and fibrinogen, it outperformed all 3 aforementioned serological markers when used as a screening test for PJI. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Saad Tarabichi
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Juan D Lizcano
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Elizabeth A Abe
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts
| | - Colin M Baker
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedic Surgery, Cleveland Clinic South Pointe, Cleveland, Ohio
| | - Javad Parvizi
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
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Tarabichi S, Johnson RM, Quinlan ND, Dennis DA, Parvizi J, Jennings JM. Commercial Synovial Antigen Testing is Inferior to Traditional Culture for the Diagnosis of Periprosthetic Joint Infection in Patients Undergoing Revision Total Knee Arthroplasty. J Arthroplasty 2024; 39:S300-S304.e2. [PMID: 38599530 DOI: 10.1016/j.arth.2024.03.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Despite its limitations, a culture remains the "gold standard" for pathogen identification in patients who have periprosthetic joint infection (PJI). Recently, a synovial fluid antigen test has been introduced by a commercial entity. The purpose of this multicenter study was to determine the accuracy of the antigen test in the diagnosis of PJI. METHODS This retrospective study identified 613 patients undergoing revision total knee arthroplasty who had undergone preoperative synovial fluid analysis. A PJI was defined using the 2018 International Consensus Meeting (ICM) criteria. Patients who had an extended period (> 180 days) from aspiration to revision procedure (n = 62), those presenting within 90 days of their index arthroplasty procedure (n = 17), and patients who had an inconclusive ICM score (n = 8) were excluded. Using receiver operator characteristic curve analyses, we examined the utility of the microbial identification (MID) antigen test and any positive culture (either preoperative or intraoperative) in the diagnosis of PJI. RESULTS A total of 526 patients were included. Of these, 125 (23.8%) were ICM positive and 401 (76.2%) were ICM negative. Culture demonstrated an area under the curve (AUC) of 0.864, sensitivity of 75.2%, and specificity of 97.5%. On the other hand, the MID test exhibited an AUC of 0.802, sensitivity of 61.6%, and specificity of 98.8%. The AUC of culture was significantly higher than that of the MID test (P = .037). The MID test was positive in 41.9% of culture-negative PJI cases. We also observed a high rate of discordance (29.7%) when both culture and the MID test were positive in the ICM-positive group. CONCLUSIONS Synovial fluid antigen testing does not provide additional clinical benefit when compared to traditional cultures for the diagnosis of PJI. The antigen test had low sensitivity in the diagnosis of PJI and a relatively high rate of discordance with culture. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Roseann M Johnson
- Colorado Joint Replacement, Orthopedic Sugery, AdventHealth Porter, Denver, Colorado
| | - Nicole D Quinlan
- Colorado Joint Replacement, Orthopedic Sugery, AdventHealth Porter, Denver, Colorado
| | - Douglas A Dennis
- Colorado Joint Replacement, Orthopedic Sugery, AdventHealth Porter, Denver, Colorado
| | - Javad Parvizi
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
| | - Jason M Jennings
- Colorado Joint Replacement, Orthopedic Sugery, AdventHealth Porter, Denver, Colorado
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Isler B, Niessen N, Campbell D, Toms AD, Daneman N, Manning L, Davis JS. Addressing important evidence gaps in the management of prosthetic joint infection: clinician attitudes and equipoise. ANZ J Surg 2024; 94:1211-1213. [PMID: 38553936 DOI: 10.1111/ans.18984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 08/28/2024]
Affiliation(s)
- Burcu Isler
- Faculty of Medicine, UQ Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
- Infection Management Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Natalie Niessen
- Infection Research Program, Hunter Medical Research Institute, University of Newcastle, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - David Campbell
- Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew D Toms
- Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon University Hospital, Exeter, UK
| | - Nick Daneman
- Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Laurens Manning
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Joshua S Davis
- Infection Research Program, Hunter Medical Research Institute, University of Newcastle, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
- Department of Infectious Diseases, John Hunter Hospital, Newcastle, New South Wales, Australia
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9
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Kim JJ, Kang H, Stewart KO. The Effect of Retained Hardware on Failure Among Prosthetic Joint Infections of the Knee in the Presence and Absence of Staphylococcus aureus. Open Forum Infect Dis 2024; 11:ofae306. [PMID: 38919513 PMCID: PMC11196895 DOI: 10.1093/ofid/ofae306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 05/30/2024] [Indexed: 06/27/2024] Open
Abstract
Background The risk of failure associated with different surgical strategies for prosthetic joint infections (PJIs) among patients with and without Staphylococcus aureus is uncertain. The purpose of this study was to assess whether S. aureus modifies the association between retained hardware and failure following revision surgery for PJI of the knee. Methods This was a single-center retrospective cohort study of 106 first PJIs of the knee between 2016 and 2020 at a rural academic medical center. The exposure was retained hardware following revision surgery for PJI, and the outcomes were recurrent infection, any infection, and a composite outcome including any infection, unplanned revision, failure to undergo reimplantation, amputation, or death within 2 years of revision. We used negative binomial regression to quantify the association between the exposure and outcome and to assess the presence of S. aureus as an effect modifier. Results Retained hardware was significantly associated with failure when defined as recurrent infection among S. aureus PJI (adjusted risk difference [aRD], 0.38; 95% CI, 0.12-0.64) but not in the absence of S. aureus (aRD, -0.02; 95% CI, -0.17 to 0.13), and S. aureus was an effect modifier (P interaction = .01). Conclusions We report a significant association between the presence of retained hardware and recurrent infection among S. aureus PJI of the knee, but not for non-S. aureus PJI. This could help inform the surgical management of PJI of the knee in cases where the microbiology is known before surgery.
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Affiliation(s)
- Justin J Kim
- Section of Infectious Disease and International Health, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
- Collaborative Healthcare-associated Infection Prevention Program, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - HeeEun Kang
- Section of Infectious Disease and International Health, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Kathleen O Stewart
- Collaborative Healthcare-associated Infection Prevention Program, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Quality Assurance and Safety, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Quality Assurance and Safety, Dartmouth Health, Lebanon, New Hampshire, USA
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10
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Young J, Mehta N, Lee SW, Rodriguez EK. How Effective Is Phage Therapy for Prosthetic Joint Infections? A Preliminary Systematic Review and Proportional Meta-Analysis of Early Outcomes. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:790. [PMID: 38792972 PMCID: PMC11122905 DOI: 10.3390/medicina60050790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 04/30/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024]
Abstract
Background and Objectives: Despite the promise of phage therapy (PT), its efficacy in prosthetic joint infection (PJI) management is unknown. Much of the current literature is largely limited to case reports and series. Materials and Methods: In order to help inform power calculations for future clinical trials and comparative analyses, we performed a systematic review and proportional meta-analysis of early PT outcomes to provide a preliminary assessment of early phage therapy treatment outcomes for cases of PJI. Results: In a search of available literature across MEDLINE (Ovid, Wolters Kluwer, Alphen aan den Rijn, The Netherlands), Embase (Elsevier, Amsterdam, The Netherlands), the Web of Science Core Collection (Clarivate, London, UK), and Cochrane Central (Wiley, Hoboken, NJ, USA) up to 23 September 2023, we identified 37 patients with PJIs receiving adjunctive PT. Patients most frequently reported Staphylococcal species infection (95%) and intraarticular phage delivery (73%). Phage cocktail (65%) and antibiotic co-administration (97%) were common. A random-effects proportional meta-analysis suggested infection remission in 78% of patients (95% CI: 39%, 95%) (I2 = 55%, p = 0.08) and 83% with a minimum 12-month follow-up (95% CI: 53%, 95%) (I2 = 26%, p = 0.26). Conclusions: Our study provides a preliminary estimate of PT's efficacy in PJIs and informs future comparative studies.
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Affiliation(s)
- Jason Young
- Harvard Combined Orthopedic Residency Program, Boston, MA 02114, USA
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Nicita Mehta
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Sang Won Lee
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Edward Kenneth Rodriguez
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
- Carl J Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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11
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Davis JS, Dewar D, Manning L. Prosthetic joint infection diagnosis in an age of changing clinical patterns of infection and new technologies. Med J Aust 2024; 220:225-228. [PMID: 38351733 DOI: 10.5694/mja2.52228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/31/2024] [Indexed: 03/18/2024]
Affiliation(s)
- Joshua S Davis
- University of Newcastle, Newcastle, NSW
- Hunter Medical Research Institute, Newcastle, NSW
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12
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Minero GA, Møllebjerg A, Thiesen C, Johansen M, Jørgensen N, Birkedal V, Otzen DE, Meyer R. Extracellular G-quadruplexes and Z-DNA protect biofilms from DNase I, and G-quadruplexes form a DNAzyme with peroxidase activity. Nucleic Acids Res 2024; 52:1575-1590. [PMID: 38296834 PMCID: PMC10939358 DOI: 10.1093/nar/gkae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 01/04/2024] [Accepted: 01/10/2024] [Indexed: 02/02/2024] Open
Abstract
Many bacteria form biofilms to protect themselves from predators or stressful environmental conditions. In the biofilm, bacteria are embedded in a protective extracellular matrix composed of polysaccharides, proteins and extracellular DNA (eDNA). eDNA most often is released from lysed bacteria or host mammalian cells, and it is the only matrix component most biofilms appear to have in common. However, little is known about the form DNA takes in the extracellular space, and how different non-canonical DNA structures such as Z-DNA or G-quadruplexes might contribute to its function in the biofilm. The aim of this study was to determine if non-canonical DNA structures form in eDNA-rich staphylococcal biofilms, and if these structures protect the biofilm from degradation by nucleases. We grew Staphylococcus epidermidis biofilms in laboratory media supplemented with hemin and NaCl to stabilize secondary DNA structures and visualized their location by immunolabelling and fluorescence microscopy. We furthermore visualized the macroscopic biofilm structure by optical coherence tomography. We developed assays to quantify degradation of Z-DNA and G-quadruplex DNA oligos by different nucleases, and subsequently investigated how these enzymes affected eDNA in the biofilms. Z-DNA and G-quadruplex DNA were abundant in the biofilm matrix, and were often present in a web-like structures. In vitro, the structures did not form in the absence of NaCl or mechanical shaking during biofilm growth, or in bacterial strains deficient in eDNA or exopolysaccharide production. We thus infer that eDNA and polysaccharides interact, leading to non-canonical DNA structures under mechanical stress when stabilized by salt. We also confirmed that G-quadruplex DNA and Z-DNA was present in biofilms from infected implants in a murine implant-associated osteomyelitis model. Mammalian DNase I lacked activity against Z-DNA and G-quadruplex DNA, while Micrococcal nuclease could degrade G-quadruplex DNA and S1 Aspergillus nuclease could degrade Z-DNA. Micrococcal nuclease, which originates from Staphylococcus aureus, may thus be key for dispersal of biofilm in staphylococci. In addition to its structural role, we show for the first time that the eDNA in biofilms forms a DNAzyme with peroxidase-like activity in the presence of hemin. While peroxidases are part of host defenses against pathogens, we now show that biofilms can possess intrinsic peroxidase activity in the extracellular matrix.
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Affiliation(s)
| | - Andreas Møllebjerg
- Interdisciplinary Nanoscience Center (iNANO), Aarhus University, Gustav Wieds Vej 14, 8000 Aarhus, Denmark
| | - Celine Thiesen
- Interdisciplinary Nanoscience Center (iNANO), Aarhus University, Gustav Wieds Vej 14, 8000 Aarhus, Denmark
| | - Mikkel Illemann Johansen
- Department Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens bvld 99, 8200 Aarhus N, Denmark
| | - Nis Pedersen Jørgensen
- Department Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens bvld 99, 8200 Aarhus N, Denmark
| | - Victoria Birkedal
- Interdisciplinary Nanoscience Center (iNANO), Aarhus University, Gustav Wieds Vej 14, 8000 Aarhus, Denmark
- Department of Chemistry, Aarhus University, Langelandsgade 140, 8000 Aarhus, Denmark
| | - Daniel Erik Otzen
- Interdisciplinary Nanoscience Center (iNANO), Aarhus University, Gustav Wieds Vej 14, 8000 Aarhus, Denmark
- Department of Molecular Biology and Genetics, Aarhus University, Universitetsbyen 81, 8000 Aarhus, Denmark
| | - Rikke Louise Meyer
- Interdisciplinary Nanoscience Center (iNANO), Aarhus University, Gustav Wieds Vej 14, 8000 Aarhus, Denmark
- Department of Biology, Aarhus University, Ny Munkegade 114, 8000 Aarhus, Denmark
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13
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Cortes-Penfield N, Krsak M, Damioli L, Henry M, Seidelman J, Hewlett A, Certain L. How We Approach Suppressive Antibiotic Therapy Following Debridement, Antibiotics, and Implant Retention for Prosthetic Joint Infection. Clin Infect Dis 2024; 78:188-198. [PMID: 37590953 DOI: 10.1093/cid/ciad484] [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] [Received: 06/07/2023] [Revised: 08/03/2023] [Accepted: 08/14/2023] [Indexed: 08/19/2023] Open
Abstract
The optimal treatment of prosthetic joint infection (PJI) remains uncertain. Patients undergoing debridement, antibiotics, and implant retention (DAIR) receive extended antimicrobial treatment, and some experts leave patients at perceived highest risk of relapse on suppressive antibiotic therapy (SAT). In this narrative review, we synthesize the literature concerning the role of SAT to prevent treatment failure following DAIR, attempting to answer 3 key questions: (1) What factors identify patients at highest risk for treatment failure after DAIR (ie, patients with the greatest potential to benefit from SAT), (2) Does SAT reduce the rate of treatment failure after DAIR, and (3) What are the rates of treatment failure and adverse events necessitating treatment discontinuation in patients receiving SAT? We conclude by proposing risk-benefit stratification criteria to guide use of SAT after DAIR for PJI, informed by the limited available literature.
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Affiliation(s)
- Nicolas Cortes-Penfield
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Martin Krsak
- Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laura Damioli
- Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Michael Henry
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
- Department of Medicine, Division of Infectious Diseases, Hospital for Special Surgery, New York, New York, USA
| | - Jessica Seidelman
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Angela Hewlett
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Laura Certain
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
- Department of Internal Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, Utah, USA
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14
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Gómez-Alonso IS, Betanzos-Cabrera G, Moreno-Lafont MC, Cancino-Diaz ME, García-Pérez BE, Cancino-Diaz JC. Non-biofilm-forming Staphylococcus epidermidis planktonic cell supernatant induces alterations in osteoblast biological function. Sci Rep 2024; 14:1807. [PMID: 38245549 PMCID: PMC10799936 DOI: 10.1038/s41598-024-51899-7] [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] [Received: 10/30/2023] [Accepted: 01/10/2024] [Indexed: 01/22/2024] Open
Abstract
Staphylococcal biofilms significantly contribute to prosthetic joint infection (PJI). However, 40% of S. epidermidis PJI isolates do not produce biofilms, which does not explain the role of biofilms in these cases. We studied whether the supernatant from planktonic S. epidermidis alters osteoblast function. Non-biofilm-forming S. epidermidis supernatants (PJI- clinical isolate, healthy skin isolate (HS), and ATCC12228 reference strain) and biofilm-forming supernatants (PJI+ clinical isolate, ATCC35984 reference strain, and Staphylococcus aureus USA300 reference strain) were included. Osteoblasts stimulated with supernatants from non-biofilm-forming isolates for 3, 7, and 14 days showed significantly reduced cellular DNA content compared with unstimulated osteoblasts, and apoptosis was induced in these osteoblasts. Similar results were obtained for biofilm-forming isolates, but with a greater reduction in DNA content and higher apoptosis. Alkaline phosphatase activity and mineralization were significantly reduced in osteoblasts treated with supernatants from non-biofilm-forming isolates compared to the control at the same time points. However, the supernatants from biofilm-forming isolates had a greater effect than those from non-biofilm-forming isolates. A significant decrease in the expression of ATF4, RUNX2, ALP, SPARC, and BGLAP, and a significant increase in RANK-L expression were observed in osteoblasts treated with both supernatants. These results demonstrate that the supernatants of the S. epidermidis isolate from the PJI- and HS (commensal) with a non-biofilm-forming phenotype alter the function of osteoblasts (apoptosis induction, failure of cell differentiation, activation of osteoblasts, and induction of bone resorption), similar to biofilm-forming isolates (PJI+, ATCC35984, and S. aureus USA300), suggesting that biofilm status contributes to impaired osteoblast function and that the planktonic state can do so independently of biofilm production.
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Affiliation(s)
- Itzia Sidney Gómez-Alonso
- Departamento de Microbiología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Manuel Carpio, Plutarco Elías Calles, Miguel Hidalgo, 11350, Mexico City, Mexico
| | - Gabriel Betanzos-Cabrera
- Área Académica de Nutrición, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado de Hidalgo, Carretera Pachuca-Actopan Camino a Tilcuautla S/N., Pueblo San Juan Tilcuautla, 42160, Pachuca Hidalgo, Mexico
| | - Martha Cecilia Moreno-Lafont
- Departamento de Inmunología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Manuel Carpio, Plutarco Elías Calles, Miguel Hidalgo, 11350, Mexico City, Mexico
| | - Mario Eugenio Cancino-Diaz
- Departamento de Inmunología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Manuel Carpio, Plutarco Elías Calles, Miguel Hidalgo, 11350, Mexico City, Mexico
| | - Blanca Estela García-Pérez
- Departamento de Microbiología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Manuel Carpio, Plutarco Elías Calles, Miguel Hidalgo, 11350, Mexico City, Mexico
| | - Juan Carlos Cancino-Diaz
- Departamento de Microbiología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Manuel Carpio, Plutarco Elías Calles, Miguel Hidalgo, 11350, Mexico City, Mexico.
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15
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Tseng J, Oladipo V, Dandamudi S, Jones CM, Levine BR. Validation of a Classification System for Optimal Application of Debridement, Antibiotics, and Implant Retention in Prosthetic Joint Infections following Total Knee Arthroplasty: A Retrospective Review. Antibiotics (Basel) 2024; 13:48. [PMID: 38247607 PMCID: PMC10812511 DOI: 10.3390/antibiotics13010048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/26/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) remains a serious complication after total knee arthroplasty (TKA). While debridement, antibiotics, and implant retention (DAIR) are considered for acute PJI, success rates vary. This study aims to assess a new scoring system's accuracy in predicting DAIR success. METHODS 119 TKA patients (2008-2019) diagnosed with PJI who underwent DAIR were included for analysis. Data were collected on demographics, laboratory values, and clinical outcomes. This was used for validation of the novel classification system consisting of PJI acuteness, microorganism classification, and host health for DAIR indication. Statistical analysis was carried out using SPSS programming. RESULTS Mean follow-up was 2.5 years with an average age of 65.5 ± 9.1 years, BMI of 31.9 ± 6.2 kg/m2, and CCI of 3.04 ± 1.8. Successful infection eradication occurred in 75.6% of patients. The classification system demonstrated 61.1% sensitivity, 72.4% specificity, and 87.3% positive predictive value (PPV) when the DAIR cutoff was a score less than 6. For a cutoff of less than 8, sensitivity was 100%, specificity was 37.9%, and PPV was 83.3%. CONCLUSIONS To date, no consensus exists on a classification system predicting DAIR success. This novel scoring system, with high PPV, shows promise. Further refinement is essential for enhanced predictive accuracy.
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Affiliation(s)
| | | | | | | | - Brett R. Levine
- Rush University Medical Center, Department of Orthopaedic Surgery, Chicago, IL 60612, USA; (J.T.); (V.O.); (S.D.); (C.M.J.)
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16
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Karczewski D, Scholz J, Hipfl C, Akgün D, Gonzalez MR, Hardt S. Gram negative periprosthetic hip infection: nearly 25% same pathogen infection persistence at a mean of 2 years. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-05104-5. [PMID: 37910220 DOI: 10.1007/s00402-023-05104-5] [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: 05/26/2023] [Accepted: 10/09/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE While gram negative (GN) periprosthetic joint infections (PJI) have previously been described as difficult to treat pathogens with high rates of reinfection, limited investigations have addressed midterm outcomes and risk of infection persistence by the same pathogen. This study analyzed (1) baseline demographics, treatment strategy, and midterm outcomes of GN PJIs, as well as (2) differences in reinfection and relapse rates compared to gram positive (GP) PJIs. METHODS We identified 29 patients that were revised for 30 GN PJIs of total hip arthroplasties (THAs) between 2010 and 2020 using a university-based hip registry. Mean age was 77 years, 63% were females (19), and mean BMI was 27 kg/m2. Major causative pathogens included Escherichia coli (12), Klebsiella pneumoniae (5), Pseudomonas aeruginosa (5), and Enterobacter cloacae complex (5). Mean follow-up was 3.5 years. Study outcomes included (1) Kaplan-Meier survivorship analyses of all 30 GN PJIs, and (2) comparison of 18 two-stage exchanges for GN PJIs and 104 two-stage exchanges for GP PJIs, performed during the time from 2013 to 2017. RESULTS (1) The 5-year survivorship free of recurrent PJI was 69%, and there were 7 recurrent PJIs at a mean of 2 years. There were 2 further suprafascial wound infections, resulting in a 61% survivorship free of any infection at 5-years. At a mean of 2 years, there were 7 patients with reinfection by the same GN pathogen (6 PJIs, one wound infection) as at index revision (23%). (2) Following two-stage exchange, the 5-year survivorship free of recurrent PJI (GN: 74%; GP: 91%; p = 0.072), any infection (GN: 61%; GP: 91%; p = 0.001), and reinfection by the same pathogen was significantly lower among GN PJIs (GN: 73%; GP: 98%; p < 0.001). CONCLUSIONS Patients revised for GN PJIs are at increased risk of reinfection as opposed to GP infections. Affected patients must be counseled on the exceptionally high risk of infection persistence with one in four developing relapses. LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Daniel Karczewski
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Chariteplatz 1, 10117, Berlin, Germany
| | - Johann Scholz
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Chariteplatz 1, 10117, Berlin, Germany.
| | - Christian Hipfl
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Chariteplatz 1, 10117, Berlin, Germany
| | - Doruk Akgün
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Chariteplatz 1, 10117, Berlin, Germany
| | - Marcos R Gonzalez
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Sebastian Hardt
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Chariteplatz 1, 10117, Berlin, Germany
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17
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Tarabichi S, Goh GS, Fernández-Rodríguez D, Baker CM, Lizcano JD, Parvizi J. Plasma D-Dimer Is a Promising Marker to Guide Timing of Reimplantation: A Prospective Cohort Study. J Arthroplasty 2023; 38:2164-2170.e1. [PMID: 37172794 DOI: 10.1016/j.arth.2023.04.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/25/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Two-stage exchange arthroplasty remains the preferred surgical treatment for chronic periprosthetic joint infection. Currently, there is no single reliable marker to determine the optimal timing for reimplantation. The purpose of this prospective study was to assess the diagnostic utility of plasma D-dimer and other serological markers in predicting successful control of infection following reimplantation. METHODS This study enrolled 136 patients undergoing reimplantation arthroplasty between November 2016 and December 2020. Strict inclusion criteria were applied including the need for a two-week "antibiotic holiday" prior to reimplantation. A total of 114 patients were included in the final analysis. Plasma D-dimer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen were measured preoperatively. Treatment success was defined using the Musculoskeletal Infection Society Outcome-Reporting Tool. Receiver operating characteristic curves were used to assess the prognostic accuracy of each biomarker in predicting failure following reimplantation at a minimum 1-year follow-up. RESULTS Treatment failure occurred in 33 patients (28.9%) at a mean follow-up of 3.2 years (range, 1.0 to 5.7). Median plasma D-dimer was significantly higher in the treatment failure group (1,604 versus 631 ng/mL, P < .001), whereas median CRP, ESR, and fibrinogen were not significantly different between the success and failure groups. Plasma D-dimer demonstrated the best diagnostic utility (area under the curve [AUC] 0.724, sensitivity 51.5%, specificity 92.6%), outperforming ESR (AUC 0.565, sensitivity 93.3%, specificity 22.5%), CRP (AUC 0.541, sensitivity 87.5%, specificity 26.3%), and fibrinogen (AUC 0.485, sensitivity 30.4%, specificity 80.0%). Plasma D-dimer level of ≥1,604 ng/mL was identified as the optimal cutoff that predicted failure following reimplantation. CONCLUSION Plasma D-dimer was superior to serum ESR, CRP, and fibrinogen in predicting failure after the second stage of a two-stage exchange arthroplasty for periprosthetic joint infection. Based on the findings of this prospective study, plasma D-dimer may be a promising marker in assessing the control of infection in patients undergoing reimplantation surgery. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Diana Fernández-Rodríguez
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Plan de Estudios Combinados en Medicina (PECEM) MD/PhD, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Colin M Baker
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Juan D Lizcano
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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18
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Manning L, Allen B, Davis JS. Design Characteristics and Recruitment Rates for Randomized Trials of Peri-Prosthetic Joint Infection Management: A Systematic Review. Antibiotics (Basel) 2023; 12:1486. [PMID: 37887189 PMCID: PMC10604750 DOI: 10.3390/antibiotics12101486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/11/2023] [Accepted: 09/14/2023] [Indexed: 10/28/2023] Open
Abstract
Prosthetic joint infections (PJI) present a major management challenge for practicing orthopedic surgeons and infectious disease physicians. There are few high-quality data to inform treatment guidelines. The aim of this systematic review was to report the design characteristics and recruitment rates for randomized controlled trials (RCTs) of PJI management. Trials were considered eligible for inclusion if human participants were randomized to any management intervention for PJI. We searched Medline, PubMed, Embase, Web of Science, Cochrane Database, ANZ Clinical Trials Registry, ClinicalTrials.gov, and the EU Clinical Trials Register until the end of May 2023. The systematic review was registered with PROSPERO (CRD42018112646). We identified 15 published RCTs with a total of 1743 participants with PJI. The median (interquartile range [IQR]) number of successfully recruited participants was 63 (38-140), with 0.28 (0.13-0.96) enrolments per site per month. Only four trials (36.4%) achieved the target recruitment. All RCTs applied different primary endpoints and varying definitions of a 'good' outcome. Despite recent improvements, PJI RCTs are characterized by slow recruitment and heterogeneous endpoint assessments, which preclude synthesis in a standard meta-analytic framework. To inform international guidelines, future PJI trials should be run as multi-country trials at high-recruiting sites.
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Affiliation(s)
- Laurens Manning
- Medical School, University of Western Australia, Perth, WA 6009, Australia;
- Infectious Diseases Department, Fiona Stanley Hospital, Murdoch, WA 6150, Australia
| | - Bethwyn Allen
- Library and Information Service for East and South Metropolitan Health Services, South Metropolitan Health Service, Fiona Stanley Hospital, Murdoch, WA 6150, Australia;
| | - Joshua S. Davis
- Infection Research Program, Hunter Medical Research Institute, The University of Newcastle, New Lambton Heights, NSW 2305, Australia
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19
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Huotari K, Vuorinen M, Vasara A. Debridement, antimicrobials, and implant retention in the treatment of late acute and early acute Staphylococcus aureus prosthetic joint infections. Infect Dis (Lond) 2023; 55:525-532. [PMID: 37255321 DOI: 10.1080/23744235.2023.2217898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 05/15/2023] [Accepted: 05/21/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Staphylococcus aureus is the most common microbe in prosthetic joint infections (PJIs). Debridement, antimicrobials, and implant retention (DAIR) are often-recommended treatment modality for acute PJIs, even though it has had relatively poor outcomes in some studies. In this study, we wanted to examine treatment results with a multidisciplinary team in a specialised centre and obtain further information for treatment decisions in acute Staphylococcus aureus PJIs. METHODS All consecutive haematogenous late acute and postoperative early acute hip and knee Staphylococcus aureus PJIs treated with DAIR during 2011-2016 were included in this retrospective study. DAIR within three weeks from symptom onset and the exchange of modular parts were required. RESULTS Eighty-five acute Staphylococcus aureus PJIs were treated with DAIR in 83 patients: 28 late acute and 57 early acute PJIs. The late acute PJI patients were older and had malignancies more often than the early acute PJI patients. Bacteraemia was present in 50.6% of Staphylococcus aureus PJI patients, more often in late acute (73.1%) than in early acute (40.4%) patients (p = .006). The implant was retained in 80.0%: 89.3% of the late acute and 75.4% of the early acute PJIs. In 17 joints, DAIR failed and the joint had to be removed. Fourteen of these joints were successfully replaced. One infection-related death occurred. The one-year all-cause mortality rate was 3.6%. Suppressive antimicrobial treatment was given to 22 (26.5%) patients. CONCLUSIONS Reasonably good treatment results for acute Staphylococcus aureus PJIs are achievable by DAIR in a specialised centre with a strict treatment protocol and a multidisciplinary team. If the DAIR fails, a two-stage exchange is usually still possible, with good results.
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Affiliation(s)
- Kaisa Huotari
- Department of Infectious Diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Markku Vuorinen
- Department of Orthopedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anna Vasara
- Department of Orthopedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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20
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Wouthuyzen-Bakker M, Scheper H. Rifampicin in periprosthetic joint infections: where do we stand and where are we headed? Expert Rev Anti Infect Ther 2023:1-7. [PMID: 37141111 DOI: 10.1080/14787210.2023.2211263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
INTRODUCTION A periprosthetic joint infection (PJI) is a major complication of arthroplasty. Treatment of PJI consists of surgical debridement with or without the exchange of the implant and long-term antimicrobial treatment. Rifampicin is regarded as one of the cornerstones of antimicrobial treatment for staphylococcal PJI, but the exact role of rifampicin for PJI in different clinical scenarios remains to be elucidated. AREAS COVERED In this perspective article, an overview is provided of in vitro, in vivo and clinical studies that were the basis of the current guidelines and recommendations for rifampicin use in daily practice for PJI. Controversial issues on indication, dosing, timing, duration and antibiotic drug interactions will be addressed. Finally, the most urgent clinical questions on rifampicin use that need answering in the nearby future will be formulated. EXPERT OPINION Many inquiries remain concerning the exact indications and clinical use of rifampicin in PJI. Randomized controlled trials are needed to answer these questions.
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Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of medical microbiology and infection prevention, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Henk Scheper
- Department of infectious diseases, Leiden University Medical Center, University of Leiden, Leiden, The Netherlands
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21
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Rahardja R, Zhu M, Davis JS, Manning L, Metcalf S, Young SW. Success of Debridement, Antibiotics, and Implant Retention in Prosthetic Joint Infection Following Primary Total Knee Arthroplasty: Results from a Prospective Multicenter Study of 189 Cases. J Arthroplasty 2023:S0883-5403(23)00370-4. [PMID: 37084921 DOI: 10.1016/j.arth.2023.04.024] [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: 12/01/2022] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND This study aimed to identify the success rate of debridement, antibiotics, and implant retention (DAIR) for prosthetic joint infection (PJI) in a large prospective cohort of patients undergoing total knee arthroplasty (TKA). The ability for different PJI classification systems to predict success was assessed. METHODS Prospective data recorded in the Prosthetic Joint Infection in Australia and New Zealand Observational (PIANO) study was analyzed. 189 newly diagnosed knee PJIs were managed with DAIR between July 2014 and December 2017. Patients were prospectively followed up for 2 years. A strict definition of success was used, requiring the patient being alive with documented absence of infection, no ongoing antibiotics and the index prosthesis in place. Success was compared against the Coventry (early PJI = ≤1 month), International Consensus Meeting (early = ≤90 days), Auckland (early = <1 year), and Tsukayama (early = ≤1 month, hematogenous = >1 month with <7 days symptoms, chronic = >1 month with >7 days symptoms) classifications. RESULTS DAIR success was 45% (85/189) and was highest in early PJIs defined according to the Coventry (adjusted odds ratio [aOdds Ratio (OR)] = 3.9, P=0.01), the ICM (aOR = 3.1, p=0.01), and the Auckland classifications (aOR = 2.6, P=0.01). Success was lower in both hematogenous (aOR = 0.4, P=0.03) and chronic infections (aOR = 0.1, P=0.003). CONCLUSION Time since primary TKA is an important predictor of DAIR success. Success was highest in infections occurring <1 month of the primary TKA and progressively decreased as time since the primary TKA increased.
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Affiliation(s)
- Richard Rahardja
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
| | - Mark Zhu
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Joshua S Davis
- School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
| | - Laurens Manning
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia; Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia
| | - Sarah Metcalf
- Department of Infectious Diseases, Christchurch Hospital, Christchurch, New Zealand
| | - Simon W Young
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
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22
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Sekar A, Lekkala S, Oral E. A Novel Method to Determine the Longitudinal Antibacterial Activity of Drug-Eluting Materials. J Vis Exp 2023:10.3791/64641. [PMID: 36939249 PMCID: PMC10859037 DOI: 10.3791/64641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Abstract
Ultrahigh molecular weight polyethylene (UHMWPE) is widely used in total joint arthroplasties as a load-bearing surface. Periprosthetic joint infections, the majority of which occur shortly after joint replacement, constitute almost 25% of total knee revision surgeries, and the complete eradication of bacterial infection poses a major challenge. A promising way to tackle this problem is to ensure the local sustained delivery of antibiotic concentrations sufficient to inhibit the bacteria to support routine systemic antibiotic prophylaxis. There is increased research into the development of efficient local drug delivery devices. Although established antibacterial testing methods for drugs can be used to test the antibacterial efficacy of drug-eluting materials, they are lacking in terms of providing real-time and longitudinal antibacterial efficacy data that can be correlated to the elution profiles of antibiotics from these devices. Here, we report a direct and versatile methodology to determine the antibacterial efficacy of antibiotic-eluting UHMWPE implants. This methodology can be used as a platform to avoid bacterial culture at each time point of a lengthy experiment and can also be adapted to other local drug delivery devices.
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Affiliation(s)
- Amita Sekar
- Harris Orthopaedics Laboratory, Massachusetts General Hospital; Department of Orthopaedic Surgery, Harvard Medical School
| | - Sashank Lekkala
- Harris Orthopaedics Laboratory, Massachusetts General Hospital
| | - Ebru Oral
- Harris Orthopaedics Laboratory, Massachusetts General Hospital; Department of Orthopaedic Surgery, Harvard Medical School;
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23
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The Impact of a Dedicated Multidisciplinary Team Approach for Prosthetic Joint Infections of the Lower Limb. Indian J Orthop 2023; 57:696-702. [PMID: 37128563 PMCID: PMC10147879 DOI: 10.1007/s43465-023-00842-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 02/07/2023] [Indexed: 02/23/2023]
Abstract
Abstract
Introduction
Prosthetic joint infections (PJI) of the hip and knee have significant morbidity and mortality, and present with varying local, host and microbiological factors. Given the broad presentation and complexity of PJI’s, we developed a dedicated multidisciplinary team (MDT) to manage this complex patient cohort, and report on our early outcomes.
Methods
This was a retrospective observational study of all patients diagnosed with a prosthetic joint infection of the hip or knee (n = 71) at our institution during a 4.5-year period. Patients treated after development of the MDT (post-MDT) (n = 44), were compared to a control group prior establishment of the MDT (pre-MDT) (n = 27).
Results
85.2% of individuals in the pre-MDT, and 85.7% of individuals in the post-MDT group were considered cured at a minimum 2 years post-operatively according to the Delphi-based definition. The total number of admissions to hospital (2.44 vs. 1.84) and total number of antibiotics used (3.37 vs. 2.75) decreased in the post-MDT group; however, differences were not considered statistically significant.
Discussion
Implementation of a dedicated MDT in the management of individuals with PJI’s of the lower limb at our hospital has allowed early and effective collaboration between healthcare personnel, with early promising results. Given the broad nature of PJI, future studies are ongoing to determine modifiable risk factors to reduce the incidence and improve outcomes of individuals with PJI’s where systems can then be implemented into already established MDTs to achieve the best clinical outcome for our patients.
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24
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Tarabichi S, Goh GS, Baker CM, Chisari E, Shahi A, Parvizi J. Plasma D-Dimer Is Noninferior to Serum C-Reactive Protein in the Diagnosis of Periprosthetic Joint Infection. J Bone Joint Surg Am 2023; 105:501-508. [PMID: 36758110 DOI: 10.2106/jbjs.22.00784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
BACKGROUND No single test has demonstrated absolute accuracy in the diagnosis of periprosthetic joint infection (PJI). Serological markers are often used as screening tools in the workup of patients with suspected PJI. This study aimed to determine the diagnostic utility of plasma D-dimer for PJI in a variety of clinical scenarios. METHODS This prospective study enrolled 502 patients undergoing revision hip or knee arthroplasty. PJI was defined per a modified version of the 2018 International Consensus Meeting (ICM) criteria. Plasma D-dimer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen were measured preoperatively. Receiver operating characteristic curves were used to assess the utility of each biomarker in the diagnosis of PJI. Pairwise comparison with Bonferroni correction was performed to determine whether the differences in areas under the curve (AUCs) between the markers were significant. RESULTS Of the 412 patients included, 317 (76.9%) did not have an infection (aseptic group) and 95 (23.1%) had an infection (PJI group). All 4 serological markers, D-dimer (AUC, 0.860; sensitivity, 81.3%; specificity, 81.7%), CRP (AUC, 0.862; sensitivity, 90.4%; specificity, 70.0%), ESR (AUC, 0.833; sensitivity, 73.9%; specificity, 85.2%), and fibrinogen (AUC, 0.798; sensitivity, 74.7%; specificity, 75.4%), demonstrated comparable accuracy for the diagnosis of PJI (all p > 0.05). When examining the performance of the different inflammatory markers in diagnosing infection caused by indolent organisms, D-dimer demonstrated the highest sensitivity at 93.8%. CONCLUSIONS We found that plasma D-dimer was noninferior to serum CRP and ESR in the diagnosis of PJI and may be a useful adjunct when screening patients undergoing revision total joint arthroplasty. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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25
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Affiliation(s)
- Robin Patel
- From the Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, and the Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
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26
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Tarabichi S, Goh GS, Zanna L, Qadiri QS, Baker CM, Gehrke T, Citak M, Parvizi J. Time to Positivity of Cultures Obtained for Periprosthetic Joint Infection. J Bone Joint Surg Am 2023; 105:107-112. [PMID: 36574630 DOI: 10.2106/jbjs.22.00766] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite its well-established limitations, culture remains the gold standard for microbial identification in periprosthetic joint infection (PJI). However, there are no benchmarks for the time to positivity (TTP) on culture for specific microorganisms. This study aimed to determine the TTP for pathogens commonly encountered in PJI. METHODS This retrospective, multicenter study reviewed prospectively maintained institutional PJI databases to identify patients who underwent hip or knee revision arthroplasty from 2017 to 2021 at 2 tertiary centers in the United States and Germany. Only patients who met the 2018 International Consensus Meeting (ICM) criteria for PJI and had a positive intraoperative culture were included. TTP on culture media was recorded for each sample taken intraoperatively. The median TTP was compared among different microbial species and different specimen types. Data are presented either as the mean and the standard deviation or as the median and the interquartile range (IQR). RESULTS A total of 536 ICM-positive patients with positive cultures were included. The mean number of positive cultures per patient was 3.9 ± 2.6. The median TTP, in days, for all positive cultures was 3.3 (IQR, 1.9 to 5.4). Overall, gram-negative organisms (TTP, 1.99 [1.1 to 4.1]; n = 225) grew significantly faster on culture compared with gram-positive organisms (TTP, 3.33 [1.9 to 5.8]; n = 1,774). Methicillin-resistant Staphylococcus aureus (TTP, 1.42 [1.0 to 2.8]; n = 85) had the fastest TTP, followed by gram-negative rods (TTP, 1.92 [1.0 to 3.9]; n = 163), methicillin-sensitive Staphylococcus aureus (TTP, 1.95 [1.1 to 3.3] n = 393), Streptococcus species (TTP, 2.92 [1.2 to 4.3]; n = 230), Staphylococcus epidermidis (TTP, 4.20 [2.4 to 5.5]; n = 555), Candida species (TTP, 5.30 [3.1 to 10]; n = 63), and Cutibacterium acnes (TTP, 6.97 [5.9 to 8.2]; n = 197). When evaluating the median TTP according to specimen type, synovial fluid (TTP, 1.97 [1.1 to 3.1]; n = 112) exhibited the shortest TTP, followed by soft tissue (TTP, 3.17 [1.4 to 5.3]; n = 1,199) and bone (TTP, 4.16 [2.3 to 5.9]; n = 782). CONCLUSIONS To our knowledge, this is the first study to examine the TTP of common microorganisms that are known to cause PJI. Increased awareness of these data may help to guide the selection of appropriate antimicrobial therapy and to predict treatment outcomes in the future. Nonetheless, additional studies with larger cohorts are needed to validate these benchmarks. LEVEL OF EVIDENCE Diagnostic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Graham S Goh
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Luigi Zanna
- Traumatology and General Orthopedics Department, Careggi University Hospital, Florence, Italy.,Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Qudratullah S Qadiri
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Colin M Baker
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Javad Parvizi
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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27
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Synovial C-Reactive Protein is a Useful Adjunct for Diagnosis of Periprosthetic Joint Infection. J Arthroplasty 2022; 37:2437-2443.e1. [PMID: 35750152 DOI: 10.1016/j.arth.2022.06.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The diagnostic utility of synovial C-reactive protein (CRP) has been debated for a while. Existing studies are limited by small sample sizes and using outdated criteria for periprosthetic joint infection (PJI). Furthermore, the relationship between synovial and serum CRP has rarely been investigated in the setting of PJI. This study aimed to evaluate the diagnostic utility of synovial CRP and to assess its relationship with serum CRP and other common biomarkers. METHODS We reviewed 621 patients who underwent evaluation for PJI prior to revision arthroplasty from 2014 to 2021. Biomarkers, including serum CRP and erythrocyte sedimentation rate, synovial CRP, polymorphonuclear leukocyte percentage, white blood cell count, and alpha-defensin, were evaluated using the 2018 International Consensus Meeting criteria. RESULTS In total, 194 patients had a PJI; 394 were considered aseptic failures and 33 were inconclusive. Synovial CRP showed an area under the curve (AUC) of 0.951 (95% CI, 0.932-0.970) with 74.2% sensitivity and 98.0% specificity, whereas, serum CRP had an AUC of 0.926 (95% CI, 0.903-0.949) with 83.5% sensitivity and 88.3% specificity. There was a good correlation between synovial and serum CRP (R = 0.703; 95% CI, 0.604-0.785). The combination of serum and synovial CRP yielded a significantly higher AUC than that obtained when using serum CRP alone (AUC 0.964 versus 0.926, P = .016). CONCLUSION Synovial CRP demonstrated excellent accuracy when used to determine the presence of PJI. There was a good correlation between serum and synovial CRP levels in revision arthroplasty patients and the combined use of serum and synovial CRP proved to be more accurate than the serum test alone. These findings support the use of synovial CRP as an adjunct in the workup of PJI.
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28
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Browning S, Manning L, Metcalf S, Paterson D, Robinson J, Clark B, Davis J. Characteristics and outcomes of culture-negative prosthetic joint infections from the Prosthetic Joint Infection in Australia and New Zealand Observational (PIANO) cohort study. J Bone Jt Infect 2022; 7:203-211. [PMID: 36267263 PMCID: PMC9562689 DOI: 10.5194/jbji-7-203-2022] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 08/31/2022] [Indexed: 09/06/2024] Open
Abstract
Introduction: Culture-negative (CN) prosthetic joint infections (PJIs) account for approximately 10 % of all PJIs and present significant challenges for clinicians. We aimed to explore the significance of CN PJIs within a large prospective cohort study, comparing their characteristics and outcomes with culture-positive (CP) cases. Methods: The Prosthetic joint Infection in Australia and New Zealand Observational (PIANO) study is a prospective, multicentre observational cohort study that was conducted at 27 hospitals between 2014 and 2017. We compared baseline characteristics and outcomes of all patients with CN PJI from the PIANO cohort with those of CP cases. We report on PJI diagnostic criteria in the CN cohort and apply internationally recognized PJI diagnostic guidelines to determine optimal CN PJI detection methods. Results: Of the 650 patients with 24-month outcome data available, 55 (8.5 %) were CN and 595 were CP. Compared with the CP cohort, CN patients were more likely to be female (32 (58.2 %) vs. 245 (41.2 %); p = 0.016), involve the shoulder joint (5 (9.1 %) vs. 16 (2.7 %); p = 0.026), and have a lower mean C-reactive protein (142 mg L- 1 vs. 187 mg L- 1 ; p = 0.016). Overall, outcomes were superior in CN patients, with culture negativity an independent predictor of treatment success at 24 months (adjusted odds ratio, aOR, of 3.78 and 95 %CI of 1.65-8.67). Suboptimal diagnostic sampling was common in both cohorts, with CN PJI case detection enhanced using the Infectious Diseases Society of America PJI diagnostic guidelines. Conclusions: Current PJI diagnostic guidelines vary substantially in their ability to detect CN PJI, with comprehensive diagnostic sampling necessary to achieve diagnostic certainty. Definitive surgical management strategies should be determined by careful assessment of infection type, rather than by culture status alone.
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Affiliation(s)
- Sarah Browning
- Infection Research Program, Hunter Medical Research Institute, Newcastle,
Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle,
Australia
| | - Laurens Manning
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia
- Medical School, The University of Western Australia, Perth, Australia
| | - Sarah Metcalf
- Department of Infectious Diseases, Christchurch Hospital, Christchurch, New
Zealand
| | - David L. Paterson
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - James O. Robinson
- Department of Infectious Diseases, Royal Perth Hospital, Perth, Australia
- PathWest Laboratory Medicine WA, Perth, Australia
- College of Science, Health, Engineering and Education, Discipline of Health,
Murdoch University, Perth, Australia
| | - Benjamin Clark
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia
| | - Joshua S. Davis
- Infection Research Program, Hunter Medical Research Institute, Newcastle,
Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle,
Australia
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
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